Hospitals must perform medical screening evaluations to patients presenting at emergency departments.
Anthem Blue Cross Blue Shield, the nation’s largest health insurer, instituted a policy last year of not paying for emergency department care if they retrospectively determined the visit was non-emergent.
It started in Georgia, Missouri, and Kentucky, and has spread to New Hampshire, Indiana, and my state of residence, Ohio. One can imagine they will roll this out to the rest of the country if they can get away with it.
In order to understand the implication of Anthem’s new policy, you need to understand the history.
The Emergency Medical Treatment and Labor Act (EMTALA) was enacted in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act of 1985, known as COBRA. EMTALA essentially mandates that anyone coming to an emergency department must have an assessment performed and needs to be stabilized, regardless of ability to pay. It is also known as the “anti-dumping law” and is intended to prevent charity cases from being sent away from hospitals.
Again, if a patient presents to an emergency department, the hospital must perform a medical screening evaluation to determine if an emergency medical condition exists. If so, the patient must be treated, or ideally, stabilized, prior to transfer to an appropriate facility. Hospitals with specialized capabilities are obligated to receive transfers from facilities unequipped to handle unstable emergency medical conditions. Hospitals are also subject to mandatory reporting for recognized violations.
Insurers, especially capitated HMO-types, began requiring patients to get pre-authorization, and were retroactively denying payment if the final diagnosis turned out to be non-emergent, according to the payer. The patients and the hospitals were getting shafted.
As a result, the “prudent layperson” definition was added in 1994 as a revision to EMTALA, and it became standard for Medicaid in 1997, for Medicare in 1998, and for the Veterans Affairs (VA) system in 1999. The prudent layperson standard is also codified in the Patient Protection and Affordable Care Act of 2010.
The “prudent layperson” definition of an emergency medical condition is any medical or behavioral condition of recent onset and severity, not limited to severe pain, that would lead a typical person possessing an average knowledge of medicine and health to believe that his or her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could jeopardize life, limb, or mental health. The presenting sign or symptom is paramount, not the final diagnosis, when determining whether to pay emergency medical claims.
Apparently, we’ve traveled back in time, because last year Anthem rolled back the standard for its non-Medicaid/Medicare policyholders, allowing the insurer to decline emergency department visit claims they deem non-emergent. If they feel the patient could have been served in an urgent care setting instead, they deny the bill. There are exemptions, including healthcare provider referral to ED, inability to access urgent care due to geography or time, receipt of IV fluids or IV medications, or undergoing a MRI or CT scan.
Online, I have read accounts of vehicle-pedestrian strikes and severe abdominal pain with fever that turned out to be ovarian cysts that were denied. We’ve had articles in our local newspaper about patients who have gotten retroactive denials from Anthem and are now reluctant to seek medical attention in the future. U.S. Sen. Claire McCaskill (D-Mo.) has become involved in trying to advocate for her constituents.
I remember years ago, there was a big push for emergency departments to open fast-track or urgent care areas for lower-acuity patients to try to reduce length of stay in the ED and improve patient and staff satisfaction. In accordance with EMTALA, there is a quick screening exam to ensure that the patient is safe to go to the fast-track area. I support control of medical expenditures, and if it can be determined that a patient does not need the highest level of care, I support his or her going to an urgent care center.
However, this new (old) policy is just plain wrong. We talked about pro basketball star Kevin Love and his panic attacks last week on Talk Ten Tuesdays. If you have chest pain and shortness of breath, it is imperative to seek medical attention. The final diagnosis should not be the determinant of coverage. It is not reasonable to expect a layperson to know.
In the ED, our philosophy is to rule out life threats. If a patient has signs and symptoms that could be indicative of serious pathology, we need to make sure that isn’t the case before we anchor on a non-life-threatening diagnosis. You don’t want to send some woman home with an erroneous diagnosis of indigestion to have her die of an acute myocardial infarction (MI) because you were banking on her having the most pedestrian “horse” of a condition (“If you hear hoofbeats, think horses, not zebras”). Patients may have a bias towards downgrading their symptoms; a patient might dismiss her symptoms and die of her MI at home if she is afraid of the insurer not covering her ED visit. It is not in a patient’s best interests to practice medicine by Google.
Is this going to backfire on Anthem? Are folks going to get sicker or die because they are hesitant to seek medical attention? Might be a pretty big lawsuit. Are providers going to start initiating IV fluids or giving parenteral meds, or order CT scans more liberally, to justify payment? This would be a disservice, too, because all treatments and studies have side effects, and could be problematic if not medically necessary.
It is not acceptable to shift costs or responsibility for making medical diagnoses to the patient. Patients should be allowed to be patients, emergency providers should provide excellent medical care to everyone regardless of ability to pay, and insurers should reimburse healthcare providers and facilities for taking care of patients.
Since Jan. 20, it seems that uncertainty in healthcare has become the new normal. After a contentious hearing, Robert F. Kennedy, Jr. was appointed to
The U.S. Department of Health and Human Services (HHS) has recently made a declaration to cease the public comment period for their proposed regulations. By
Please log in to your account to comment on this article.
Physician queries are essential for accurate documentation and claims data, but they are increasingly scrutinized by payors, leading to denials and revenue leakage. This webcast, led by industry expert Cheryl Ericson, RN, MS, CCDS, CDIP, provides actionable strategies to craft compliant queries, reduce denials, and enhance revenue integrity. Attendees will gain insights into clinical validation queries, how to avoid common pitfalls, and learn best practices to defend against query denials. Don’t miss this opportunity to refine your query process and protect your organization’s financial health.
Master the complexities of heart failure coding with this expert-led webcast by Emily Montemayor, CCS, CMBCS, COC, CPC, CPMA. Discover strategies to ensure compliance with ICD-10-CM guidelines, documentation integrity, and capture comorbidities like CKD and hypertension. Learn how to resolve coding challenges, improve documentation practices, and submit clean claims to minimize denials and safeguard your organization’s financial health. With practical insights and real-world examples, this session equips you to prevent revenue leakage, enhance compliance, and secure optimal reimbursement—all while supporting better patient outcomes.
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.
Dr. Ronald Hirsch dives into the basics of Medicare for clinicians to be successful as utilization review professionals. He’ll break down what Medicare does and doesn’t pay for, what services it provides and how hospitals get paid for providing those services – including both inpatient and outpatient. Learn how claims are prepared and how much patients must pay for their care. By attending our webcast, you will gain a new understanding of these issues and be better equipped to talk to patients, to their medical staff, and to their administrative team.
Hospitals face growing challenges in measuring observation metrics due to inconsistencies in classification, payer policies, and benchmarking practices. Join Tiffany Ferguson, LMSW, CMAC, ACM, and Anuja Mohla, DO, FACP, MBA, ACPA-C, CHCQM-PHYADV as they provide critical insights into refining observation metrics. This webcast will address key issues affecting observation data integrity and offer strategies for improving consistency in reporting. You will learn how to define meaningful metrics, clarify commonly misinterpreted terms, and apply best practices for benchmarking, and gain actionable strategies to enhance observation data reliability, mitigate financial risk, and drive better decision-making.
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.
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
