If you use Anthem Blue Cross Blue Shield, make sure you read your policy regarding Emergency visits.
Beginning this year, Ohio is now one of six states where Anthem may decide whether an ER visit will be covered per their undisclosed guidelines.
The American College of Emergency Physicians is opposed to the policy and has been posting videos explaining their position.
Dr. Purva Grover is president of Ohio American College of Emergency Physicians and says she’s worried about patient safety.
“I cannot expect a patient to differentiate a headache between a simple migraine or a brain aneurysm, it is not safe for the patient I would implore and encourage patients to seek care,” Dr. Grover said.
She’s also concerned that patients might not get care if they’re worried an ER visit won’t be covered.
Shortly before 6 p.m. on Thursday, we received the following statement from Anthem Blue Cross Blue Shield spokesman Jeff Blunt:
“Anthem’s goal is to ensure access to high quality, affordable health care, and one of the ways to help achieve that goal is to encourage consumers to receive care in the most appropriate setting.”
The following is Anthem’s position on the issue:
Emergency rooms treat life and limb threatening situations, and if a consumer feels he or she has an emergency they should always call 911 or go to the ER. But for non-emergency ailments, ERs are an expensive and time-consuming place to receive care. Primary care physicians are often the best and least costly option for the treatment of any non-emergency medical concerns, with urgent care, telemedicine, retail clinics available to assist consumers in after-hours situations. Anthem also offers a free 24/7 nurse line as well as smartphone-based anytime access to physicians through LiveHealth Online.
Important Points
• Anthem has seen an increase in emergency room visits for non-emergency treatment, despite education campaigns to inform the public about the costs and inconvenience of going to the ER for non-emergent care. A large percentage of these visits were for non-emergency ailments like itchy eyes from seasonal allergies, treatment for ingrown toenails and suture removal.
• Anthem will cover ER visits that are for emergency medical conditions, and this includes instances that meet the prudent layperson standard.
• Anthem educates and encourages members to immediately call 911 or go to the ER when they believe their condition to be life-threatening. For those that need help choosing the best care setting, Anthem offers a free 24-7 nurse hotline as well as covered 24-7 online and smartphone-based access to physicians.
• It’s also important to note that Anthem will cover non-emergency ER visits under the following conditions:
- A consumer was directed to the emergency room by a provider (including an ambulance provider)
- Services were provided to a consumer under the age 15
- The consumer’s home address is more than 15 miles from an urgent care center\
- The visit occurs between 8:00 PM Saturday and 8:00 AM Monday or on a major holiday
- The consumer is traveling out of state
- The consumer received any kind of surgery
- The consumer received IV fluids or IV medications
- The consumer received an MRI or CT scan
- The visit was billed as urgent care
- The ER visit is associated with an outpatient or inpatient admission
• The cost of an ER visit can be 10-times the cost of a visit to a non-emergent care provider. With deductibles and co-payments, these higher costs are often borne by the consumer.
• If a member chooses to receive care for non-emergency ailments at the ER when a more appropriate setting is available, their claim will be reviewed using the prudent layperson standard and potentially denied. Anthem will cover ER visits that are for emergency medical conditions, and this includes claims that meet the prudent layperson standard.