A new law set to take effect in Missouri is meant to counteract a controversial emergency room policy by insurance company Anthem Blue Cross Blue Shield.

Anthem launched its avoidable ER program in July 2017 to cut down on costly emergency room claims it contends are a driver of high premium prices.

Under the policy, the company denies claims when a consumer goes to an emergency room for an ailment Anthem considers not to be an emergency.  The insurer began enforcing the program in July 2017 in Missouri and Georgia, which resulted in a spike in claim denials.

Dave Dillon, the spokesperson for the Missouri Hospital Association, says some of Anthem’s denials have risen to the level of absurdity.

“We had seen people who had been hit by a car, or were in a car accident, were rejected,” said Dillon.   “We had an experience where people were sent from an urgent center that was immediately across the street from a hospital to the hospital and the claim was rejected.  These things were frankly, in light of the situation, ridiculous.”

Missouri’s Democratic Senator Claire McCaskill called for a full review of Anthem practice to deny emergency room coverage.  In December 2017 she wrote a letter to the company, saying it was forcing people to self-diagnose themselves and scaring them away from seeking medical care.

“Patients are not physicians,” said McCaskill.  “I am concerned that Anthem is requiring its patients to act as medical professionals when they are experiencing urgent medical events. Missouri state law and federal law protects patients from having to make these types of medical decisions… Anthem’s policies are discouraging individuals from receiving needed care and treatment out of fear they may personally be fully financially responsible for the cost of treatment, even though they have insurance.”

Republican State Senator Paul Wieland of Imperial sponsored the legislation that creates the new law.  He says it clarifies the state’s “prudent layperson standard”, which already requires health insurance companies to cover visits based on a patient’s symptoms, not just the final diagnosis.

“The bill adds eight words, and it just says, ‘regardless of the final diagnosis given’,” said Weiland.  “So, what this reinforces is that the coverage decision on whether or not the emergency claim will be covered has to do with looking at the front end and not the back end.”

Scott Golden is a spokesperson for Anthem in Missouri.  He says the company’s policy is meant to make health care more affordable by encouraging consumers to receive care in the most appropriate setting.

“Anthem’s avoidable ER program aims to reduce the trend in recent years of inappropriate use of ERs for non-emergencies as the costs of treating non-emergency ailments in the ER has an impact on the cost of healthcare for consumers, employers and the healthcare system as a whole,” said Golden.

A sampling of emergency room bills analyzed by the American College of Emergency Physicians showed that Anthem denied thousands of claims last year under the avoidable E.R. program.

The New York Times reported that emergency room physicians said the company did not routinely request medical records for denied patients, and therefore could not review the symptoms that brought them to the emergency room.  Anthem’s Golden says the company has procedures in place in Missouri that eliminate such oversights.

“If a consumer chooses to receive care for non-emergency ailments at the ER when a more appropriate setting is available, an Anthem medical director will review the claim information and medical records using the prudent layperson standard,” Golden said.  “In the event a member’s claim is denied, they have the right to appeal.”

The prudent layperson standard was made federal law in 1997 as part of the Balanced Budget Act, and it was renewed in the Affordable Care Act. Golden says Anthem is abiding by the new Missouri law’s specific execution of the standard.

“Anthem’s avoidable ER program complies with the recently passed Missouri legislation (SB 982) and we will continue to make enhancements to effectively implement the program.”

Another provision of the new law requires that if an insurance company rejects a claim, it must have a board-certified emergency physician review the denial.

Dillon with the Missouri Hospital Association says the stipulation will ensure proper decisions are made.  “If for example the claim is rejected and the doctor for the insurance company is a podiatrist, and may not be an expert on emergency medicine, that could create some room for rejections that are outside of the scope of the expertise of the physician,” said Dillon.

He notes that the Missouri Hospital Association is joined in opposing Anthem’s avoidable ER program by the American College of Emergency Physicians, the Missouri Medical Association, and the American Heart Association.

Former Governor Eric Greitens signed the new law on his last day in office June 1st.