A Congressional report on Anthem's policy of denying emergency room claims for patient care in Missouri, Georgia, and Kentucky that the company later deemed non-emergent found that although thousands of emergency room claims initially were denied after the policy was instituted, a majority of the denials patients contested were overturned on appeal between July 2017 and November 2017.
Moreover, according to the report, subsequent modifications to the policy resulted in a sharp decrease in denials of emergency room claims.
The report followed a request by U.S. Senator Claire McCaskill (D-MO) for information from the insurer on the policy and how it was being implemented.
Anthem first instituted the policy in Kentucky and then in Missouri and Georgia. After pushback, Anthem amended the policy this past January.
The report's key findings include:
- From July to December 2017, out of 73,000 emergency room claims in Missouri, Anthem reviewed 7,500 and denied 3,700, deeming them non-emergent; in Kentucky, out of 117,000 emergency room claims, Anthem reviewed 13,000 and denied 5,000; and in Georgia, out of 51,000 emergency room claims, Anthem reviewed 10,000 and denied 3,500.
- Anthem overturned 62 percent of denied emergency room claims in Missouri on appeal from July 2017 to November 2017 – with the rate of overturned decisions increasing each month. Similar results were seen in Georgia and Kentucky as well.
- Since Anthem revised its emergency room policy in January of this year, the percentage of denied claims for each of the three states has dropped to zero.
- Anthem denied requests for additional information.
Earlier this year, Senator McCaskill called for a full review by the federal government to determine whether or not Anthem's policy was in violation of federal law by disapproving emergency room claims that might be required to be allowed under the Prudent Layperson Standard, which requires emergency room coverage where absence of immediate medical attention would place the health of the individual in serious jeopardy.
Last week, the American College of Emergency Physicians and the Medical Association of Georgia sued Anthem and two of its subsidiaries in a federal court in Georgia in an effort to compel the defendants to rescind its emergency care policy that, the plaintiffs alleged, retroactively denied coverage for emergency patients.
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Steven A. Meyerowitz
Steven A. Meyerowitz, a Harvard Law School graduate, is the founder and president of Meyerowitz Communications Inc., a law firm marketing communications consulting company. He may be contacted at [email protected].