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Policy Denying Coverage for Nonemergent ED Visits Imprecise

Of the visits meeting criteria for denial of coverage, 39.7 percent received ED-level care

emergency room sign

TUESDAY, Oct. 23, 2018 (HealthDay News) -- A policy retrospectively denying insurance coverage if an emergency department discharge diagnosis is determined to be nonemergent is not associated with accurate identification of unnecessary emergency department visits, according to a study published online Oct. 19 in JAMA Network Open.

Shih-Chuan Chou, M.D., M.P.H., from Brigham and Women's Hospital in Boston, and colleagues conducted a cross-sectional analysis of probability-sampled emergency department visits from the nationally representative National Hospital Ambulatory Medical Care Survey ED subsample. Visits with emergency department discharge diagnoses defined by Anthem's policy as nonemergent and therefore subject to possible denial of coverage were categorized as denial diagnosis visits. The primary presenting symptoms of these visits were identified.

The researchers found that 15.7 percent of commercially insured adult emergency department visits were denial diagnosis visits. Of these, 39.7 percent received emergency department-level care: 24.5 and 26 percent were initially triaged as urgent or emergent and received two or more diagnostic tests, respectively. The denial diagnosis visits shared the same presenting symptoms as 87.9 percent of commercially insured adult emergency department visits. Of the visits with denial symptoms, 65.1 percent received emergency department-level care: 43.2, 51.9, and 9.7 percent, respectively, were triaged as urgent or emergent, received two or more diagnostic tests, and were admitted or transferred.

"Our results demonstrate the inaccuracy of such a policy in identifying unnecessary emergency department visits," the authors write. "Furthermore, patients cannot reliably avoid coverage denial as most presenting symptoms could potentially lead to a non-emergent diagnosis."

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