Is Anthem’s ER policy legal? Health executives want state insurance director to weigh in

A few health care industry executives have sent a letter to Missouri’s insurance director, asking her to take a “hard and earnest look” at Anthem’s emergency room policy and whether it is legal.This summer, Anthem began warning members that if they were to go to the ER for a minor ailment, then the patients would be stuck with the entire bill. Anthem said it would no longer cover emergency visits for such ailments as the common cold amid what Anthem said is an increasing trend of unnecessary ER visits by its members.“We think this policy is unfair to policyholders, and downright dangerous for patients,” according to a letter dated July 27 and addressed to Insurance Director Chlora Lindley-Myers.The letter was signed by Herb Kuhn, CEO of the Missouri Hospital Association; Dr. Jonathan Heidt, president of the Missouri College of Emergency Physicians; Brian Bowles, executive director of the Missouri Association of Osteopathic Physicians and Surgeons; and Thomas Holloway, executive vice president of the Missouri State Medical Association.The signers allege that Anthem’s policy violates the “prudent layperson” standard. In other words, there are legal protections for people with limited medical knowledge who need what they believe is immediate care.That standard is “critically important,” the letter said. “Is that chest pain just unwelcome indigestion, or is it a life-threatening cardiac event?”The letter calls the policy by Anthem a way to shift costs from the insurer to the patient and says it will have a “chilling effect” on patients who will forgo care, worried they may be on the hook for the entire bill.Holloway, one of the authors, said he’s hoping for a sit-down with the insurance director.A spokesman for the Department of Insurance did not respond to a request for comment.Anthem has said the policy is more nuanced and has exceptions, such as chest pain. A member who ultimately has indigestion and not an actual heart attack will not be financially responsible for the entire visit.Also, ER visits for children under the age of 14 will always be covered regardless of the reason for the visit.Dr. Jay Moore, senior clinical director at Anthem, said his organization met with the Missouri Hospital Association, including its director Herb Kuhn, and other groups that signed the letter before the policy took effect to try to be as open as possible about the policy change.“This is the first we heard they were not comfortable with this program,” Moore said. “I don’t know how we could be more transparent or open.”Anthem also previously told the Department of Insurance about its plans to notify members about the enforcement of the ER policy.Business Briefing from St. Louis Post-DispatchMake it your business. Get twice-daily updates on what the St. Louis business community is talking about.

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