ACEP fires back at Anthem for its discretionary ED policy

The American College of Emergency Physicians criticized Anthem's recent moves to incentivize patients with nonemergent symptoms to seek care outside of the emergency department.

Under Anthem's policy, which is effective in several states, Anthem will review diagnoses after members' emergency room visits. If the condition is determined to be nonemergent, Anthem may not cover the ED visit. Exceptions include ED visits for policyholders under age 14, patients with physician referrals to the ED, a lack of urgent care accessibility, and if the visit occurs on a holiday or Sunday when nonemergent facilities may be closed.

ACEP responded to the policy change with a tongue-in-cheek video featuring three patients presenting to the ED with stomach pain. ED physicians then ask the patients which one has "simple diarrhea" or "a leaking abdominal aortic aneurysm‎ — a true, life-threatening emergency?"

Paul Kivela, MD, president of ACEP, said, "Insurers cannot reasonably expect patients to know the difference" between emergent and nonemergent symptoms. Dr. Kivela argued Anthem's policy is "unlawful" and the "'prudent layperson standard' is federal law and requires health insurance companies to cover emergencies visits based on the patient's symptoms, not the final diagnoses."

Anthem previously said it will cover claims that meet the so-called layperson standard.

In August, Anthem spokesperson Tony Felts told Becker's Hospital Review claims submitted for nonemergent care will be reviewed by an Anthem medical director, who will consider the patient's symptoms when he or she came to the ER and the diagnosis. In Indiana, where Anthem rolled out the policy this month, the insurer will use a list of about 300 codes it considers nonemergent, which the company developed with four board-certified ER physicians.

More articles on payer issues:
Humana faces backlash for raising breast cancer drug copays
Des Moines Register: Iowa Medicaid traps enrollees in endless appeals process
Mutual of Omaha enters Medicare Advantage market

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