The exceptions include patients who:
- are sent to the ER by another provider, including an ambulance
- visit an ER between 8 p.m. Saturday and 8 a.m. Monday, or on a major holiday
- are younger than 15
- live more than 15 miles from an urgent care center
- are traveling out of state
- receive any kind of surgery
- get intravenous fluids or IV medications, or an MRI or CT scan
- have an ER visit associated with an outpatient or inpatient admission
The company said in a prepared statement, “Anthem stands by our belief that emergency rooms are an expensive place to receive routine care. The costs of treating non-emergency ailments in the ER has an impact on the cost of healthcare for consumers, employers and the health care system as a whole.”
The changes did not satisfy the American College of Emergency Physicians. "This is still a fundamentally flawed policy,” Laura Wooster, the group's associate executive director of public affairs for the American College of Emergency Physicians, told Small. “Making fixes around the edges doesn’t end this dangerous policy that’s really going to scare patients away from going to the ER or even considering going to the ER.”
Small reports, "Anthem’s program was meant to deter members from using the emergency room for illnesses or injuries that aren’t life-threatening. But critics say patients shouldn’t be forced to self-diagnose, warning that the new policies will encourage people to avoid seeking care for serious medical conditions out of fear that their claim will be denied."
Shannon Muchmore reports for HealthcareDive, "Anthem has said its program denies a small percentage of claims, but the change in policy signals the payer may be worried about the backlash, including from patients who have gone public with denied claims."