December 30. 2017 6:50PM

Anthem cracking down on ER visits

By MICHAEL COUSINEAU
Union Leader Staff


 

MANCHESTER - Anthem wants to prevent trips to the emergency room for people who are seeking medical help for constipation or an ingrown nail.

Starting in 2018, the state's largest health insurer plans to stop covering certain services it deems are not medically necessary if people seek treatment at the emergency room.

The cost-control measure lists more than a dozen services, including pregnancy tests, high-blood pressure checks as well as mild contusions and sprains. The costs would be covered for children under 14.

The American College of Emergency Physicians and its New Hampshire chapter this month announced its opposition to Anthem's move.

"Health insurance companies can't expect patients to know which symptoms are life-threatening and which ones are not, and they shouldn't be punished financially because of it," said Dr. Thomas Joseph Lydon, vice president of ACEP's New Hampshire chapter.

"This violates the prudent layperson standard, which is part of Medicare and Medicaid laws, as well as the Affordable Care Act and requires coverage to be based on a patient's symptoms rather than a diagnosis," Lydon said.

Anthem spokesman Colin Manning said Friday that emergency rooms are "an expensive and time-consuming place to receive care."

"Anthem's overall goal is to ensure the broadest access to high quality, affordable health care, and one of the ways to help achieve that goal is to encourage our members to receive care in the most appropriate setting," Manning said.

"Emergency rooms treat life- and limb-threatening situations, and if a member feels he or she has an emergency they should always call 911 or go to the ER," he said.

Manning said he couldn't confirm the date the new policy will go into effect, but there had been discussions of delaying the planned Jan. 1 start date.

Other services include eyelid disorders, ringworm, rashes and itching skin, dental disorders, removal of wound dressings or sutures, follow-up exams, plantar warts, issuing repeat prescriptions and general medical exams.

Anthem shared its plans with the state Insurance Department, according to department spokeswoman Danielle Barrick.

"This is not a plan that by law requires the department's prior approval, and the department has not given any approval," Barrick said. "We will be monitoring it to ensure that it doesn't violate any insurance laws or consumers' rights under state and federal insurance laws."

"Consumers should be aware that they can appeal a denial, first to the insurance company and then through the Insurance Department's consumer services unit," she said.

According to Anthem, it will cover non-emergency ER visits if a person was directed to the emergency room by another medical provider, if there isn't an urgent care or retail clinic within 15 miles or if the visit occurs between 8 p.m. Saturday and 8 a.m. Monday or on a major holiday.

The cost of an ER visit can be 10 times the cost of a visit to a non-emergency medical provider, according to the insurer.

mcousineau@unionleader.com