Anthem Blue Cross Blue Shield ER policy criticized by Ohio lawmakers

Several Democratic state lawmakers want to penalize Anthem Blue Cross Blue Shield for a new policy that does not cover some emergency room visits deemed by the insurer not to be emergencies.

Anthem, which has the majority of the market share in the Dayton area, instituted the new ER policy at the first of the year. The policy, which affects only commercial plans, has been in place in other states, according to Anthem.

Emergency room doctors have pushed back, saying patients don’t always know how serious symptoms are when they come to the ER. 

RELATED: Anthem criticized here for cutting some non-emergency ER coverage

Rep. Alicia Reece, D-Cincinnati, said at a press conference Wednesday that she and other representatives want to introduce a bill in response to Anthem’s policy.

The bill is expected to forbid state government agencies from doing business with any insurance agency with an ER policy like Anthem, under the principal that the state shouldn’t be doing business with a company that has a selective ER policy for Ohio residents with commercial insurance, Reece’s office said Friday. The bill is still being drafted, her spokesman said.

Anthem spokesman Jeff Blunt declined to comment on the proposed bill.

But in a statement Blunt said the emergency room policy was created to reduce the trend of inappropriate ER use. When insurers pay for expensive care that could have been treated at a cheaper setting, all policy holders end up paying for those costs when insurance premiums inflate to cover the costs, according to the statement.

“If a consumer feels he or she has an emergency, they should always call 911 or go to the ER,” the statement says. “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.”

Blunt said primary care physicians should always be the first medical professional patients see with any non-emergencies, and there are urgent cares, telemedicine, retail clinics and Anthem’s free 24-7 nurse lines for after-hours situations.

RELATED: Dayton Children’s plans urgent care center in Huber Heights

Reece held the press conference with Rep. Stephanie Howse, D-Cleveland, and Rep. Thomas West, D-Canton. Along with drafting a bill, Reece said the group is sending a letter to Gov. John Kasich’s administration to intervene with Anthem and any other insurer that enacts a similar policy. They also want the Attorney General to look into whether the policy is a violation of federal law.

A 2013 report in the Journal of the American Medical Association found about 6.3 percent of ER visits had a primary care treatable diagnosis. 

Reece said she is “outraged” that an insurance company is deciding whether an ER visit was necessary.

“We don’t buy insurance for the insurance company to be the doctor,” she said. “We don’t buy instance for the insurance company to be the surgeon.”

LOCAL: Premier to sell insurance business after $40M loss in 2 years

The Anthem policy does not affect Medicaid and Medicare plans. The insurer also says policyholders have the right to appeal “in the event a member’s claim is denied.”

Anthem provided a lengthy list of circumstances in which non-emergencies are covered. Among the more common ones are: If the patient was directed to the emergency room by another medical provider such as an ambulance, if the patient is in another state, if services were provided to a child under the age 15, if there isn’t an urgent care or retail clinic within 15 miles, or if the visit occurs between 8 p.m. Saturday and 8 a.m. Monday or on a major holiday.

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