11 In an Emergency, Get Fined for Being Fine: Accuracy and Insurance Policy to Retrospectively Deny Emergency Department Coverage Based on Discharge Diagnoses

Abstract

Public and commercial insurers have increasingly sought ways to reduce emergency department (ED) visits. Anthem Inc., a large national insurer that covers 1 in 8 Americans, recently began denying coverage for ED visits if the final visit diagnosis was among a pre-specified list of “non-emergent” diagnoses. The insurer implemented this policy in 6 states and is expanding to others. We examine the impact to ED patients if all commercial insurers adopt similar policies of retroactive coverage denial for emergency care. We performed a cross-sectional, stratified analysis of a nationally representative sample of ED visits from the 2011-2015 National Hospital Ambulatory Medical Care Survey ED sub-sample. We included ED visits by patients aged 15 to 64 years with commercial insurance and classified them into 3 non-exclusive cohorts for stratified analysis (Figure). First, “policy visits” were the ED visits with a “non-emergent” diagnosis in accordance with Anthem’s policy. Second, “denial visits” were the subset of policy visits that could be denied coverage after we applied the exclusion criteria specified by the insurer, such as hospital admission. Third, “denial-associated complaint visits” were the ED visits with the same presenting chief complaints as the denial visits. Between 2011 and 2015, 21.9% (95% confidence interval [CI] 20.9-22.9) of all U.S. ED visits, representing 29.6 million visits annually, were made by commercially insured adults. Of these ED visits, 34.0% (95% CI 32.9-35.0), or 10.1 million (95% CI 8.8-11.3) visits annually, were policy visits, of which 35.5% (95% CI 32.4-38.7) were triaged as urgent or emergent, 42.9% (95% CI 40.8-45.0) received 2 or more diagnostic tests, and 5.4% (95% CI 4.6-6.2) were hospitalized or transferred. After applying exclusion criteria to policy visits, 15.7% (95% [CI] 15.0-16.4) of all included ED visits remained as denial visits, representing 4.6 million (95% CI 4.1-5.2) visits annually, of which 24.5% (95% CI 21.7-27.4) were initially triaged as urgent or emergent and 26.0% (95% CI 23.8-28.3) received 2 or more diagnostic tests. These denial visits had the same presenting chief complaints as 87.9% (95% CI 87.3-88.4) of all U.S. commercially insured adult ED visits, representing 26.0 million (95% CI 23.1-28.9) denial-associated complaint visits annually. Of these visits, 43.2% (95% CI 40.2-46.4) were triaged as urgent or emergent, 51.9% (95% CI 50.0-53.9) received 2 or more diagnostic tests, and 9.7% (95% CI 8.8-10.6) were hospitalized or transferred. “Non-emergent” diagnoses correlate poorly with visit severity and the need for multiple diagnostic testing and hospital care. Furthermore, since patients present with symptoms, not diagnoses, nearly 9 in 10 ED patients may be at risk of coverage denial for their ED care. If commercial insurers begin adopting similar policies and retrospectively deny coverage for ED visits using discharge diagnoses, patients will be forced to weigh the odds of foregoing potentially necessary care against the risk of facing significant financial burden if they guessed wrong.