ED Coding and Reimbursement Alert

As complaints mount, states are taking issues into their own hands.

As complaints continue to rise against Anthem Blue Cross Blue Shield's controversial ED policy, lawmakers in one state are hoping to stem the issue to save consumers from out-of-pocket bills.

Background: Anthem has a policy impacting patients in Missouri, Georgia, Kentucky, Connecticut, Ohio, New Hampshire, and Indiana in which the payer will deny ED claims for conditions that Anthem labels "non-emergent."

The policy requires patients to personally determine whether their diagnoses are true emergencies, which can be challenging when patients have symptoms that could be of serious, emergent conditions or could be something more minor. "If you chose to receive care for non-emergency ailments at the ER when a more appropriate setting is available, your claim will be reviewed using the prudent layperson standard and potentially denied," Anthem writes on its website. "The review by a medical director will take into consideration the symptoms that brought you to the emergency room even if the diagnosis turned out to be a non-emergency ailment."

If, for example, a patient believes he is having a heart attack and the ED physician diagnoses him with heartburn, that may be a reason for denial. At issue, however, is the ability of patients to use "the prudent layperson standard" to make diagnostic determinations, opponents of the policy say.

"Countless symptoms can either be something minor or something life-threatening," said Paul Kivela, MD, MBA, FACEP, president of the American College of Emergency Physicians, in a May 1 statement. "We can't possibly expect people with no medical expertise to know the difference between the two before they even leave their house. Anthem is forcing them to play doctor and threatening them financially if they go to the ER."

Missouri Lawmakers Take Action

On May 18, Missouri state legislators approved a law barring insurers from denying emergency department claims based solely on the final diagnosis that the physician assigns to the visit. This move is intended to help those in the state face fewer denials.

The legislation defines "emergency medical condition" as "the sudden and, at the time, unexpected onset of a health condition that manifests itself by symptoms of sufficient severity, regardless of the final diagnosis that is given, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that immediate medical care is required..."

The bolded portion of the text above is indeed bolded in the bill, demonstrating lawmakers' commitment to fixing the issue going forward. The insurer would have to look at the symptoms that prompted the ED visit, rather than the final diagnosis, to determine whether to pay the claim.

At press time, the bill was awaiting the governor's signature. Stay tuned to future issues of ED Coding Alert for more on this topic.

Reference: To read the legislation, visit https://legiscan.com/MO/text/SB982/id/1715551.