Anthem’s emergency room coverage denials draw scrutiny

Paul Sweatman was back at the emergency room. It was fall 2017 and a week before his left ankle had swollen to three times its normal size. His first stop, an urgent care clinic, said the problem was out of its league and to get to a hospital. At Atlanta Medical Center caregivers spoke of a mystery bacterial infection and possibly having to amputate. But they kept him three days, tested and treated it. All seemed well, until the swelling returned

He rushed back to the ER.

The wrong call, said his medical insurance company, Blue Cross Blue Shield of Georgia, now known as Anthem. It said the return visit wasn’t really an emergency, Sweatman recalled in an account he provided to The Atlanta Journal-Constitution. He should have gone to a much cheaper urgent care clinic; the company refused to pay.

The hospital bill now went to Sweatman in spite of his insurance — a practice now known as “surprise billing.” Traditionally, surprise bills have involved different types of unexpected gaps in insurance policies, such as contract physicians who turn out not to be in the patient’s network. This insurance gap was different, and Sweatman was one of thousands of patients in several states that were about to receive the bills.

Starting in summer 2017, Anthem began saying that if patients made the wrong decision about whether their condition was an emergency, the entire bill would be on them. ER bills easily run into the thousands of dollars.

Surprise billing has spread across the U.S. health care system, landing properly insured patients with bills they thought insurance would pay. It’s yet one more way that the burden of skyrocketing health costs has shifted to patients over the past decade. But the Anthem ER review policy rolled out first in Georgia, Kentucky and Missouri has catapulted the issue to a new level.

It has earned harsh headlines nationwide. A congresswoman investigated. Doctors sued in federal court in Atlanta, calling it a blatant violation of federal law. Georgia patients have complained to the state. The American Medical Association protested. Georgia legislators have held hearings.

Anthem is defending the policy and, in some cases, winning legal battles to keep it. The company is fighting the federal lawsuit, saying the professional associations that filed the suit don’t have a legal place in the dispute. At least one state, Missouri, has passed a law designed to address it. In Georgia, legislators say the best they may be able to do is to better uphold current law. Yet, at least one county judge said that Anthem was doing just that, following the law.

State Department of Insurance officials, concerned by Anthem’s response, are examining the company’s market conduct.

Meanwhile, doctors say they fear that patients who need to go to the ER will suffer or die instead because they fear a bill.

“This affects Georgians and quite frankly people across this country,” said state Rep. David Knight, R-Griffin, who is trying to bring attention to the issue and is critical of Anthem. “They act with complete immunity. Once you’re in there they can do whatever they want.”

Thousands denied

Anthem declined an interview for this story but said in a statement that it was simply making sure the costs it paid were warranted so it could continue to help patients fund their care.

“If a consumer reasonably believes that he or she is experiencing an emergency medical condition, then they should always call 911 or go to the ED (emergency department),” the statement said. “But for non-emergency health care needs, EDs are often a time-consuming place to receive care and in many instances 10 times higher in cost than urgent care.”

The AJC reported in September that advocates for doctors sampled a handful of hospitals and said they found at least 500 Georgia ER bills have been denied under Anthem’s policy. That was an undercount.

A report by then-U.S. Sen. Claire McCaskill of Missouri showed that in the six months after the initiative launched in 2017, Anthem denied 12,200 of its customers’ claims for emergency room care in Georgia, Kentucky and Missouri, 3,500 of those in Georgia alone. In those beginning months Anthem admitted it was wrong to do so in the majority of cases where the customers appealed, reversing its decisions more than half the time.

Appeals that were denied, though, meant the patients simply had to pay, or else the hospital ate the debt.

Anthem responded that it improved its review process in 2018 and has since made fewer incorrect denials. The insurer would not provide records for McCaskill to evaluate its process or track the ongoing data, the report said. But data the insurance company provided for her review show the rate of denials declined steeply at the end of the period she was reviewing.

McCaskill reported that one of the steps Anthem said it would add to its review process was to always request medical records.

A dangerous infection

Paul Sweatman was one of those 3,500 denied. He says he tried to appeal.

When he headed to Atlanta Medical Center he made sure it was in the Blue Cross network. He knew the score; he’s an insurance agent. But his network was not the issue for Anthem; Sweatman’s own medical judgment was.

For his return visit AMC gave him more IV medicine, he recalls, and sent him home with more antibiotics that day. He was finally cured. He said he was sure the ER was the right place to go, especially since urgent care sent him to the hospital originally and the potential consequences were so serious.

Sweatman says communicating with Anthem was so hard he eventually gave up. The company forced him to write and mail documents, he said, then would not acknowledge receiving them.

“I’ve never had a late bill in my life,” he said. “Every time I tried to follow up on my appeal I was passed around to different departments, some people couldn’t find my appeal, some people could find my appeal. I know I was hung up on at least two or three times. Eventually you just get frustrated and quit fighting.”

Sweatman’s not sure what he’ll do about the latest collection notices, now coming from an attorney. He had started paying but stopped with about $500 left. He’s got student loans to pay, plus a dog that needs surgery. Maybe his tax return will help.

Many types of surprise bills

A hospital bill such as Sweatman’s, following denial for a non-emergency ER visit, is only one type of surprise billLong before Anthem’s 2017 policy went into effect, patients with insurance from any number of companies were receiving surprise bills because of gaps in their policies.

Insurance companies across the spectrum are selling policies that cover less than they used to. In one common problem, people go to the hospital after checking to make sure it’s in network but later receive an unexpected bill from a doctor who was a contractor to the hospital rather than a staff employee.

The common theme is that as costs rise, they’re being pushed by the big players onto patients, said Michele Kimball, the president of the Washington-based advocacy group Physicians for Fair Coverage. The nationally known consulting firm Avalere did research for Kimball’s group that she cites to make that claim.

“They’re putting profits before patients,” Kimball said.

Insurance companies dispute that, adding that hospitals and doctors start the problem by charging 10 times what it costs to go to a clinic. And the more hospitals consolidate, the insurers say, the more they use near-monopoly power to increase prices.

And no one doubts that some people who go to the ER shouldn’t.

Georgia’s Legislature created several study committees to deal with the crisis of inadequate hospital funding and identified part of the problem as overuse of the emergency rooms. Some go there with the sniffles when they should see a regular doctor. That’s expensive, but patient advocates say such cases are few, perhaps 4 percent or 6 percent of the ER population.

More importantly, they say, symptoms such as chest pain are shared by people who are in danger and those who aren’t. They say that’s the whole reason you go to the ER, to find out. Doctors are concerned that some of those people who need care may stay away, rolling the dice.

Since 1997, federal law has required insurers to pay emergency room bills if the patient showed up with what a “prudent layperson” — a rational person who’s not a medical expert — could think was an emergency. In 2010 that requirement was also enshrined in the Affordable Care Act’s 10 essential health benefits that insurance policies must cover, and it’s in Georgia law.

Insurance companies say they’re following the law with a system designed by medical professionals and each denial finalized by doctors.

A gunshot wound

Knight scoffs at that.

“There’s no transparency; we can’t know,” he said. However, he suggested, “there is no way a human is doing that. They’re simply responding to codes.”

“How does a gunshot not be an emergency?” Knight said. “I mean come on, you tell me.”

Knight was referring to a case where Anthem denied a claim for a Georgia policyholder who sought ER care for a gunshot wound.

A Fulton County judge, however, agreed with Anthem.

The gunshot case was part of a larger suit against Anthem where Northeast Georgia Medical Center asked a judge to order the company to stop its after-the-fact emergency care denials.

In the incident, a woman with Blue Cross was shot in the hand as her husband attempted to commit suicide. The judge in the case, then-Fulton County Superior Court Judge Todd Markle, raised a number of points in Anthem’s favor.

Markle noted that the woman waited a day before getting her own care in the emergency room; it does not say whether her husband’s suicidal behavior the first day was a factor in her delay. At the ER the wound, in her finger, had stopped bleeding and her pain level was “moderate.” Furthermore, “ ‘her speech (was) normal and her behavior (was) normal,’ ” Markle wrote, citing the medical record.

A prudent layperson could say her case was not emergency-room material, Markle decided. Markle was at one time Gov. Nathan Deal’s executive counsel, and before leaving office Deal appointed him to the state Court of Appeals.

It’s unclear who will clarify this statewide. Knight led a study committee that investigated the issue, and he’s not sure new legislation is needed since there’s already the prudent layperson law. “I think right now the need is to look at existing laws, and to first look and see if the enforcement is there and if not, ask the question why,” he said.

It’s not a front-burner issue for state lawmakers this year. House Majority Leader Jon Burns, R-Newington, agreed the problem merited examination and said he didn’t know whether legislation was needed. “That’s a good question,” he said.

Struggling to appeal

So the lawyers await the decision on whether the federal court case can go forward. And while the Department of Insurance completes its review — which may or may not be made public — it’s left to patients to fight their own bills.

The woman with the bullet wound didn’t, and Markle noted that.

But many don’t. Even fewer took the next step of complaining to the state Department of Insurance: seven.

Jim Hopkins won his appeal and understands why others would give up. His battle was hard enough, and he’s an accountant. He shares Sweatman’s account of bureaucracy, of being made to file paperwork by mail and then having Anthem struggle to find it.

Hopkins’ problem wasn’t the same ER review policy that Sweatman and the hand patient dealt with. He was disputing a different type of surprising rejection by Blue Cross Blue Shield of Georgia, one patients have dealt with for longer. Hopkins’ son had a Georgia policy but was injured out of state and used out-of-network emergency providers. Insurance should usually pay no matter what if it’s an emergency and appropriate, but Hopkins started receiving the bills and insurance denials anyway.

Hopkins’ son Joey died from a head injury and other trauma following a 50-foot fall hiking the Appalachian Trail. Emergency crews flew Joey off the mountain to an out-of-network North Carolina hospital, where he died the next day.

Hopkins fought for 10 months to get the bills paid, he said, especially the ambulance and the life flight. The last one got paid when he threatened legal action, he said.

“If I wasn’t going to pay it and Blue wasn’t going to pay it, somebody was going to pay it,” he said. “Joey had insurance. Big Blue had a contractual obligation to pay.”