Anthem may save money simply by announcing its policy, even if it is never enforced.
The health insurer Anthem is coming under intense criticism for denying claims for emergency room visits it has deemed unwarranted. A new congressional report suggests Anthem has effectively reversed that policy, even as it is being hit with a new lawsuit about it from doctors.
The insurer initially rolled out the policy in three states, sending letters to its members warning them that, if their emergency room visits were for minor ailments, they might not be covered. Last year, Anthem denied more than 12,000 claims on the grounds that the visits were “avoidable,” according to data the insurer provided to Senator Claire McCaskill, a Democrat from Missouri, one of the affected states.
But when patients challenged their denials, Anthem reversed itself most of the time, according to data the company gave Ms. McCaskill. The report concludes that the high rate of reversals suggests that Anthem did not do a good initial job of identifying improper claims, meaning some patients who did not challenge their denials may have been stuck paying big bills they should not have been responsible for.
The report also indicates Anthem has largely abandoned the avoidable visits policy, in keeping with findings The Times presented in May, using a similar data set. This year, Anthem added a list of exceptions to the policy, including emergency room visits made during the weekend, visits in which children are treated, or visits in which an advanced imaging test was ordered.
Anthem did not provide data to Ms. McCaskill about the number of denials it has issued since the change. But data from a sample of claims provided by the American College of Emergency Room Physicians, a trade group, suggests that the denials plummeted to near zero this year.
“This appears to have been an example of an insurance company looking for ways to save a buck at the expense of their patients, only to then reverse course to try and save face once folks noticed and called them out,” Senator McCaskill said in a written statement. “I will continue digging in to make sure this reversal is not short-lived.”
The trade group and other doctors groups in Georgia filed suit against the Anthem company doing business in the state on Tuesday, arguing that the policy violated the law by requiring patients to know their own medical diagnoses before receiving treatment. The lawsuit asks a judge to stop the company from enforcing the policy. Legislators in Missouri have also tightened the legal standard, making it harder for insurers to deny coverage for emergency room claims.
Consumer advocacy groups, including the American Heart Association, have said that the policy could prevent patients from seeking care when they have life-threatening emergencies.
In a statement, Anthem emphasized the recent changes it has made to its policy, but defended its continued use.
“Anthem is committed to our avoidable E.R. program because the costs of treating nonemergency ailments in the E.R. has an impact on the cost of health care for consumers, employers and the health care system as a whole,” wrote Jill Becher, a spokeswoman for the company. But she indicated the policy was under review. “Anthem has made, and will continue to make, enhancements to ensure consumers are receiving the right care at the right place and time,” she said.
Even as Anthem has reduced the number of claims it is denying, it has expanded its policy to new states. Jonathan Kolstad, an associate professor at the Haas School of Business at the University of California, Berkeley, said the company may save money by announcing such a policy, even if it is never enforced. By sending letters to its customers, the company may discourage some patients from going to the emergency room for less serious complaints.
“You may get as much or more bang for your buck frankly by just telling people you’re not going to pay,” he said. “Even if, at the end of the day, you do pay.”
Margot Sanger-Katz is a domestic correspondent and writes about health care for The Upshot. She was previously a reporter at National Journal and The Concord Monitor and an editor at Legal Affairs and the Yale Alumni Magazine. @sangerkatz • Facebook
Reed Abelson covers the business of health care, focusing on health insurance and how financial incentives affect the delivery of medical care. She has been a reporter for The Times since 1995. @ReedAbelson