Note from the ACDIS Director: Fighting the good fight against arbitrary denials—Bravo, ACEP and MAG

By Brian Murphy

Recently, the American College of Emergency Physicians (ACEP) and the Medical Association of Georgia (MAG) came out swinging against an insurer, Anthem. The pair of associations filed lawsuit against Anthem for its recently-implemented policy of denying medical treatment in the emergency department for “non-emergent conditions.”

I’ve been following this case with close attention as it piques my interest on multiple levels.

The ACEP and MAG rightfully claim that most patients cannot possibly distinguish urgent from non-urgent levels of care, and that Anthem is operating from hindsight by retrospectively denying claims that may have seemed urgent at the time. This practice violates the “prudent layperson” standard from the Affordable Care Act, ACEP and MAG claim.

“The prudent layperson standard means that a health plan must cover services delivered in an emergency department if the patient presents there with symptoms that a prudent layperson, possessing an average knowledge of health and medicine, could reasonably expect to result in serious impairment to his or her health.”

The end result of Anthem’s policy is denied claims and patients hit with unexpected bills for non-covered ED services.

Here is an excellent summary of this issue from an article written by Steven Porter of HealthLeaders Media. In it, Porter quotes ACEP President Paul Kivela, MD, FACEP, statement on the matter which calls Anthem’s policy “dangerous,” adding "We can't possibly expect people with no medical expertise to know the difference between something minor or something life-threatening, such as an ovarian cyst versus a burst appendix." 

Though it hasn’t received as much attention as the “prudent layperson” argument, I’m also deeply bothered by Anthem’s refusal to publish a comprehensive list of diagnosis codes it is using to deny these claims, or to provide these codes to ACEP despite multiple requests. From the lawsuit:

Despite ACEP and MAG's advocacy efforts, [the] defendants [Anthem] refused to publicly release the list of diagnosis codes used as a basis for considering which claims to deny in most of the states. . .

In this era of supposed transparency, in which hospitals must report dozens of quality measures which are then abstracted into publicly available scorecards, and are being asked by CMS to publish their chargemaster data to the public, it is a disgrace that Anthem would deny claims using a seemingly arbitrary—and certainly opaque—standard.

Of course, as ACDIS director I have to mention that there is a valuable action item here for CDI specialists. Review your ED notes. Work with your ED physicians to paint a proper level of severity in the medical record, from the first point of contact.

This is a great opportunity to institute CDI coverage in your ED, particularly for those operating in the six states in which Anthem’s policy applies (Georgia, Missouri, Kentucky, Indiana, New Hampshire, Ohio), but also in other states who may be considering similar coverage policies. We have many resources on the ACDIS website about CDI in the ED you may wish to consider.

To be fair, I suspect Anthem has seen many cases of high-cost care delivered to patients who use the ED as they would their primary care, for various reasons. If, during your chart reviews, you do see questionable admissions or patterns of questionable outpatient treatment, don’t pretend it’s not your responsibility. Bring it to case management, or your physician advisor.

Thank you, ACEP and MAG, for fighting the good fight.

Editor’s note: Murphy is the director of ACDIS. contact him at bmurphy@acdis.org.