Appropriations for “appropriate” visits: Payment denials for emergency department care

Published:December 27, 2017DOI:
      Recently, several large insurers including Anthem in New York, Kentucky, and Missouri as well as Blue Cross Blue Shield (BCBS) of Georgia announced policies to deny payment for visits to the Emergency Department (ED) retrospectively deemed “inappropriate.” These policies rest on the assumption that patients are misusing EDs for low-severity conditions that are more appropriately treated in settings other than the ED that are less expensive to insurers. While the particulars of these policies are still emerging–indeed, at least one prominent insurer was unable to provide any details of their program–the concept of dissuading ED use is not new. If history is a guide, these policies are unlikely to succeed. Previous attempts, most notably in the heyday of Health Maintenance Organization (HMO) in the 1990s, were stymied by patient harm from refusal of HMOs to approve or pay for emergency care [
      • Young G.P.
      • Lowe R.A.
      Adverse outcomes of managed care gatekeeping.
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