INDIANAPOLIS – Indiana-based Anthem will notify Hoosiers during the upcoming open enrollment period that it will stop paying for emergency rooms visits the health insurance company deems a non-emergency.
The company tells CBS4 the change, which has already been implemented in Missouri, Kentucky and Georgia, is the result of a steady increase in visits to the emergency room that the health insurer said could easily be treated with other options like primary care or urgent care.
Anthem said it anticipates of the 190,000 annual visits to Indiana emergency rooms for its customers, it will begin denying roughly four percent of claims, or about 7,600 a year.
“If a member chooses to receive care for non-emergency ailments at the ER when a more appropriate setting is available, their claim will be reviewed using the prudent layperson standard and potentially denied,” the company said in a statement to CBS4.
Anthem said, each claim will be reviewed by an Anthem medical director taking into consideration the patient’s symptoms and eventual diagnosis and patients can appeal any denial.
Exceptions to the new rule will be made – including for anyone under the age of 14, situations where there isn’t an urgent care or retail clinic within 15 miles of the patient or on Sundays.
Still, a number of hospital officials are expressing concern.
"Fundamentally there's a concern about a policy that would call into question an individual's instinct about whether or not they are going to seek care in the emergency department," Brian Tabor said, president of the Indiana Hospital Association. "Emergencies are emergencies. And when an individual pauses or hesitates and has to go through that process, it can lead to some very bad outcomes."
The emergency room, Anthem said, is the most expensive option – with the average cost at about $1,200 per visit, compared to $190 for urgent care, $125 for walk-ins at a doctor’s office, $85 for a retail health clinic and $49 for LiveHealth online.
As part of the decision, Anthem cited internal data showing of the 6.5 million annual ER visits for people under the age of 65, nearly 75 percent do not require immediate attention.
"If a patient has what they consider is an emergency, they should go to the emergency room," Dr. Richard Fogel said, the chief clinical officer at St. Vincent. "That's what the emergency room is for. At the same token, if someone has a minor injury or illness, if they've got a sore throat or ear ache, that might not be appropriate for the emergency room."
An exact implementation date has not been determined by Anthem.
The company told CBS4 it wants to provide adequate education before full implementation.
Read Anthem's full statement:
Anthem is committed to providing access to high quality, affordable health care. As part of that mission, we are committed to promoting care delivery in the most appropriate clinical setting; for non-emergent care, generally this is the patient’s primary care provider. Anthem believes that primary care doctors are in the best position to have a comprehensive view of their patient’s health status and should be the first medical professional patients see with any non-emergency medical concerns.
If a member can’t get an appointment with their primary care doctor, most non-emergent medical conditions can be easily treated at retail clinics, urgent care clinics or 24/7 telehealth services such as LiveHealth Online. Those alternatives typically are much less expensive and have lower member cost sharing than the emergency room. If a member chooses to receive care for non-emergency ailments at the ER when a more appropriate setting is available, their claim will be reviewed using the prudent layperson standard and potentially denied. The review by an Anthem medical director will take into consideration the presenting symptoms that brought the member to the emergency room as well as the diagnosis.
It’s important to note that Anthem’s 24/7 nurse line and online tools are always available to help members find the right care option for their neighborhood. Anthem will cover non-emergent ER visits if a member was directed to the emergency room by another medical provider, if services were provided to a child under the age 14, if there isn’t an urgent care or retail clinic within 15 miles of the member or if the visit occurs on a Sunday or major holiday.