By: David Ostrowsky
Earlier this month, as the healthcare industry was receiving an inordinate amount of unwanted public attention and scrutiny, there was actually a positive development stemming from one of the country’s largest health insurers. Indeed, lost in the shuffle amidst the chaotic aftermath of the murder of UnitedHealthcare CEO Brian Thompson was Anthem Blue Cross Blue Shield’s reversal of its initial decision to stop paying for anesthesia care in certain states if the surgery or procedure extends beyond a particular time limit. Had such a titan of the health insurance industry proceeded in not paying for medically necessary anesthesia services, tens of thousands of Americans – many of whom are of limited financial means -- would have been at risk of getting cut off from a life-saving service.
On November 1, Elevance Health, which recently rebranded from Anthem Blue Cross Blue Shield, issued a news release detailing its proposed billing guidelines changes for Connecticut, New York, and Missouri whereby starting this February, time limits pre-set by the insurer would have dictated the amount of anesthesia care to be covered. It also appears that a similar note had been issued to providers in Colorado, with a March start date.
More specifically, Anthem had said that beginning in February it would use metrics — known as Physician Work Time values — from the Centers for Medicare and Medicaid Services (CMS) to “target the number of minutes reported for anesthesia services.” Claims for anesthesia care stretching beyond that set number of minutes would be denied. In more layperson terms, if a patient’s procedure ran longer than anticipated, well, there would be a no-pun-intended rude awakening as they’d be left to foot the unexpected bill.
In fairness, Anthem declared it would exempt maternity-related care and patients under the age of 22 from this new rule and that providers could have recourse to dispute claims if they disagreed with a reimbursement decision. Meanwhile, there was a belief among some that Anthem’s intention was not to create an undue financial burden for patients but rather to hold providers accountable by standardizing anesthesiologists’ pay at a set rate.
“Anthem’s policy would not have increased costs for their enrollees,” opined Eric Levitz, a senior correspondent at Vox in a December 6 article. “Rather, it would have reduced payments for some of the most overpaid physicians in America. And when millionaire doctors beat back cost controls — as they have here — patients pay the price through higher premiums.
“Anesthesia services are billed partially on the basis of how long a procedure takes. This creates an incentive for anesthesiologists to err on the side of exaggerating how long their services were required during an operation. And a few studies have found that a small portion of anesthesiologists may engage in overbilling by overstating the length of a procedure, or the degree of risk a patient faces in undergoing anesthesia.”
But regardless of the actual motive, the optics were not favorable and the public backlash to Anthem’s announcement was, as expected, intense. In addition to the American Society of Anesthesiologists (ASA), many politicians articulated strong frustration over some commercial health insurers seeking to boost their profits at the expense of patients’ welfare – a sentiment that many Americans surely feel at this hour. New York governor Kathy Hochul was not shy about expressing her outrage at the proposal. Meanwhile, in Connecticut (where Anthem is the provider of the state employee health plan) multiple public officials lobbied the insurance carrier to alter its decision. While US Senator Chris Murphy called on Anthem to take swift action and reverse course, State Senator Jeff Gordon, a practicing oncologist and hematologist who knows full well that a surgery or procedure can face unforeseen challenges and take longer than originally planned for, sent a letter to Connecticut Anthem Blue Cross and Blue Shield urging them to follow suit, claiming “people's healthcare and lives depend on it.” Though it’s hard to fathom that a surgeon and anesthesiologist would ever contemplate truncating a surgery prematurely, the prospect of an unsuspecting patient being saddled with a mountain of medical debt – which is after all, the leading driver of homelessness in America -- is unnerving.
But now, thanks to Anthem doing an about-face, that situation is no longer an impending reality.