The CMA is calling for an investigation of Anthem Blue Cross after the company quietly pulls coverage for intravenous anesthesia during cataract surgery, calling it “unnecessary”.
Over the holidays at the end of December 2017, Anthem Blue Cross quietly changed their guidelines in a seemingly small matter regarding cataract surgery. However, the ramifications and implications of their decision has profound real life consequences for many Californians. In a move almost certainly designed to improve their profit margins, Anthem is now claiming that intravenous (IV) anesthesia for cataract surgery is not medically necessary — which means that patients who want it will need to pay out of their own pocket.
Unsurprisingly, the California Medical Association (CMA) and many prominent physicians disagree strongly with the judgement made by Anthem. It is the stance of many of these doctors that IV anesthesia is absolutely medically necessary to perform cataract surgery on many patients. In fact, they say, patients can experience serious consequences if they interfere with the surgery in process due to a less powerful anesthetic being used… including blindness.
And that’s just the patient care angle when it comes to this matter. It’s probably illegal as well, as the CMA notes that “California law… requires health plans to prove that medical decisions are rendered by qualified medical providers.” In this matter, that’s simply not the case, and a decision is being made to save Anthem money at the expense of patient rights and safety. That’s absolutely unacceptable, but it’s symptomatic of the larger, systemic problems that exist in our healthcare system in America.
It’s more important than ever that doctors take a pragmatic approach with their patients that addresses the financial aspects of their care in great detail. An Anthem patient who isn’t aware of the new guidelines on cataract surgery might end up accruing a financially devastating medical bill if they’re not informed of the change. Or, they might be aware of the lack of coverage, but feel unsure of their options.
The patient does in fact have a path to go down in these cases: filing an IMR (independent medical review) with the regulator. This mechanism is meant to look at patients’ IV anesthesia necessity on a case-by-case basis and determine in which instances the IV is actually necessary. Taking this decision out of the hands of the attending physician and putting it in the hands of an insurance billing regulator is a travesty, and a scenario where everyone loses.
At Urgent 9, we’ll continue to structure our practices to keep you, our patient, aware of all your options at all times. We offer innovative pricing models at our urgent care center in the hopes that our patients never find themselves in a situation like the one Anthem is putting thousands of people in with this transparently profit-driven policy reversal.