Written by Andy Selesnick
Chair of Health Care Litigation at Buchalter
Health insurance companies spend tremendous amounts of time, energy, and money to create policies that result in them not paying providers. For both in and out-of-network emergency physicians, Anthem’s latest is something else.
Over a year ago, Anthem’s Special Investigative Unit (SIU) began looking at emergency physician E&M codes and did not like what it saw. Using what some suspect is an algorithm, the SIU began targeting multiple groups who were billing Level 5s (CPT Code 99285), where there was no admission to the hospital, and within a certain subset of diagnosis codes. Anthem’s SIU would place the groups on prepayment review, requiring them to send in medical records for every Level 5. Anthem would then have a non-emergency physician coder review the claims, and using a policy that is not entirely known, would “freeze” those Level 5 claims with no admission to the hospital. In the past, if Anthem disagreed with a code, it would simply downcode or deny. But now, Anthem decided to pend the claims, effectively neither denying it nor paying it (or any part of it).
What does this mean for the affected groups? Despite the law that requires Anthem to reimburse emergency services, Anthem has refused to do so. Instead, its position is that the emergency physician has to re-bill the claim at a Level 4 (or Level 3) in order to have the claim, and any ancillary codes, paid. This is despite the fact that the documentation supports a Level 5. With a claim that is frozen, the emergency physician not only is not reimbursed even what Anthem thinks is appropriate, but also can’t bill the patient for their co-pay or deductible, because Anthem won’t disclose it.
Anthem’s policy is being applied both in and out of network and means that Anthem won’t reimburse the claim unless it is coded to Anthem’s satisfaction, regardless of what the documentation supports. Many groups are now facing claims that are running $30,000-50,000 or more per month in zero payments.
Many people believe that this policy is illegal, and if left unchallenged, will be adopted by other payers who care little about the impact on staffing and the safety net reduced revenue causes. Multiple groups – including some who are in IEPC – have joined together to fight this practice, filing a lawsuit in California Superior Court seeking an injunction to stop the practice, reimbursement of amounts owed, and punitive damages for Anthem’s interfering with the right to collect co-pays and deductibles from the patients. If you have been impacted by this policy, please feel free to reach out to Andy Selesnick at firstname.lastname@example.org.