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Anthem ER Payment Policy Attracting Critics

Josh James
The emergency room at University of Kentucky HealthCare on Oct. 10, 2017.

A national group of emergency physicians says policies put in place by health insurance giant Anthem Blue Cross Blue Shield are shifting the bill for some ER trips to patients.

According to the American College of Emergency Physicians, Anthem’s policy – now in effect in Kentucky – creates a secret list of diagnoses it will not cover, even if a patient thought the condition was a medical emergency.

"Meaning if you go to the emergency department where we're federally mandated to provide the care for you if you seek care there, that they're going to turn around afterwards with hindsight being 20/20 and say that was not an emergency. You didn't need to go to the ER, so you, as the patient, are going to be responsible for the bill," says emergency physician Dr. Ryan Stanton.

Further complicating matters, Stanton argues, is Anthem's decision not to release the list of conditions that could result in denied coverage, even to doctors. Still, the physician's group managed to obtain a list currently in use in Missouri. And although some conditions appear reasonable, Stanton says some only reveal themselves after doctors have ruled out other, more serious health concerns.

Take pleurisy, an inflammatory condition that can lead to sharp chest pains. 

While it's not particularly dangerous, Stanton says "when you come to the emergency department, I've got to rule out that it's a heart attack, that it's a pulmonary embolism, that it's pneumonia, and only once we get to the end and rule out these things is that diagnosis there."

Yet an Anthem spokesperson says the ER payment policy has already been in place in the commonwealth for two years with “very little abrasion for members.” In a statement to WUKY, the insurer says if a member chooses to receive care for non-emergency ailments at the ER when a more appropriate setting is available, "their claim will be reviewed using the prudent layperson standard and potentially denied."

The statement adds that, "Anthem will cover non-emergent ER visits if a member was directed to the emergency room by another medical provider, if services were provided to a child under the age 14, if there isn’t an urgent care or retail clinic within 15 miles of the member or if the visit occurs on a Sunday or major holiday."

Stanton, however, sees dollar signs at the heart of the policy.

"The motivation is all about money," he says. "Even though they'll tell you they're barely scraping by and can't make it through... somehow having these record profits that honestly are settled on the backs of the providers, physicians, hospitals, and more importantly, the patients."

Anthem counters that the "primary focus of this program is to promote appropriate care settings for members when they have a non-emergency medical condition. It’s about getting our members the right care at the right time. If a member feels he or she has an emergency, they should always call 911 or go to the emergency room."

Josh James fell in love with college radio at Western Kentucky University's student station, New Rock 92 (now Revolution 91.7). After working as a DJ and program director, he knew he wanted to come home to Lexington and try his hand in public radio.