Anthem denied 12K ER claims in second half of 2017, but paid most of them anyway

Anthem has come under intense scrutiny by providers in recent months for denying patients' emergency room claims it deemed unwarranted. While a recent congressional report indicates Anthem has largely reversed the policy, some experts suggest the insurer may still be primed to save thousands of dollars on patient claims, The New York Times reports.

Anthem rolled out a policy in multiple states warning members it may not cover their emergency room visits for minor ailments. Data provided by Anthem to Sen. Claire McCaskill, D-Mo., who authored the report, indicated in three states the insurer denied 12,200 claims during the second half of 2017 on the grounds the ER visits were "avoidable." The denials reflected about 5.8 percent of total ER claims submitted in the three states — Missouri, Kentucky and Georgia — during this period. However, when patients challenged the denials, Anthem proceeded to reverse itself and pay the claims most of the time.

The report also examined the effects of Anthem's decision to add a list of exceptions to the policy, including emergency room visits made during weekends, visits during which children are treated or visits during which an advanced imaging test was ordered. The insurer did not provide Ms. McCaskill with data on the number of denials it has issued since adding the exceptions, but data from the American College of Emergency Room Physicians provided to The New York Times suggest denials plummeted to nearly zero, the report states.

In a statement to the publication, Anthem said it remains committed to its avoidable ER policy "because the costs of treating nonemergency ailments in the ER has an impact on the cost of healthcare for consumers, employers and the healthcare system as a whole. Anthem has made, and will continue to make, enhancements to ensure consumers are receiving the right care at the right place and time."

Jonathan Kolstad, PhD, an associate professor at the University of California, Berkeley Haas School of Business, said the insurer may still save money by announcing such an initiative, even if it is never enforced, because it may discourage some patients from going to the ER for less serious ailments.

"You may get as much or more bang for your buck frankly by just telling people you're not going to pay. Even if, at the end of the day, you do pay," he told the publication.

To access the full report, click here.

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