Insurers and Physicians Clash Over “Avoidable Visits”

Anthem, one of the largest health insurance companies in the U.S., is coming under fire for denying patients’ claims for emergency room visits for what it deems minor ailments, according to The New York Times. Though the company stated that it is trying to limit the overuse of health-care resources, doctors, patients, and consumer advocates are loudly criticizing Anthem’s “avoidable ER program.”

Emergency departments are one of the most expensive places to receive treatment, and one of the targets for reducing medical costs. Through this program, the insurer is urging patients instead to visit primary-care physicians or walk-in clinics for sprains, upper respiratory infections, and other non-emergency conditions. However, doctors claim that this policy will have the unintended effect of forcing patients to self-diagnose or self-manage their illnesses – even serious illnesses.

“The costs of treating non-emergency ailments in the [emergency room] has an impact on the cost of health care for consumers, employers and the health care system as a whole,” Jill Becher, a spokesperson for Anthem, told The New York Times.

“It’s the place where the incentives in health care break down,” Zack Cooper, PhD, a health economist at Yale University who studies patterns in out-of-network bills, added. “You’ve ended up with this death struggle between insurers, hospitals, and emergency-room physicians, and patients get caught in the middle.”

Anthem piloted the program in 2015 in Kentucky, and has expanded it to Missouri and Georgia, among other states. However, the company appears to have been denying fewer claims since receiving feedback from physicians and consumer advocates, according to a sample of emergency room bills analyzed by the American College of Emergency Physicians. The company also announced several exceptions to its policy, including for patients who live far from an urgent-care facility, those younger than 15, those who receive certain treatments in the emergency room, and those admitted to the hospital.

Legislators in several states also are hesitant to accept the avoidable ER program; Missouri lawmakers passed a bill that prevents insurance companies from rejecting claims solely on the basis of a final diagnosis.

Source: The New York Times, May 19, 2018.