Buyer Beware

A compelling story on this weekend titled, “Beware this insurer’s sneak attack on emergency care coverage.” The report focuses on Anthem’s recent decision to deny coverage for emergency services it deems unnecessary.

The excerpt below is from the story, written by Shih-Chuan (Andrew) Chou, M.D., an attending emergency physician and health policy research fellow, and Jeremiah D. Schuur, M.D., vice chair of clinical affairs for the Department of Emergency Medicine, both at Brigham and Women’s Hospital in Boston.

Simply put, Anthem’s retrospective denial of emergency care coverage is unethical and illegal. It threatens patients’ safety and their access to emergency care. Individuals covered by health insurance with this restriction won’t have the financial protection they expect when seeking care for a medical emergency. Instead, patients may find that their insurance did not cover the visit cost when they receive a bill out of the blue.

Patients will be forced to be their own doctors, weighing a trip to the emergency department for what could be lifesaving care against possible financial repercussions if they guess wrong.

Despite the outrage by lawmakers and physician organizations, Anthem has continued to expand this dangerous policy nationally, threatening to reverse the progress we’ve made in patient safety and access.

Denying retrospectively determined “inappropriate” emergency department visits is as unsafe today as it was 25 years ago. Patients across the nation need to examine the details about emergency care coverage in their health insurance plans, especially if they are covered by Anthem, Unicare, Blue Cross Blue Shield, or one of the other subsidiaries. This fine print needs to be exposed so physicians and patients can fight back.

We recently wrote a blog that focused on several national organizations that are fighting back. The American Hospital Association, American College of Radiology and American College of Emergency Physicians wrote a letter to Anthem asking the company to rescind its coverage policies for emergency care.

According to a recent story on, “Anthem’s cost-cutting drive is angering providers, and they’re looking to push back as yet more policies go into effect.”

In the past year, the giant Blue Cross plan has sought to limit the use of anesthesiologists during cataract surgery and refused to pay for MRIs and CT scans performed at a hospital on an outpatient basis.

Anthem was forced to somewhat soften its move to not pay for Emergency Department (ED) care it deems unnecessary after complaints that patients would have to self-diagnose or would avoid seeking needed care.

Providers will next week see another of Anthem’s attempts to whack at healthcare costs. The payer is cutting provider payments by 25% for separate evaluation and management (E/M) services billed using CPT modifier 25 when physicians provide services on the same day for a different procedure or another service.

We’d love to hear your thoughts on Anthem’s cost-cutting decisions. Are they sound business moves or do they put patients at risk? Driving important and meaningful conversations around the health stories making headlines is another way we are working toward our long-term goal of one day making Arizona the Healthiest State in the Nation!

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s