Ingrown Nail? Mild Sprain? Anthem Says Avoid the ER, or Prepare to Pay Up

Nov 14, 2017

Anthem is planning to get tougher about covering ER visits for ailments that could be treated outside of an emergency room.

The New Hampshire Insurance Department said Anthem recently proposed a list of 14 categories of non-emergency services it will deny (with some exceptions) when delivered in an emergency room setting. The proposed list include ingrown nails, pregnancy tests, eyelid disorders, high blood pressure checks, constipation, mild sprains and contusions, rashes, dental disorders, plantar warts and general medical exams.

Also included on the list of proposed services to deny in ER settings were the removal of sutures and the issuance of repeat prescriptions.

The insurance department said Anthem indicated that it would still cover the above services for patients under age 14. The company’s proposal does not require prior state approval, but the insurance department still plans to monitor its implementation to make sure customers’ rights aren’t being violated.

This move to deny coverage for certain kinds of treatment in the ER is part of a broader effort from the state’s largest insurer to curb unnecessary ER use. Anthem also recently issued guidance to hospitals across the state reminding them of the company’s policy against covering non-emergency services in emergency rooms.

John Marzinzik, CEO of Frisbie Memorial Hospital in Rochester, said he welcomes the company’s efforts to steer patients away from relying on emergency care when it’s not really needed. Too often, he says his emergency department treats people who use it “as a primary care office or walk-in center for convenience.”

“I personally believe that patients are always responsible for their own decisions,” Marzinzik said. “And if they elect to go to the ER when they’re talking about a bad cold or a sinus infection or a bad rash on their arm that could wait to go to a lesser setting the next day — well, you know, it may be uncomfortable for the night but I think those decisions are made by the individual.”

Marzinzik said he understands that in certain situations, the ER is someone’s only option. But generally, he said patients should turn to their primary care providers, many of whom have on-call physicians who can answer questions about symptoms without a trip to the hospital, or urgent care clinics as a first line of defense.

But Anthem’s renewed emphasis on enforcing ER coverage has drawn criticism from other local doctors.

Dr. David Heller, the medical director of Portsmouth Regional Hospital’s emergency department, told Seacoast Online he was concerned this would steer people away from seeking care for seemingly mild symptoms that could be the sign of something more serious.

“People cannot be afraid to go to the hospital,” Heller said. “I am mortified by this. If a person has a rash, it could be less serious, but it could be indicative of Stevens-Johnson syndrome, meningococcemia, Kawasaki’s disease, toxic shock syndrome. I could go on. These are all rashes that are indicative of conditions that can kill you if not properly identified and treated quickly. This is a very bad move on the part of Anthem.”

Anthem spokesman Colin Manning said the insurer has been telling customers for years that “non emergency care received in [an] emergency room” might not be covered under their policies.

“Most people would agree emergency rooms should be focused on providing care to those suffering from emergency situations,” Manning wrote in an email. “This is not a new area of focus for Anthem. For years, our certificate of coverage – which explains to the member which services are covered – has stated that claims for inappropriate use of emergency rooms may be reviewed and could be denied.”

Manning said Anthem will still evaluate each patient’s claim on a case-by-case basis and won't deny coverage if someone had a legitimate reason to believe their symptoms could be an emergency.

So, for example, if someone shows up in the ER with chest pain that turns out to be heartburn — but they thought it was something more serious, like a heart attack — Manning says that would still be covered.