Insurers Spark Blowback by Reducing Emergency Room Coverage

June 12, 2018 | By Renuka Rayasam and Paul Demko | Politico

Health plans intent on driving down costs are zeroing in on emergency room visits — one of the biggest drivers of medical inflation but a category of care that’s seldom been subject to denials.

Anthem, the country’s largest Blue Cross Blue Shield plan, shook the market last year by refusing to pay for some ER visits it deemed unnecessary, triggering heated battles with hospitals and doctors and fueling a broader debate over whether patients can find less expensive settings without putting their health at risk.

Since then, Blue Cross Blue Shield of Texas has adopted a similar policy limited to patients with HMO plans at out-of-network hospitals. And UnitedHealth Group, the country’s largest insurer, is using its own methodology to scrutinize if hospitals are charging too much for emergency care. If it concludes they are, UnitedHealth won’t cover the full amount of the claim.

“Many insures are watching what the big dogs are doing, and there would be interest” in taking similar steps, said Fred Bentley, a vice president at the consulting firm Avalere Health.

Hospitals and doctors are livid about the trend, and in some cases taking insurers to court, arguing the companies are potentially putting patients at risk in order to pad their profits.

“I don’t think it’s a good idea to tell people, ‘If you go to an emergency room, I will decide later whether to pay or not,’” said Texas Medical Association president Douglas Curran.

The dust-ups have grabbed the attention of some in Congress. Sen. Claire McCaskill (D-Mo.) and Ben Cardin (D-Md.) in March sent a letter to HHS Secretary Alex Azar and Labor Secretary Alexander Acosta asking them to look into whether Anthem’s new policy violates federal law.

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