Healthcare News & Insights

Major payor stops coverage for non-emergency conditions treated in EDs

Non-emergency medical conditions treated in the emergency department (ED) will no longer be covered by Anthem in Georgia, Missouri and Kentucky – and this could be the sign of a growing trend among payors. 

Healthcare Finance News reported that the payor’s policy, which was implemented in Georgia and Missouri this summer and Kentucky in 2015, is meant to crack down on patients who use the ED for conditions that could be addressed in a primary care visit.

ED visits cost $1,200 on average, while an urgent care clinic costs $190, according to Anthem.

Opposition emerges

The policy change isn’t meant to impact actual emergencies, but many doctors are against the new policy.

Example: The American College of Emergency Physicians objects to the change, saying the problem is that providers and patients don’t always know when a medical condition is an actual emergency until the patient is seen.

Anthem will no longer cover the ICD-10 codes of more than 1,900 conditions if they’re treated in an ED, such as:

  • unspecified chest pain on breathing
  • abrasion of ear or lip
  • acute bronchitis
  • first degree burns of wrist or fingers
  • cough
  • influenza
  • sprains
  • head abrasion, and
  • pain in a leg.

Many of these conditions may be symptoms of an emergency, but Anthem will only look at the final diagnosis when deciding whether to pay – even if extensive screening was required to determine whether the patient was in danger.

A study published in August by the International Journal for Quality in Health Care found that only 3.3% of all visits to the ED are avoidable.

The concern for many providers is that patients will self-diagnose and delay medical care, leading to worse problems.

ACA rules

Some healthcare experts think this new policy violates the Affordable Care Act’s “prudent layperson” standard, which requires insurance coverage to be based on patient symptoms, not a final diagnosis.

Conditions that qualify as emergencies and are noted in Anthem’s policy include:

  • chest pain
  • stroke
  • poisoning
  • serious breathing problems
  • unconsciousness
  • severe burns or cuts
  • uncontrolled bleeding, and
  • seizures.

However, some symptoms of these conditions overlap with the ones that aren’t covered by Anthem, which can be a problem for patients who may not know what’s causing their illness.

Exceptions exist

There are a few exceptions to the new rule, however.

They are:

  • patients who were directed to the ED by another medical provider
  • patients under 14 years old if there’s no urgent care clinic within 15 miles, or
  • patients who visit between 8 p.m. Saturday through 8 a.m. Monday or on a major holiday.

Anthem said its goal with this new policy is to direct patients to less expensive and more appropriate options, such as primary care providers, urgent care clinics, retail clinics and 24/7 telehealth services.

While the policy could be helpful with easing ED overcrowding and cutting down on ED overuse, it may also make it more difficult for hospitals to get paid for providing patients with necessary care, should minor symptoms mask major aliments.

The focus on value-based care and reducing healthcare costs may cause more payors to jump on Anthem’s bandwagon in additional states. That means ED providers may have to be more vigilant about directing patients with minor ailments to an alternative healthcare setting for care – or even being more proactive with keeping them healthy in the first place. We’ll keep you posted.

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