In some states, the list of reasons to reject a claim is confidential


It is hard to know how many visits are “avoidable” or “non-emergent.” Studies have estimated that anywhere between 4.8 and 90 percent of emergency room visits are “avoidable,” depending on the criteria and methods used.

Emergency physicians tend to cite the lower numbers, arguing that unnecessary trips to their department are few and far between. Insurers, however, often gravitate to the higher numbers that indicate they’re massively overpaying for routine care that could be delivered elsewhere.

The topic can be especially difficult to study because it often requires understanding initial symptoms — chest pain, for example, could be a heart attack or indigestion. Many studies, however, only rely on the final diagnosis.

“If you look at insurance claims data, you have diagnoses but you don’t have what the patient came in with,” Hsia said. “It’s not fair to expect the patient [to come] in knowing their diagnosis. If they did, they wouldn’t come in and wait for ours.”

Anthem appears to use a list of diagnostic codes — which indicate the patient’s final diagnosis upon leaving the emergency room — to screen for non-emergency visits. A version of the diagnosis codes that would trigger review in Indiana from early January 2018 includes “pain in extremities” and “low back pain.”

A list of codes from Missouri is significantly longer, with more than 1,900 diagnostic codes that could indicate non-emergency visits. The list includes multiple types of “unspecified injuries” and “chest pain on breathing.” When asked about the Missouri list, an Anthem spokesperson said the latter diagnostic code regarding chest pain has since been removed from the list, which has been updated and revised.

In other states, the list of diagnosis codes remains confidential. Georgia insurance regulators have asked Anthem to provide a copy of that state’s list, but so far, that hasn’t happened.

There are no current estimates of how many patients the Anthem policy has affected, or what results it has achieved for the health insurance plan in deterring unnecessary visits. Anthem declined to provide such figures, only saying denials represented a small percentage of claims.

Congress, however, has begun to get interested in those questions. On December 20, Sen. Claire McCaskill (D-MO) sent Anthem a letter stating, “I am concerned Anthem is requiring its patients to act as medical professionals when they are experiencing urgent medical events.”

McCaskill has requested that Anthem provide “all complaints received by Anthem from any entity relating to coverage of emergency room care in Missouri, Kentucky, or Georgia” and “all internal communications … relating to the company’s decision to clarify its policies regarding emergency room care utilization.”

“I’m currently sitting with a $12,000 debt over my head because I thought my appendix had ruptured”

Cloyd was shocked when she received the denial notice. She immediately got to work appealing the decision.

“I consider myself intelligent and generally knowledgeable about my own health,” she wrote in a letter dated August 22. “I am not a doctor, which is why I immediately sought experienced medical care when I felt my symptoms could be dangerous and potentially lethal.”

Anthem reviewed Cloyd’s appeal two months later and, once again, denied coverage for the visit.

“Based on a review by a medical doctor … we’ve evaluated your appeal of denial of ER services,” the letter stated. “We cannot approve coverage for your emergency room visit.”

Anthem wrote that it did not have sufficient medical records from her hospital. The hospital told Cloyd they had sent the health plan all the necessary documents. Cloyd made a second appeal.

“The claim has caused unnecessary stress, which certainly hasn’t improved any of my other medical conditions,” she wrote on December 27. “You can easily review my claims and note that I do not overuse the emergency room or hospital services in any capacity! I’ve been covered by Anthem for several years and have never overused or misused any benefits.”

The letter continued, “I’m currently sitting with a $12,000 debt over my head because I thought my appendix had ruptured.”

One week after Vox interviewed Cloyd about her emergency bill and inquired to Anthem about its emergency billing practices, Cloyd received a letter stating that the denial would be reversed — she had won her second appeal.

“We deeply regret if we caused Ms. Cloyd any concern,” Anthem said in a statement to 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.”

Emergency room physicians are currently exploring what options they may have to push back against Anthem’s new policies. A meeting between the health plan and the American College of Emergency Physicians took place in Washington last December but yielded few results.

“There were a couple of questions I had but couldn’t get answers to, like what does success look like? And how many patients are actually being denied?” said John Rogers, president-elect of the American College of Emergency Physicians, who practices at a hospital in Macon, Georgia. “They may have the answers to them, but I didn’t hear them.”

Rogers said his group is looking at possible lawsuits or legislation, at either the state or national level.

Right now his group is focused on collecting patient stories to get a sense of what the denial policy looks like on the ground.

“Hospitals are starting to talk to patient advocacy groups, asking whether they’re aware of the situation,” he said. “We’re starting to sit down with legislators to say, ‘This is happening, we don’t think it’s a good idea, and these are other, better solutions.’”

The experience completely changed how Cloyd thinks about the emergency room. She would still take her 7-year-old daughter in case of emergency, but she says she no longer thinks she’d ever seek emergency care unless forced by a medical provider.

“I have numerous health issues, and it’s upsetting and scary to think that I don’t have that option, but it’s just not worth the stress,” she said. “I told my husband, I’ll go to primary care, and they’ll have to force me into an ambulance to go to the emergency room.”

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