Stanton says the problem is Anthem’s method of reviewing emergency department cases, often basing its denial solely on diagnostic ICD-10 codes instead of medical records. While providers can appeal, it’s only at that point that Anthem will request to review the patient’s records. Large providers experience so many denials that it costs them more to appeal than to simply pass along the cost to the patient or chalk it up to uncompensated care, but smaller hospitals can be put in financial jeopardy by accumulating so much bad debt.

Says Stanton in the report, “If we don’t fight and the patient doesn’t fight, then Anthem wins. They’re just seeing how many balls they can throw and we’re going to watch go by without taking a swing at them. So far they’re doing pretty good.”

Stanton also fears patients will self-diagnose for fear Anthem won’t cover emergency room treatment, saying, “Unfortunately, we’re going to end up having to send them coroner reports on things that were not evaluated because the patient didn’t want to go the ER because they assumed Anthem wouldn’t cover it.”

According to the report, Anthem has said in the past that its decision to implement the policy had to do with increases it has experienced in claims for non-emergent ED visits in those states.

The policy doesn’t affect Anthem’s Medicare patients, only commercial plan members.

In a letter sent to Anthem’s CEO, McCaskill said the policy raised “serious concerns” about whether Anthem was in violation of state and federal laws that require insurance coverage be based on a patient’s symptoms, not the final diagnosis.

McCaskill has asked for all internal correspondence related to Anthem’s decision to institute its policy, as well as any presentations to senior corporate management or government entities regarding emergency care utilization.

Other documents she’s asked for are any complaint Anthem has received from any entity related to its emergency care coverage in Georgia, Kentucky and Missouri, communications the insurer received from hospitals about the policy, documentation related to the potential cost savings expected from the policy change and any documents detailing possible exceptions to the policy.

Anthem plans to expand the policy to Indiana, New Hampshire and Ohio as of January 1.