COLUMBUS (WCMH) — Recent changes to an Anthem Blue Cross and Blue Shield program has caused consternation among Ohio lawmakers.
Anthem has decided to make a significant change to their ER program. According to Jeff Blunt, a spokesman for the company here in Ohio:
Anthem’s goal is to ensure access to high quality, affordable health care, and one of the ways to help achieve that goal is to encourage consumers to receive care in the most appropriate setting. Anthem’s ER program aims to reduce the trend in recent years of inappropriate use of ERs for non-emergencies. If a consumer feels he or she has an emergency they should always call 911 or go to the ER. But for non-emergency health care needs, ERs are often a time-consuming place to receive care and in many instances 10 times higher in cost than urgent care.
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 submitted by the provider using the prudent layperson standard. In the event a member’s claim is denied, they have the right to appeal.
Anthem has, and will continue to make, enhancements to our ER program to ensure effective implementation.
State Representative Alicia Reece says this is a dangerous change that opens the door for people to make decisions based on the fear of paying for a bill they can’t afford over the care they may need; and the consequences of that decision could be fatal.
“This is a quiet storm that’s sneaking up on Ohio like a heart attack sneaks up on an individual,” said Reece, describing the lack of knowledge her constituents, and others in Ohio, had of the change.
State Representative Thomas West agreed with Reece that this is not how he expects health insurers to conduct business in Ohio.
“These are the most vulnerable times of your life, and then you find out later that the insurance company’s not going to pay. We have a problem with that,” said West.
According to Anthem it will pay for some non-emergency care if a client goes to the ER, and they provided this list of instances:
- The consumer was directed to the emergency room by a provider (including an ambulance provider)
- Services were provided to a consumer under the age 15
- The consumer’s home address is more than 15 miles from an urgent care center
- The visit occurs between 8:00 PM Saturday and 8:00 AM Monday or on a major holiday*
- The consumer is traveling out of state
- The consumer received any kind of surgery
- The consumer received IV fluids or IV medications
- The consumer received an MRI or CT scan
- The visit was billed as urgent care
- The ER visit is associated with an outpatient or inpatient admission
*Major holidays include New Year’s Day, Martin Luther King Day, President’s Day, Memorial Day, Independence Day, Labor Day, Columbus Day, Veterans Day, Thanksgiving Day and Christmas.
Anthem also says they will continue to review this list and may expand it.
Reece says her legislation is still being drafted but she would like it to include provisions that would deny Anthem, or any health insurer who refused to pay for services at the ER, access to tax credits and government contracts with the State, Counties, and Cities of Ohio.
She wants to send a strong message that Ohio will not stand for these kinds of business practices and has sent a letter to Governor Kasich seeking his assistance in this matter as well.