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Hospitals Decry Insurance Giant's Denial of some ER Service Claims

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Unless the recent policy change of Anthem, an insurance giant in the US, is challenged in the court, more emergencies may be denied payment and the bill left in the hand of patients. The policy, although it will apply to six states, will be rolled out in all 14 states where Anthem has Blue Cross Blue Shield affiliates.

The American College of Emergency Physicians and other groups asked Anthem to reconsider the policy. Dr. William Thorwarth, the CEO of the American College of Radiology, said that if doctors would not challenge the rule, other insurers will follow Anthem’s example, Naples News reported.

Policy in unlawful

In a video released in January, the ACEP called Anthem’s policy as unlawful. In 2017, Anthem, based in Indianapolis, started to deny payment coverage for emergency room services after it decided that a beneficiary did not face an emergency. It warned policyholders in Missouri, Kentucky, Ohio, New Hampshire, Georgia, and Indianapolis in 2017 of the new regulation. Anthem initially scheduled it to take effect in Indianapolis in 2017 but moved it to January 1, 2018.

The insurer has a second policy to deny payment coverage for advanced imaging in an outpatient hospital setting if Anthem determines, after a review and decision, that there was no emergency condition for the patient. But the second policy has exceptions.

Lawsuits by Piedmont

Because of the new Anthem policies, the Piedmont Hospital group, based in Atlanta, filed a lawsuit against Anthem and Blue Cross Blue Shield of Georgia. It claimed that the policies were a breach of contract and harmful because it intentionally and maliciously sought to deteriorate health care coverage for the members and significantly reduce reimbursement for the providers.

An Anthem medical director uses a prudent layperson standard to deny an emergency room claim. The standard requires insurance coverage based on symptoms and not a final diagnosis. Anthem wants the patients in the affected states to instead go to urgent care centers rather than emergency rooms for treatment.

The 11 national medical associations wrote a letter to the insurer in January to tell Anthem that the new policy could violate the prudent layperson standard. The groups pointed out that in essence, Anthem is expecting the patient to act as a medical professional. They asked the insurance giant to rescind the harmful policies.

Not applicable in Florida

But Christie Hyde DeNave, the spokeswoman of Florida Blue, insisted that Anthem – which is its parent company – is a separate company. She said Anthem has no control over the policies of Florida Blue.

While the insurance benefits of an insured individual usually follow when the person is in another state, Anthem’s list of emergency room coverage denial includes when the beneficiary is traveling out of state and during holidays. The exceptions are if the doctor tells a patient to go to the ER or when the ambulance brings the patient to the emergency room. But there must be a document justification for the ER visit.

Aetna versus CNN

Meanwhile, another insurance giant, Aetna, accused CNN of taking a deposition out of context. Aetna said CNN did it to create media and courtroom leverage, Fox News reported. According to CNN, Dave Jones, the insurance commissioner of California, was outraged when he was shown a transcript of the testimony which he felt proved that Dr. Jay Ken Iinuma, an ex-medical director of Aetna, never looked at patient records when he decided when to approve or deny care.

After Iinuma admitted under oath that he never looked at the record of the patient when deciding to approve or deny care, Jones launched an investigation of Aetna. He said he was following the training of Aetna. CNN reported that a lawsuit was filed by a college student against Aetna after he suffered from a rare immune disorder which Iinuma knew nothing about and did not look at the student’s medical records.

In a sworn statement after CNN published the story, Iinuma insisted that the patient’s medical records were an integral part of the clinical review process and there was a review of the relevant portions of the submitted medical records.

The lawsuit was filed by Gillen Washington, a student at Northern Arizona University. Aetna denied him authorization for a costly drug infusion which he receives monthly to treat a rare immunodeficiency disease. He appealed Aetna’s decision, but while waiting, he was hospitalized with pneumonia and collapsed lungs.

Kaiser Health Network reported that Iinuma said in his sworn deposition that he relied on what the nurses at Aetna told him. The nurses checked if Washington’s requested treatments met the guidelines of the insurer. He said it was his general policy to review the summary of the nurses, notes, and the applicable Aetna Clinical Policy Bulletins as well as his medical training, experience, and judgment to reach an appropriate coverage determination.

[메디컬리포트=​Vittorio Hernandez 기자]

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