New Anthem policy may not cover your ER visits

Posted at 12:34 PM, Aug 23, 2017
and last updated 2017-08-23 18:49:35-04

INDIANAPOLIS -- Your visit to the the emergency room may not be covered by Anthem insurance thanks to a change in company policy.

Anthem is trying to discourage unnecessary visits to emergency rooms, so the company is notifying providers that it may deny a claim for non-emergency ER visits. 

This would apply to visits like suture removals, athlete's foot and the common cold.

This change has not been put into effect in Indiana yet. The effective date has not been announced.

According to Anthem, a visit to an emergency room costs $1,200, on average. While an urgent care clinic costs about $190 per visit. About three-fourths of emergency room visits do not require immediate attention, also according to Anthem.

The insurer said members in Indiana collectively visit the ER about $190,000 timer per year.

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The change would not impact visits for actual emergencies.

St. Vincent's Chief Clinical Officer Dr. Richard Fogel said he is concerned the change could impact patient's decisions on seeking medical care. 

"We think that we shouldn't put the onus on the patient to make that critical determination about what is or isn't appropriate. If a patient thinks they have an emergency, they should call 911 or they should go to the emergency room directly," said Fogel. "Sometimes, chest pain can be not related to your heart. Sometimes, it can be indigestion or a pulled muscle. And sometimes, it can be a life-threatening heart attack. It's not right to make the patient make that decision. It really is what we in the medical profession have to make."

There are a few exceptions to the rule: ER visits for members under the age of 14, if the member was referred to ER by a doctor, if no urgent care is nearby, if visit occurs on a Sunday or holiday when other care settings would be closed.

Anthem spokesperson Tony Felts released a statement on the change:

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 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.