Anthem BCBS to cap anesthesia coverage after time limits : NPR

Doctors and policymakers are sounding the alarm after one of the country’s largest health insurers announced that starting next year, in certain states, it will no longer pay for anesthesia care if the surgery or procedure goes beyond a particular time limit.

Anthem Blue Cross Blue Shield says that starting in February it will 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 submitted with reported time above the established number of minutes will only pay up to the CMS established amount,” it said in a note to New York providers earlier this week.

It is not clear which states will see the policy rolled out first. The American Society of Anesthesiologists (ASA) said the move will take effect in Connecticut, New York and Missouri. And it appears a similar notice has also been issued to providers in Colorado, with a March start date. On Wednesday, officials in Connecticut announced that following conversations with Anthem, the policy will no longer take effect in the state.

NPR has reached out to Anthem for more information.

Anthem says it will exempt maternity-related care and patients under the age of 22, and that providers can follow a process to dispute claims if they disagree with a reimbursement decision.

Even so, the backlash to the announcement was swift and has mounted this week, especially after the fatal shooting of the CEO of another health insurance company captivated social media and further cast a spotlight on the industry.

The announcement blazed a trail of fury and fear across social media, with users joking about being woken up mid-surgery and worrying about their doctors having to rush through procedures. Others, however, say that standardizing anesthesiologists’ pay at a fixed rate is actually beneficial for patients who might otherwise get overcharged — which is the argument Anthem is also making.

Anesthesiologists accuse Anthem of putting profits over patients

In mid-November, the ASA issued a statement calling the policy a “cynical money grab” and urging Anthem to reverse it immediately.

“This egregious policy breaks the trust between Anthem and its policyholders who expect their health insurer to pay physicians for the entirety of the care they need,” said ASA president Dr. Donald Arnold.

Payment for anesthesia services is based on multiple factors, the society explained, including the exact amount of time needed for anesthesiologists to deliver care before, during and immediately after an operation.

The ASA says that by “arbitrarily” determining the time allotted for anesthesia care during a procedure, Anthem “will not pay anesthesiologists for delivering safe and effective care to patients who may need extra attention because their surgery is difficult, unusual or because a complication arises.”

That would leave patients to shoulder the out-of-pocket costs, which could range from hundreds to thousands of dollars.

“This is just the latest in a long line of appalling behavior by commercial health insurers looking to drive their profits up at the expense of patients and physicians providing essential care,” said Arnold.

The ASA noted that Anthem — which rebranded to Elevance Health in recent years — reported a 24.12% increase in its year-over-year net income to $2.3 billion in June.

Anthem hasn’t responded to NPR’s request for comment. But in a statement provided to Connecticut’s FOX61, it characterized its decision as a way to “safeguard against potential anesthesia provider overbilling.”

“Anthem strives to help make health care simpler and more affordable,” it said. “One of the ways to achieve that goal is to help ensure that claims are accurately coded, and providers are reimbursed appropriately for the services they provide to members. Improper coding drives healthcare costs higher than they otherwise would be.”

Elected officials are getting involved, at least one successfully

The ASA is encouraging people concerned about the policy change to contact their state insurance commissioner or legislators.

And this week, as news of Anthem’s announcement spread across social media, elected officials in some affected states issued their own calls to action.

On Wednesday afternoon, Connecticut Comptroller Sean Scanlon tweeted that his office had successfully intervened.

“After hearing from people across the state about this concerning policy, my office reached out to Anthem, and I’m pleased to share this policy will no longer be going into effect here in Connecticut,” he wrote.

He wasn’t the first official from Connecticut — where Anthem is the provider of the state employee health plan — to lobby the company in recent days.

Earlier this week, Sen. Chris Murphy, D-Conn., publicly urged Anthem to reverse course immediately.

“This is appalling. Saddling patients with thousands of dollars in surprise additional medical debt,” Murphy tweeted. “And for what? Just to boost corporate profits?”

And Republican State Sen. Jeff Gordon of Connecticut — who is a practicing oncologist and hematologist — sent a letter to Connecticut Anthem Blue Cross and Blue Shield last month calling on them to reverse the decision, saying “people’s healthcare and lives depend on it.”

In the letter, Gordon requested more information about the company’s reasons for setting a time limit, including whether it is supported by any research or data.

“This policy is contrary to providing good and safe medical care for people in Connecticut and other states,” he wrote. “It could lead to avoidable adverse events and/or unnecessary bad outcomes. Why would Anthem BCBS pursue such a policy?”

Gordon reiterated that there are many reasons why a surgery or procedure could take longer than its scheduled time, including unexpected challenges.

For example, he said, if a woman is undergoing a hysterectomy for fibroid bleeding, and the surgeon decides to extend the surgery time to control bleeding, the surgeon and anesthesiologist would have to decide whether to stop because of Anthem’s policy or continue knowing the patient would have to cover the additional costs, “possibly leading to crippling medical debt.”

Anthem’s limit on anesthesia coverage “disregards these real-world medical circumstances,” he added, imploring the company to “do the right thing.”

Officials in New York are also trying to block the change from taking effect there.

Gov. Kathy Hochul, calling the decision “outrageous,” said she would “make sure New Yorkers are protected,” though did not specify how. And on Wednesday, New York State Sen. Mike Gianaris tweeted that he will introduce legislation to “prohibit this practice and protect patients who need care.”

“Ridiculous,” he wrote. “Does Anthem expect a patient to get up in the middle of a surgery and walk away?”