ANTHEM BLUE CROSS COMES TO ITS SENSES

In one of the most tone deaf, uninformed, out-of-touch with reality decisions ever made in the history of American health care, Anthem Blue Cross announced November 1 that “it would deny claims for anesthesia that exceeded time limits set by the insurer, with exceptions for maternity care and patients younger than 22 years. The policy was set to begin February 1 for commercial plans and Medicaid managed care plans in Colorado, Connecticut, New York, and Missouri.” 

That means that if during an operation, the patient was under anesthesia for two hours (120 minutes) and Anthem, in its infinite wisdom, thought that procedure should only require 90 minutes of anesthesia, the insurer would not pay the hospital and the doctor for the extra 30 minutes. The length of anesthesia time exceeds the determined limit and thus is not reimbursed. That’s like going to the grocery, picking up 4 cartons of milk, but only having to pay the grocer for 3 of them. The grocer essentially, out of the goodness of his heart, gives the customer a free bottle. 

This short-changing on payment is not a new phenomenon, however. For over 30, maybe even 40, years, Medicare has paid doctors an “allowed amount” for every charge they submit. That’s the amount the government, disguised as an insurance payer, will reimburse a doctor for the service provided. For example: say for a level 4 office visit (CPT code 99214), the doctor’s fee is $200. However, Medicare has determined that 99214 is worth only $84.75. That is the “allowed amount.” So, the allowed amount for a $200 fee is only $84.75. That’s what Medicare says they will pay the doctor for 99214. Ah! Not so fast, Kimosabe! Mr. Medicare only pays the doctor 80% of the allowed amount! Yes, that’s right. The fee is further reduced by 20%. So, now, for our $200 charge, instead of $84.75, the doctor will receive $67.80. The remaining $132.20 is written off. If the patient has a Medicare supplement policy, some of that write-off may be paid by the insurer. 

Besides the insurance company’s desire to increase profits at the expense of the hospital and the doctor, their inability to understand the variables that affect the length of a surgical procedure, and thus the length of time needed for anesthesia, is appalling. The time needed for anesthesia is not controlled by the anesthesiologist. It is solely determined by the degree of complexity of the operation, the severity of the patient’s problem, and the technical expertise and skill of the surgeon. No two hernia operations take the same amount of time. No two splenectomies take the same time, either. There are an infinite number of possible scenarios/complications that can occur during a surgical procedure. “The case lasts as long as the surgeon needs to finish the procedure.” For an insurance company to be so naive, or plain ignorant, and not consider that, means the folks at Anthem making these policy decisions are terribly uninformed. Or their greed has biased their judgement.

Reaction to this policy decision was swift and vocal. Anesthesiology groups and lobbying organizations were joined by “intense public outcry,” and made their opinion well known. The appearance of making bad decisions, the inability to grasp the reality of surgical anesthesia, and placing money/profit above patient safety served to “publicly shame” Anthem officials and led them, finally, to rescind the policy. One American Society of Anesthesiologists official stated, “We are very happy to have nipped this in the bud.” 

Nip it they did! They successfully protected their turf. What other limitations will Anthem set? What other procedure will they target? Who knows? They have to make a profit so someone needs to be the sacrificial lamb. Oh, wait! The other 1,075,960 non-anesthesiologist doctors have been “taking one for the team” since the beginning of the Resource-Based-Relative-Value System and the ever-declining Medicare Conversion factor, forty years ago. The AMA, AAFP, ACS, ABIM, and every other physician lobbying group tried to nip that in the bud, too, but failed miserably. Oh, well, everybody knows doctors……….. (choose your own aspersion).

Reference: Ault A. Anthem Reverses Course on Anesthesia Time Limits Medscape Medical News—Business of Medicine 2024 December 6.