A program put forth by insurance giant Anthem has made healthcare even more complex. The program known as the Emergency Department Review (ED Review), launched in 2017, with the intent of reducing unnecessary visits to the nation’s emergency departments. The program is currently in effect in five states — Missouri, Georgia, Ohio, Kentucky and Indiana.
The idea isn’t such a bad thing, since emergency departments are sometimes misused. However, per Anthem’s policy, if a person goes to the ED with symptoms that turn out not to be life-threatening, they could be on the hook for the bill. This was the reason for starting Staunton Primary Care under the Direct Primary Care (DPC) model.
If a consumer chooses to receive care for non-emergency conditions at the ED when a more appropriate setting is available (i.e., urgent care or primary care), Anthem will request more information from the hospital and a statement from the consumer as to why they went to the ED.
Then, Anthem will review the information using the “prudent layperson standard,”and the claim might be denied as not a covered service.
The Prudent Layperson Standard, enacted by Congress in 1997, requires health insurance companies to cover visits based on the patient’s symptoms, not the final diagnosis. This means if a patient has chest pain but turns out to have a non-urgent medical condition, such as muscular pain, the insurance company must still cover the visit.
Anthem is forcing the patients to be doctors and completely disregarding federal and state laws that protect patients.
Anthem will, however, always cover ED visits under certain conditions, for example:
⚫️A consumer was directed to the emergency room by a provider.
⚫️Services were provided to a consumer under the age 15.
⚫️The consumer’s home is greater than 15 miles from an urgent care.
⚫️The visit occurred between 8:00 p.m. Saturday and 8:00 a.m. Monday or on a major holiday.
⚫️The patient received surgery, IV fluids, IV medications, an MRI or CT scan.
⚫️The patient had conditions such as chest pain, difficulty breathing, convulsions, fainting, drug overdoses, etc.
The scary part is many conditions present with similar symptoms, whether they wind up being benign or truly life-threatening. Chest pain can be a heart attack or heartburn. Abdominal pain can be appendicitis or gas. A headache can be a ruptured aneurysm or a hangover.
There are lots of reasons why patients end up going to the emergency department instead of seeing their primary care provider or going to an urgent care center. For starters, one in four patients are sent to the emergency department from another provider. This happens for a number of reasons: primary care practices already have their 15 minute slots filled; inconvenient office hours; providers not being comfortable tackling complicated conditions; same-day access to labs, imaging, specialists.
This goes back to the benefits of Direct Primary Care (DPC). Patients of Staunton Primary Care receive unrestricted access to treatment across a variety of platforms. When calling after hours, our patients can expect to talk to their own provider, Ciara Staunton, a board certified family nurse practitioner with urgent care and emergency medicine experience. Our practice allows us to develop a trusting relationship, which fosters open communication and increased compliance with medical advice, both of which have been demonstrated to lead to better health outcomes. In our DPC model, we have enough time to gather complete medical histories, perform thorough physical exams and think through challenging dilemmas. Many primary care practices can’t offer this, which is why they send their patients to the ED.
Our role at Staunton Primary Care is to keep you healthy and out of Cincinnati’s busy Emergency Departments and Urgent Cares. However, if you feel your life or health are at risk, please always go to the ED.