Anthem Insurance Companies, Inc., overturned a large number of denied reimbursement claims from patients that have gone to the emergency room (ER). The payer denied claims on the grounds that the patient’s visit was not considered enough of an emergency to justify the visit. Anthem’s initial justification for these denials is based on an emergency department (ED) policy they initiated across multiple states in 2017 and it is a policy they continue to implement across the US.
However, according to a report by Sen. Claire McCaskill (D-Mo.) discussed in Modern Healthcare, a large number of these denial claims are now being overturned in a way that implies “a significant percentage of initial denials were improper—a troubling result given that Anthem places the burden of appeal on beneficiaries, and individuals without the time and resources to file an appeal.” This is concerning as patients may have significant out-of-pocket costs that then may need to be reimbursed by insurance. Additionally, McCaskill’s report raises the concern that this may be occurring because “Anthem employees may not have appropriate training or experience to carry out its ED policy.”
More critically, there are fears that even with claims being overturned, the policy may “deter people who think they are having an emergency from seeking help.” Moreover, according to Dr. Vidor Friedman, president-elect of the American College of Emergency Physicians, this may also create a situation where Anthem is “asking patients to diagnose themselves.”
Further, although Anthem denied 12,200 emergency claims in Missouri, Kentucky, and Georgia from July 2017 through December 2017 and overturned roughly 60-70% of appealed claims, it is “unclear […] how many patients appealed their denied claims.” In addition, it is important to note that the claims that were not appealed were not overturned, and thus, not reimbursed.
More optimistically, McCaskill’s report states that once Anthem received pushback over its ED policy, they initiated “several exceptions to [their] ED policy” which led to their claim denials dropping to “nearly 0% in the three states as of March 2018.”
With six states now adhering to their new ED policy, it remains to be seen whether the rest of Anthem’s covered states will have the same denied claims response or, as Anthem hopes, their exceptions will be enough to lead to patients “request[ing] fewer appeals.”
The GIRS InContact Reimbursement Hotline® center has assisted several cases that are reported on the Hotline to be appealed and overturned each year. We also have adopted appealing claims as a surrogate for establishing positive coverage with major payers like Anthem.
Is your medical technology experiencing pushback and claims denials? GIRS can help you. Contact us by email or call us toll-free at 1-844-514-4477 and follow our LinkedIn Company Page for more bi-weekly news on reimbursement trends, milestones, and achievements.