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5/6/2018 10:36:00 AM
Emergency room doctors: Anthem's payment denial for some visits is dangerous
This is the entrance to the emergency room at Memorial Hospital in South Bend. Anthem Blue Cross and Blue Shield has implemented a policy that could allow it to deny emergency claims. Staff photo by Robert Franklin
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This is the entrance to the emergency room at Memorial Hospital in South Bend. Anthem Blue Cross and Blue Shield has implemented a policy that could allow it to deny emergency claims. Staff photo by Robert Franklin
At a glance
Anthem will always cover ER visits under the following conditions:

A consumer was directed to the emergency room by a provider (including an ambulance provider)

Services were provided to a consumer under the age 15

The consumer’s home address is more than 15 miles from an urgent care center

The visit occurs between 8 p.m. Saturday and 8 a.m. Monday or on a major holiday

The consumer is traveling out of state

The consumer received any kind of surgery

The consumer received IV fluids or IV medications

The consumer received an MRI or CT scan

The visit was billed as urgent care

The ER visit is associated with an outpatient or inpatient admission



Ed Semmler, South Bend Tribune Staff Writer

A group of emergency room doctors is pushing back on a program from Anthem Blue Cross and Blue Shield that could deny reimbursement for those using the hospital emergency room for treatment the insurer doesn’t deem an emergency.

Emergency room physicians say the policy ultimately could lead to higher health-care costs or even lost lives.

But the Indianapolis-based insurance company said treatment in a hospital emergency room is considerably more expensive and time-consuming than if a patient had gone to an urgent care or walk-in clinic.

In an attempt to contain healthcare costs, it began testing a program — that began rolling out in Georgia, Missouri and Kentucky in 2015 and was extended Jan. 1 to include Indiana, Ohio and New Hampshire — that could deny reimbursement for emergency room visits the insurer deems unnecessary.

The program applies to those with an Anthem plan provided from an Indiana employer or a policy that was purchased on the individual market. Anthem would not reveal how many customers it has, but the company indicated it is the largest health plan in the state.

“Anthem’s avoidable ER program aims to reduce the trend in recent years of inappropriate use of ERs for non-emergencies as the costs of treating non-emergency ailments in the ER has an impact on the cost of healthcare for consumers, employers and the health care system as a whole,” Anthem spokesman Tony Felts said via email.

But the change has caused a backlash of criticism and stories of people who went to the emergency room because they thought they were suffering from a serious issues, but ended up with significant medical bills because their conditions were deemed to be non-emergency matters.

The American College of Emergency Physicians has fought back against the policy by issuing press releases and videos highlighting the dangers in the program. Beacon Health System declined to comment on the issue, but Saint Joseph Health System indicated it has taken action to build awareness about the change with signage and handouts throughout its physician network locations.

Related Links:
• South Bend Tribune full text

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