In the next few months, Anthem Blue Cross and Blue Shield (BCBS) plans to not pay for non-emergent use of emergency departments (EDs) in at least four states.
Evidence of the uptick in ED visits for non-emergent care in recent years includes a 20 percent increase in overall ED visits since 2014, says Gene Rodriguez, director of public relations for Anthem Inc., noting that “a large percentage of those visits were for non-emergency ailments.”
In June, Anthem implemented the policy in Kentucky, resulting in reduced repeat avoidable ED claims and a small percentage of claims being denied as unnecessary ED use cases, Rodriguez says.
Other insurers are implementing “similar” plans, says Cathryn Donaldson, a spokeswoman for America’s Health Insurance Plans.
Implementing this policy is likely to pose challenges, including explaining the policy to patients and educating them about alternative care sites, says Rachel Sokol, practice manager for research at the Advisory Board.
Health plans will review claims for ED use for non-emergency ailments against the prudent layperson standard for what entails an emergency, including consideration of symptoms and the diagnoses.
The policy is expected to increase hospital and physician bad debt, says Ethan James, executive vice president for the Georgia Hospital Association. “When you see these folks denying coverage for claims, it will absolutely put the burden for that financial loss on providers,” James said.
This is an excerpt from an article originally published in HFMA’s Healthcare Business News.