Physicians argue Anthem's ER policy violates federal law

Physicians are concerned about a new policy Anthem is rolling out in Indiana in January, according to WBOI

Under the new policy, which is already effective in three other states, Anthem will review diagnoses after members' emergency room visits. If the condition is determined to be nonemergent, Anthem may not cover the ER visit.

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, an Anthem spokesperson told Becker's Hospital Review in August. In Indiana, Anthem will use a list of about 300 codes it considers nonemergent, which the company developed with four board-certified ER physicians.

There are several exceptions to the new policy, including ER visits for policyholders under age 14, patients with physician referrals to the ER, a lack of urgent care accessibility, and if the visit occurs on a holiday or Sunday when nonemergent facilities may be closed, the spokesperson told Becker's

Gina Huhnke, MD, American College of Emergency Physicians Indiana chapter president, told WBOI physicians believe Anthem's ER policy violates federal law.

"Currently under federal law prudent layperson states that anyone who has symptoms suggestive of an emergency should be allowed to access care," she told WBOI.

Anthem said it will cover claims that meet the so-called layperson standard, according to the report.

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