June 9, 2021

There is a film shot off the shores of Ireland involving a hapless fisherman played by the well-known Irish actor, Colin Farrell. He’s out trawling one day, having little luck, when suddenly his nets haul in an unexpected catch: an unconscious woman. He performs CPR and, to his disbelief, she’s not dead. She has survived some unknown odyssey in the depths of the sea. Is anyone thinking mermaid at this point? After reviving his strange new passenger, Farrell’s character tells the woman he should take her to the hospital to get checked out. She flatly refuses. She’ll have none of it; and, as it turns out, her instincts were probably right—because the way things are progressing in today’s healthcare environment, she may have been stuck with the entire bill.

We’ve all witnessed occasions where someone who’s had a tumble, but looks to be unharmed, is nevertheless encouraged to go to the emergency room to have a once-over—just to be sure. Now, however, you’d have to stop and give that some additional thought, because we are seeing increasing signs that payers are beginning to redefine what they deem to be reasonable and payable emergency department (ED) services.

The Scrutiny Begins

No later than 2015, Anthem Blue Cross Blue Shield (BCBS) began implementing a more rigorous review of ED claims, presumably based on what it perceived as an increased rate of potentially unnecessary utilization of emergency services. According to one source, this review process began in Kentucky; but, by 2020, Anthem’s ED audits had spread to other states: Georgia, Indiana, Missouri, Ohio and New Hampshire.

Essentially, if Anthem finds upon review that an ED service was unnecessary under the circumstances, the payer could potentially deny coverage of the entire service. For example, if BCBS of KY determines that the patient’s condition could have been treated at an urgent care center (UCC), the payer may make the decision to deny reimbursement, leaving the patient with the full cost of the service.

To a certain extent—at least from the payer’s perspective—this tougher approach on ED reimbursement is understandable. Trips to the emergency room are more expensive than a visit to the doctor or the UCC, and there has been a rise in ED utilization over the last several years. It’s not surprising, then, that payers may be taking the position that the emergency room should only be reserved for an immediate threat to one’s life or body part. (The fully recovered woman fished from the ocean would not seem to meet either criterion.)

Nevertheless, these new rules put in place by Anthem did create some controversy in certain circles, as well as a few headaches for patients. Here’s a case in point. According to Vox Media, a patient went to the emergency room in Kentucky with debilitating abdominal pain and fever. Her mother, a former nurse, had advised her to go to the ER as her symptoms were associated with appendicitis, which is considered a medical emergency. After examination, it turned out that she had ovarian cysts. Anthem sent the patient a bill for over $12,000, indicating a claim denial because she had used the emergency room for non-emergency care. Fortunately, after an appeal, Anthem paid the bill for the emergency services. While it turned out alright in the end, this case study points to a concern that patients may now begin second-guessing a decision to rush to the ER. But what if they guess wrong?

The Screws Tighten

Anthem’s policy in this regard has now been joined by another major payer. According to the website of UnitedHealthcare (UHC), the giant insurer will also begin reviewing and ultimately denying certain ED claims based on a finding of nonemergent circumstances. The policy will take effect on July 1 in most states.

According to the UHC website, ED claims will be evaluated based on factors, such as:

The patient’s presenting problem
The intensity of diagnostic services performed
Other patient complicating factors and external causes
Claims determined to be non-emergent will be subject to no coverage or limited coverage in accordance with the new policy. The policy goes on to provide the following:

If an ED event is determined to be non-emergent, you’ll have the opportunity to complete an attestation if the event met the definition of an emergency consistent with the prudent layperson standard.
It is significant that the payer acknowledges that there is a distinction between the “immediate threat to life or limb” standard and a layperson’s prudent actions in seeking emergency care. It may be, then, that UHC will ultimately allow many claims it initially denies to be ultimately paid, in full or in part, as with the Anthem example cited above.

Key Takeaways

The upshot of all this is that, as such policies proliferate and become known to the public, a certain percentage of services may be redirected from the hospital to alternate healthcare settings. Whether or not such policies are seen as reasonable attempts to minimize costs to the payers, the end result may inevitably be a reduction in insurance-based case flow to the hospital and thus the loss of potential revenue. Does this mean the hospital emergency department will need to start implementing more intensive triage of ER cases as they come in the door, advising some patients to head to the local clinic or UCC instead (assuming there are no legal or contractual impediments to this)? The weighing of clinical costs and care protocols has just become a higher priority, which means you’ll need to take a closer look at what you’ve just found in your net.

We at MiraMed Global Services work to keep you informed and also offer business solutions for your facility. If you have questions about our services, please go to www.miramedgs.com or reach out to us at info@miramedgs.com.