Insurance Company Policies in the ED

Another big health insurance company has rolled out an emergency department claims-payment strategy that is raising concern. Modern Healthcare reported last week that UnitedHealth Group announced a plan to review all ED Level 4 and Level 5 evaluation-and-management codes and possibly downgrade them or deny them if United feels the higher level codes are not justified. Higher codes – representing more serious, complex cases – are more expensive for insurers and United says the use of them has increased in recent years. Some hospitals have said the blanket review of the high-end codes is just a convenient way for the insurer to reduce claims payments.

Another large insurer, Anthem, which does not have a presence in Massachusetts, has been receiving great criticism for its new plan to deny claims from patients who show up in emergency rooms with conditions that the insurer later determines not to be emergent. That is, someone in great pain, who rushes to the ED, but who is later found to have an ailment that is painful and frightening – but not necessarily an “emergency” – will have the claim denied.

Last week, two U.S. senators – Ben Cardin (D-Md.) and Claire McCaskill (D-Mo.) – wrote to the U.S. secretaries of Labor and Health & Human Services seeking a federal investigation into Anthem. The senators said Anthem is violating the “prudent layperson standard,” which says, essentially, that an “emergency medical condition” is one in which a prudent layperson, possessing an average knowledge of health and medicine, could reasonably conclude that they need medical attention.

“While we appreciate Anthem on their effort to encourage patients to seek medical care in lower-cost settings, we remain concerned that Anthem’s ED policy still forces patients to determine, before they even leave their home, if their symptoms are serious enough to go to the emergency room ... Patients should not be forced to act as their own doctors and second guess themselves when they truly believe that they are having a medical emergency,” the senators wrote.