Anthem's discretionary ED policy lands patient with $12k bill: 8 things to know

A Kentucky resident received a $12,596 bill from Frankfort (K.Y.) Regional Medical Center after her insurer, Anthem, deemed her trip to the hospital's emergency department nonemergent, according to Vox.

Here are eight things to know about the bill.

1. Brittany Cloyd went to Frankfort Regional's ED July 21, 2017, after experiencing increasing pain on the right side of her stomach. She feared her appendix had ruptured.

2. ED physicians at Frankfort Regional administered several tests, including an ultrasound and CT scan, to determine the problem. Physicians diagnosed Ms. Cloyd with ovarian cysts and not appendicitis, prescribing Ms. Cloyd pain medication and a follow-up with a gynecologist. 

3. Frankfort Regional billed Ms. Cloyd for $12,596 a few weeks later after Anthem denied the hospital's claim.

4. Across six states — Missouri, Georiga, Kentucky, Indiana, New Hampshire and Ohio — Anthem has recently decided to stop covering emergency department visits it deems unnecessary for policyholders. The policy, which has several exceptions, aims to steer Anthem members with nonemergent ailments toward a primary care physician or an urgent care provider instead of costly ED visits.

5. Anthem uses a list of diagnostic codes to identify nonemergent visits to the ED. However, Vox notes Anthem's denials are based on physician diagnoses, not the symptoms patients present to the ED — such as Ms. Cloyd's intense stomach pain.

6. Anthem, which covers 40 million-plus members, initially said it would speak with Vox about Ms. Cloyd's situation. Anthem later declined an interview and gave the following statement:

"Anthem's goal is to ensure access to high-quality, affordable health care, and one of the ways to help achieve that goal is to encourage consumers to receive care in the most appropriate setting."

7. Following Vox's interchange with Anthem — and two appeals from Ms. Cloyd — Anthem reversed its decision to not cover the bill.

"We deeply regret if we caused Ms. Cloyd any concern," Anthem told Vox. "Anthem has made, and will continue to make, enhancements to our ER program to ensure more effective implementation of this program on behalf of consumers."

8. Several groups, including the American College of Emergency Physicians, have criticized Anthem's discretionary ED policy and even questioned its legality.

For Sarah Kliff's full report, click here

Editor's note: This article was updated on Jan. 31 at 11:22 a.m. CT to reflect Anthem's ER policy affects six states, not four. We regret this error.

More articles on payer issues:
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Aetna grows profit by 75.5% in Q4: 3 things to know
OSF HealthCare still negotiating with payers ahead of Presence acquisition

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