Senator presses Anthem on decision to clamp down on ER reimbursements

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U.S. Sen. Claire McCaskill is asking Indianapolis-based health insurer Anthem Inc. to provide internal documents related to its recent decision to clamp down on emergency room visits.

In a Dec. 20 letter to Anthem, the Missouri Democrat said she is concerned the insurer is requiring its members “to act as medical professionals when they are experiencing urgent medical events.”

Anthem this year began denying claims in some states for hundreds of non-emergency diagnosis codes, such as bruises, rashes, minor burns, swimmer’s ear and athlete’s foot. The company has said it is frustrated that people continue to show up in the ER with problems that aren’t life-threatening.

The insurer is warning members that if they continue to show up in the ER with non-urgent matters, they will be responsible for the cost, which could easily run into the thousands of dollars.

IBJ first reported in August on Anthem’s new policy, which will go into effect in Indiana in January. Anthem previously rolled out the new policy in several other states, including Kentucky, Missouri and Georgia. Anthem said the policy is already decreasing unnecessary ER visits in Kentucky.

But some members have said Anthem has denied claims for ER visits for serious medical issues, such as ruptured ovarian cysts, car crash injuries and several antibiotic reactions. Those denials mean that members and hospitals can be on the hook for thousands of dollars if the denials aren't overturned on appeal.

“Patients are not physicians,” McCaskill wrote. She pointed out that Anthem "has a strong presence in Missouri" and the company's decision will affect the health-care costs for thousands of Missouri residents.

She wants Anthem to give her all internal emails, documents and presentations relating to its new policy, along with any complaints from patients or members and any communications from hospitals.

She also wants all documents that spell out potential cost savings expected because of the policy, and a narrative description of reimbursement process, including identification of questionable costs and dispute resolutions.

“Lawmakers have recognized it is unreasonable and unfair to expect patients to have the same knowledge as doctors and be able to distinguish between the chest pain caused by indigestion and chest pain caused by a heart attack,” McCaskill wrote.

She is asking Anthem to provide the information by Jan. 19. Anthem did not have an immediate response to McCaskill’s letter.

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