Starting Next Month, Anthem Cracks Down On Unnecessary ER Visits For Indiana Policyholders

Dec 15, 2017

Indiana emergency physicians are concerned a new insurance policy to curb emergency department visits could scare away patients. The policy, already in place in three other states, will take effect for Indiana Anthem policy holders next month.

Under the new policy, Anthem reviews claims after emergency room visits. If it determines the condition that brought a patient to the emergency room wasn’t an emergency, it may not cover the ER trip — leaving patients on the hook for a bill that could cost them thousands of dollars.

The policy was put in place in an effort to cut costs for the Indianapolis-based insurance giant. The emergency room is one of the most expensive places to receive health care. Anthem hopes the policy will drive people with non-emergency ailments to urgent-care clinics or ambulatory care centers, which cost significantly less.

However, American College of Emergency Physicians Indiana chapter president Gina Huhnke says patients can’t expect to know which symptoms are life-threatening.

“For example, patients come with abdominal pain and they may have an ovarian torsion which requires surgery or they may just have gastroenteritis which they can manage at home,” Huhnke says.

Huhnke says physicians believe the policy violates the federal “prudent layperson” standard, which requires coverage based on symptoms, not a final diagnosis.

“Currently under federal law, prudent layperson states that anyone who has symptoms suggestive of an emergency should be allowed to access care,” says Huhnke.

In a statement, Anthem says it will cover claims that meet that standard. The Indianapolis-based insurance company says its policy will also cover ER visits if there isn’t another provider nearby or available.

This story is the product of a partnership between IPB News and Side Effects Public Media, a reporting collaborative focused on public health.