Anthem’s Coverage Denials Draw Scrutiny

Anthem remains under the gun for its rollout of policies that deny coverage for emergency room visits that later turn out to be nonemergencies, as well as refusing coverage for medical imaging performed in expensive hospital settings.

My story last week covered the groundswell of opposition to the policy changes, including state-level lawsuits against the insurance company, a video campaign by an emergency physicians’ group, state legislative action, and outcry from two Democratic senators.

At least one hospital appears to have gained some traction with Anthem.

Piedmont Hospital in Atlanta has dismissed its lawsuit against Anthem Blue Cross of Georgia “in connection with the resolution of the contract negotiations,” Elisabeth Wang, a spokesperson for the hospital, told me.

Wang wouldn’t say how the new contract addresses emergency services or medical imaging coverage, the two Anthem policies at issue in the lawsuit. But, presumably these matters have been resolved to Piedmont’s satisfaction, for now.

For its part, the American Hospital Association also weighed in on Anthem’s approach to steering patients to lower-cost options.

“This is a big issue for our members,” said Molly Smith, vice president of coverage and state issues at AHA. “It’s part of a larger trend where payers are saying where they think services can be delivered in a lower cost setting without regard for other factors such as quality.”

Smith said AHA has met with Anthem and sent letters regarding the emergency department policy but they have not reached a resolution. AHA has said it wants Anthem to fully rescind the emergency services policy and that it favors an approach that uses patient education tools to help reduce emergency room visits.

There seems to be consensus among hospital and physician groups that Anthem’s approach is more stick than carrot in educating patients. Fewer unneeded trips to the emergency room is a worthy goal, certainly.

But, according to Smith, “There really has to be a better way. You don’t have to put patients’ health at risk to solve affordability in the health-care system.”

Anthem did not respond to requests for comment.

Read my story here.

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