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A new insurance policy from Anthem Blue Cross Blue Shield could leave doctors with an impossible decision: End a surgery early or leave patients with crushing medical debt. Earlier today, after The Lever first broke this story online, Connecticut’s State Comptroller announced that Anthem’s new policy would not take effect in Connecticut. The policy is still set to take effect in other states. Rock the boat.
Big Insurer Sets Time Limits On Anesthesia Coverage During Surgeries
By Helen Santoro
[View in browser] Editor’s Note: On Thursday, Dec. 5, following The Lever’s reporting on Wednesday, Dec. 4, Connecticut’s State Comptroller announced in a statement that Anthem’s new policy would not take effect in Connecticut, though it is still set to take effect in other states. One of the country’s largest health insurance companies says it will no longer automatically pay for patients’ anesthesia if a medical procedure takes longer than a predetermined time limit, regardless of complications or other factors that impact operation time. The new policy published last month by Anthem Blue Cross Blue Shield means patients will not know whether they’re going to be stuck with the massive bill until they wake up from surgery. The policy change will affect more than eight million people covered by Anthem’s commercial and Medicaid insurance plans in Connecticut, New York, and Missouri. “The federal government has clarified multiple times that insurers must cover the full cost of medically necessary anesthesia services” for preventative colonoscopies, according to health policy foundation KFF, and a recent federal rule aims to crack down on anesthesia-related surprise bills. However, President Trump and congressional Republicans could try to repeal such mandates. The American Society of Anesthesiologists, which represents tens of thousands of anesthesiology professionals, has called on Anthem to immediately reverse the policy. “When we first learned about this maneuver by Anthem, it was really shocking, and it came completely out of left field,” said Donald Arnold, president of the American Society of Anesthesiologists. “This is an arbitrary time limit that is being imposed on care. Nobody else has done anything like this — no government insurer or commercial insurer.”
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According to Arnold, the new “arbitrary time limit” is set by Anthem based on estimated times for physicians to perform medical services. For example, if a particular surgery is estimated to take two hours and 10 minutes, and the surgery ends up taking two hours and 12 minutes, Anthem won’t cover any of the anesthesia services provided, said Arnold. Anthem will determine the time limit for each surgery based on the Center for Medicare and Medicaid Services’ “physician work time,” or the amount of time a physician spends providing medical services. According to the policy, which will go into effect Feb. 1, 2025, an anesthesiologist’s “work time” includes everything from preparing the patient for surgery to handing them off to other providers following the operation. This coverage cap does not apply to patients under 22 years old and those seeking maternity-related care. The costs of anesthesia, which prevents patients from feeling pain and involves everything from localized numbing creams to medications that leave you unconscious, vary significantly depending on the type of procedure, the anesthesia used, and the patient’s anatomy. These costs can reach thousands of dollars and patients may be left with crushing medical bills for anesthesia services following surgeries if insurance fails to pay. Elevance Health, Anthem’s parent company, brought in more than $170 billion in revenue last year. CEO Gail Boudreaux’s total income, including her base salary, stock awards, and other compensation, was nearly $22 million. In 2018 alone, the federal health insurance program Medicare, which serves more than 65 million Americans, paid over $2 billion for anesthesia services. Private insurers, which are charged significantly more for hospital and physician services, paid about 3.5 times more than that, according to a 2020 report by the Government Accountability Office. “We at Anthem strive to make health care simpler and more affordable,” Janey Kiryluik from corporate communications at Elevance Health wrote in an email to The Lever. “One of the ways to achieve that goal is to help ensure that claims are accurately coded… we are putting safeguards and validation processes in place for how we evaluate billed time on claims for anesthesia services, using the [Center for Medicare and Medicaid Services]’ Physician Work Time values to determine the appropriate number of minutes.” “For procedures requiring more time than set or recommended by these standards, providers will be able to submit documentation for further review, as outlined in our claim-dispute process,” Kiryluik added. While it’s hard to know exactly how much Anthem will save through this new policy, “we do know that they continue to report significant increases in revenue, significant increases in profit,” said Arnold. “I think it is very fair to conclude that this maneuver has not been developed to negatively impact their profit margins.” Profits Over Patients Each year, nearly 40 million anesthetics are administered nationwide for procedures ranging from dental work to brain surgeries. Each case is individualized — even within the same procedure, different patients have unique needs depending on their age and weight, therefore requiring a higher or lower dose of anesthesia, and more or less time under sedation. These variations are some of the many reasons why the American Society of Anesthesiologists strongly opposes Anthem’s new move. In its Nov. 12 letter to Anthem, the organization claims that using the Center for Medicare and Medicaid Services’ physician work time value to determine the time cutoff and subsequent insurance reimbursement for procedures requiring anesthesia is “not an accepted, reliable, or rational method for payment,” demonstrating “Anthem’s lack of knowledge regarding how anesthesia payments are made.” The physician work time estimate is based on information that was “not developed at all for use in payment,” Arnold explained. “We have never seen this dataset before, we have asked Medicare to explain to us — how it’s developed and what it means — and we haven’t gotten an answer.” Regardless, Anthem has now used these values to set arbitrary time limits for surgeons to perform operations, Arnold said.
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“Why would Anthem [Blue Cross Blue Shield] set a time limit on covering anesthesiology time for surgeries and procedures? Is there research or data that supports the company’s policy on this matter?” Connecticut State Sen. Jeff Gordon wrote in a Nov. 20 letter to Anthem Blue Cross and Blue Shield Connecticut. “For patients, it raises the concern that profits are being prioritized over medical care.” Gordon, a practicing physician, gives the example of a woman undergoing a hysterectomy for bleeding from noncancerous tumors in her uterus. In this situation, the patient’s surgeon may make the decision to extend the surgery time to control the bleeding. Anthem’s new policy “leaves the surgeon and anesthesiologist with two options,” Gordon wrote. “1) Continue the surgery, and the patient will incur additional anesthesia charges beyond the time limit (possibly leading to crippling medical debt); or 2) Prematurely stop the surgery because of Anthem [Blue Cross Blue Shield’s] time limit.” Across the U.S., people owe at least $220 billion in medical debt, impacting nearly one in every 12 adults. Middle-aged adults and Black people are more likely to have medical debt, along with those from low- and middle-income households. This is despite the fact that more than 90 percent of the population has some form of health insurance. On Nov. 15, two weeks after Anthem published the policy for its commercial insurance plans in Connecticut, New York, and Missouri, Arnold and his colleagues spoke with Anthem officials about their concerns. Following the call, Arnold says the health insurer announced it would be extending parts of these coverage limits to its Medicaid services in these states as well. Under Medicaid, Anthem will now only cover anesthesia services that are performed within the predetermined time limits. Coverage for additional anesthesia will be denied. “We view that frankly as them doubling down on arbitrary time limits for services independent of patient needs, independent of surgeons’ needs,” said Arnold.
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