Emergency Care Can't Stop at the Insurance Denials

— But higher volumes of denied claims harm doctors and patients alike

MedpageToday
A patient’s eye view of two healthcare workers in full protective gear

This pandemic has not been easy for emergency physicians on the front lines. I am a full-time partner in a small medical practice in Northern California, and I have seen the strain of the last 2 years push healthcare workers to the brink and drive many independent medical practices out of business. But as an emergency physician, I am committed to treating anyone, anytime, even when I am exhausted and understaffed.

Many have called emergency physicians "heroes" during this pandemic, but some insurance companies don't see us that way. In early 2020, at the height of the first COVID-19 surge in the U.S., many emergency physician groups all over California, like mine, began seeing an uptick in claims denials from Anthem Blue Cross California, the largest insurance carrier in the state.

For many of us, we're continuing to see a heightened volume of denials, which occur regardless of whether the physicians are in- or out-of-network with the insurer. In the last year alone, Anthem has refused to reimburse physicians in California for the care of thousands of patients, including treatment for those with worrisome chest pain, excruciating abdominal pain, multiple fractured ribs, and other severe emergencies.

Denying payments to physicians on the front lines during a pandemic is unethical, and the American College of Emergency Physicians (ACEP) and its California chapter are deeply concerned that these tactics may violate California law. Even worse, based on what my colleagues and I see firsthand across California, many of the groups with heightened claims denials are small, independent emergency physician groups.

These physician groups do not have the resources to fight a major corporation, and as small businesses, they are least able to absorb delays and denials of payment.

Emergency physicians are required by law to treat anyone, regardless of their insurance status or ability to pay, and Anthem is refusing to meet their responsibility to pay for the care provided. By deploying a process known as "pre-payment review," Anthem is refusing or reducing physician reimbursement, asserting the care delivered by the physician did not match the severity of the illness or injury.

Failure to reimburse emergency physicians can have consequences for patients.

With our budgets stretched so thin, my practice will be challenged to afford new supplies and equipment. We also need to hire more staff to meet the growing demand for care in our community, but we cannot. Small medical practices like mine rely on fair reimbursement from our insurers to keep our doors open 24/7.

Without immediate action, many of the smaller independent emergency physician groups affected by Anthem may be at risk of going out of business. Emergency physicians could leave the state and wait times will likely go up. The emergency healthcare safety net in these communities could unravel, severely limiting access to the lifesaving emergency care that all Californians need and deserve.

The American College of Emergency Physicians and its California chapter have jointly written to California's members of Congress to call for the state to intervene, enforce existing law, and protect the physicians who continue to give their all to serve patients on the front lines.

John Wallace, MD, president of the Independent Emergency Physicians Consortium, a group reviewing claims of defrauded physicians, said, "Emergency physicians are like David trying to fight off Goliath. When health plans don't pay the doctors, they hurt the hospitals, patients, and the community."

Anthem Blue Cross California's wrongful denying of claims needs to stop.

Policymakers and regulators must protect patients' access to emergency care and require insurers to fully compensate emergency physicians for the necessary care they deliver. An unexpected health scare can affect anyone at any time, and we must make sure that the emergency departments in our communities are there when needed.

Andrew Fenton, MD, is an emergency physician in Northern California and a member of the California chapter of the American College of Emergency Physicians.