Anthem Reverts to Previous ED Policy: Part II

If a patient does not have liability for a particular expense, the insurer is similarly absolved of responsibility.

The June 14 issue of RACmonitor focused in part on Anthem’s policy regarding coverage of ED services. The relevant article suggested that insured patients should not face responsibility for emergency room bills. To understand why that is permissible, it is necessary to understand how the law views insurance.

An insurer has a legal obligation to pay any expense that an insured person or entity incurs, as long as that expense is covered by the policy. In essence, the insurer stands in the shoes of the policyholder and is responsible for any obligation they would otherwise have. As a result, a basic principle of insurance law is that if, say, a patient does not have liability for a particular expense, the insurer is similarly absolved of responsibility.

The insurer’s duty to pay derives entirely from the patient’s obligation. If a healthcare organization says to the patient, “you are not responsible for this expense,” in most cases the organization has functionally made the same promise to the insurer.

For example, a number of courts have held that if a healthcare organization advertises that it will accept insurance as payment in full without any co-payments or deductibles, or otherwise promises not to charge the patient, the insurer is not obligated to make payment.

Yet the article asserts that you may tell a patient that if the insurer denies ED care, you won’t charge the patient. How can these statements both be true? The answer is that in the case of these emergency department services, what you are telling the patient is that if the services were not necessary, neither the insurer nor the patient is responsible for them. In essence, if the services were not medically appropriate, no one is required to make a payment.

That promise is also consistent with the terms of the implied contract created when a patient presents to a doctor. When most people receive healthcare, there is little discussion about price. In that case, the law imposes what is called an implied contract.

The terms of that “contract” are that the medical organization is to submit a reasonable charge, and the patient is required to pay it. If, for any reason, the services provided by the hospital are unreasonable, the patient does not have a legal obligation to make a payment. In other words, for emergency services, there are two possibilities: either both the patient and the insurance company should be responsible for the cost, with the patient responsible for any deductible and co-insurance, and the remaining balance falls to the insurance company, or, alternatively, neither the insurer nor the patient are responsible.

Legal issues can arise when you treat the patient and the insurer differently. (There are still a few other exceptions where it is possible to absolve the patient of liability while requesting payment from an insurer. For example, waiving beneficiary liability for a patient who has a legal claim is likely defensible.) However, if the insurer asserts that it isn’t responsible for the cost of care, there is little risk if you extend a courtesy discount to the patient.

Program Note:

Listen to David Glaser every Monday on Monitor Mondays, 10-10:30 a.m. EDT.

 

Comment on this article

Facebook
Twitter
LinkedIn

David M. Glaser, Esq.

David M. Glaser is a shareholder in Fredrikson & Byron's Health Law Group. David assists clinics, hospitals, and other health care entities negotiate the maze of healthcare regulations, providing advice about risk management, reimbursement, and business planning issues. He has considerable experience in healthcare regulation and litigation, including compliance, criminal and civil fraud investigations, and reimbursement disputes. David's goal is to explain the government's enforcement position, and to analyze whether this position is supported by the law or represents government overreaching. David is a member of the RACmonitor editorial board and is a popular guest on Monitor Mondays.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

2026 IPPS Masterclass 3: Master MS-DRG Shifts and NTAPs

2026 IPPS Masterclass Day 3: MS-DRG Shifts and NTAPs

This third session in our 2026 IPPS Masterclass will feature a review of FY26 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 14, 2025
2026 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

2026 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

This second session in our 2026 IPPS Masterclass will feature a review the FY26 changes to ICD-10-PCS codes. This information will be presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 13, 2025
2026 IPPS Masterclass 1: Master ICD-10-CM Changes

2026 IPPS Masterclass Day 1: Master ICD-10-CM Changes

This first session in our 2026 IPPS Masterclass will feature an in-depth explanation of FY26 changes to ICD-10-CM codes and guidelines, CCs/MCCs, and revisions to the MCE, presented by presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 12, 2025

Trending News

Featured Webcasts

The Two-Midnight Rule: New Challenges, Proven Strategies

The Two-Midnight Rule: New Challenges, Proven Strategies

RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.

June 19, 2025
Open Door Forum Webcast Series

Open Door Forum Webcast Series

Bring your questions and join the conversation during this open forum series, live every Wednesday at 10 a.m. EST from June 11–July 30. Hosted by Chuck Buck, these fast-paced 30-minute sessions connect you directly with top healthcare experts tackling today’s most urgent compliance and policy issues.

June 11, 2025
Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Substance abuse is everywhere. It’s a complicated diagnosis with wide-ranging implications well beyond acute care. The face of addiction continues to change so it’s important to remember not just the addict but the spectrum of extended victims and the other social determinants and legal ramifications. Join John K. Hall, MD, JD, MBA, FCLM, FRCPC, for a critical Q&A on navigating substance abuse in 2025.  Register today and be a part of the conversation!

July 16, 2025

Trending News

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