Anthem’s ED policy prompted a Missouri law that defines a medical emergency.
The Upshot column in the New York Times on May 19 focused on Anthem’s experiment with denying emergency room visits, arguing that patients should have known that ED care was unnecessary.
One of the anecdotes in the column perfectly illustrates the giant flaw in Anthem’s policy. When “Jason” became short of breath in 2015, he went to the emergency room. He was treated for a panic attack. Two days later, again experiencing shortness of breath and fearing he had heart problems, he returned. His pulse was over 150. How did Anthem handle these two visits?
The first visit was denied because it was coded as a panic attack. The second visit was allowed because it included the diagnosis of breathing trouble. To Anthem’s credit, when Jason appealed the denial, that first visit was paid.
But think about how illogical this situation is. The first time he had symptoms, they denied the care, but they actually allowed the repeat visit. Why? Anthem focused on the final diagnosis code, not the symptoms. It should be obvious to any rational person that the final diagnosis isn’t material for determining whether the patient was acting reasonably in visiting the ED.
Chest pain can be caused by a range of conditions that could include anything from an MI to gas. Obviously, the latter isn’t an emergency. However, a layperson’s ability to determine which of these conditions is actually present is presumably very limited.
In fact, as a layperson, if I attempted to help you determine whether you had an MI or gas, I would be breaking the law: specifically, practicing medicine without a license. Non-physicians are not supposed to make medical judgments. Nevertheless, according to the New York Times and the American College of Emergency Physicians study on which the Times’ story was based, Anthem conducted an experiment in six states – Kentucky, Missouri, Indiana, Ohio, New Hampshire, and Connecticut – performing reviews based solely on the final diagnosis and without the review of medical records.
The good news is that Anthem has reverted to its previous policy. During the experiment, approximately 3 percent of emergency visits in Missouri were being denied. Anthem has now returned to paying well over 99 percent of emergency visits.
As a result of Anthem’s policy, Missouri has passed a new Senate bill: 982. That law defines an emergency medical condition as one that is sudden and would lead a prudent layperson to believe that immediate medical care is required.
The bill does something else very interesting. It requires healthcare professionals and insurance companies to enter into binding arbitration when a health professional provides emergency care to an out-of-network patient and the insurer and healthcare organization are unable to agree on reimbursement. The professional is prohibited from sending a bill to the patient in excess of whatever the arbitration process determines.
There is definite logic to this provision. When a patient has insurance that covers an emergency medical condition, one thing is clear. If they go to the emergency room, either the care provided is reasonable and the insurer should pay, or if the care is unreasonable, the fault lies with the professional or facility. In either case, the patient should not be responsible for the bill.
I recommend that readers adopt this policy. In a fight with an insurer about reimbursement, consider telling the patient that if the insurer won’t pay, they won’t face liability. Note that in many situations, telling a patient that you will accept insurance payment as payment in full can void insurance coverage. A future article will explain why this situation is different.
The bottom line is that when an insured person reasonably thinks they have an emergency medical condition, both the law and common sense say that the patient shouldn’t be responsible for the cost of the medical care.
Program Note:
Listen to David Glaser every Monday on Monitor Mondays, 10-10:30 a.m. ET.
News reports have revealed that the ammunition used in the fatal shooting earlier this week of Brian Thompson, Chief Executive Officer (CEO) for UnitedHealthcare (UHC),
Nearly 20 hours after an assailant fatally shot Brian Thompson, chief executive officer for UnitedHealthcare (UHC), the manhunt continues for what witnesses described as a
Please log in to your account to comment on this article.
Prepare your organization for the 2025 OPPS updates with expert insights from Tiffani Bouchard, CCS, CRCR, a Revenue Integrity Professional with over 30 years of experience. This webcast will address critical challenges in charge capture and coding, providing clarity on APC policies, C-APC packaging, exclusions, and payer-specific requirements. Attendees will learn actionable strategies to ensure compliance, optimize reimbursement, and mitigate risks of claim denials. Gain the knowledge needed to implement updates effectively, educate your team, and maintain seamless revenue cycle operations in the face of evolving OPPS complexities.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
The 2025 Medicare Physician Fee Schedule brings significant changes to payment rates, coverage, and coding for physician services, impacting practices nationwide. Join Stanley Nachimson, MS., as he provides a comprehensive guide to understanding these updates, offering actionable insights on new Medicare-covered services, revised coding rules, and payment policies effective January 1. Learn how to adapt your practices to maintain compliance, maximize reimbursement, and plan for revenue in 2025. Whether you’re a physician, coder, or financial staff member, this session equips you with the tools to navigate Medicare’s evolving requirements confidently and efficiently.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
Copyright © 2025 RACmonitor. Powered by MedLearn Media.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
