On January 1, 2018 Anthem Blue Cross Blue Shield implemented a new policy for Ohio in which patients treated in emergency departments may have coverage denied and be responsible for the entire cost of the visit if Anthem retrospectively decides that based on the diagnosis the visit was non-emergent and the patient should have sought care at an alternative facility. The Ohio State Medical Association (OSMA), the Ohio Chapter of the American College of Emergency Physicians (Ohio ACEP), and the Ohio Hospital Association have all raised significant concerns with this change and communicated directly with Anthem as well as the Ohio Department of Insurance.
In addition to the public relations efforts currently under way to call attention to this problematic change, the regulatory process also provides physicians and patients an opportunity to challenge the policy. Current law in Ohio provides patients with the ability to externally appeal a health insurer’s decision. This independent review is administered by the Ohio Department of Insurance (ODI). While reviewing individual cases, if over a period of time the majority of cases are overturned on appeal, the validity of the entire policy moving forward can be brought into question. Therefore, it is very important for physician practices to monitor this situation closely and, when an ED claim is denied to determine whether the denial is based on this new policy. If it is and the patient would have had no way of knowing the visit was non-emergent (as defined by Anthem), Ohio ACEP and OSMA encourage you to work with the impacted patient to first seek Anthem’s internal review of the denied claim, and then, if necessary, seek external review.
Any claim denial can be appealed internally with Anthem. If unsuccessful, the matter can be forwarded externally to ODI for review either by an Independent Review Organization (IRO) or department staff. ODI has developed a simple toolkit and decision tree to assist patients and providers in navigating the internal and external review process. Please review these documents carefully and provide any necessary information to your patients. Anthem’s specific internal appeals process should be noted on any Explanation of Benefits (EOB) sent to the provider and patient. The appeals process should be detailed in the provider manual as well.
Ohio ACEP and the OSMA will stay in regular contact with ODI and Anthem to monitor the implementation of the new policy and will provide any updates to you as they become available. So that we can stay updated with activities in the field, we ask that you inform us when any claims proceed to external review (please don’t provide any specific information regarding the claim just the date it was filed and that it was related to this policy).
Please direct any questions to Ohio ACEP Executive Director, Laura Tiberi. Email her at ltiberi@ohacep.org or call (614) 792-6506.