Anthem Coverage Leaves Senators Dissatisfied

Federal HHS Secretary Alex Azar fielded questions from two US senators about whether his agency and the Labor Department have investigated and taken enforcement action against Anthem and other insurers that allegedly violated consumer rights by denying coverage for emergency care.

Last year, Anthem caused a furor by rolling out a policy in five states of denying payment for emergency department visits that it subsequently determined did not involve true emergencies.Blue Cross and Blue Shield of Texas launched a similar policy for its HMO plans. Some federal and state lawmakers see this is part of a broader set of issues that call for legislative or regulatory action to protect healthcare consumers.

Azar reported that the states are generally responsible for insurance regulation and enforcement, but that HHS has been monitoring state action on this issue and will work with the states to ensure that appropriate action is taken.

The two Senators wrote to Azar and Labor Secretary Alex Acosta in March, asking the agencies to report their actions to enforce federal laws requiring insurers to cover care for emergency conditions, singling out Anthem for scrutiny.

The two senators specifically cited reports that Anthem makes coverage decisions for ED claims based on codes for the patients' final diagnosis rather than considering their symptoms at the time of the emergency, saying this appears to violate federal law. 

While Azar’s letter clearly said that diagnostic codes should not be the only factor in determining whether a medical emergency condition occurred, and that federal law requires insurers to consider the facts and circumstances of individual patient cases, the senators were not satisfied with his response but didn’t indicate whether they would push a legislative solution. 

Anthem's ED coverage policy led to a large spike in coverage denials among ED patients. The company later overturned more than 60% of the coverage denials that were appealed by patients.  Earlier this year, Anthem announced it would tweak its policy by having its claims reviewers request patient records before making a coverage decision.

Source:  http://www.modernhealthcare.com/article/20180913/NEWS/180919940