Anthem retracts ‘morally abhorrent’ policy to put time limit on anesthesia during surgery
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Following backlash, Anthem Blue Cross Blue Shield stalled its policy change that would have put a time limit on coverage for anesthesiology services during surgery and other procedures in Connecticut, Missouri and New York.
The proposed policy update, set to be effective Feb. 1, 2025, would have allowed Anthem to determine the allowed allotted time for anesthesia during a surgery and would only cover care for that time period. If the procedure went beyond the Anthem-approved time, the insurer would not pay for that care.
This policy could impact countless surgeries and procedures in various fields including gastroenterology services such as colorectal surgery and endoscopic procedures. Endoscopists and gastroenterologists previously clashed with anesthesiologists over halting glucagon-like peptide-1 receptor agonist use prior to endoscopic procedures to curb the risk for regurgitation and pulmonary aspiration. The conflict established anesthesiologists as the final decisionmakers on procedure-related airway protection measures – an authority that may now be compromised by insurance company edicts.
A ‘mistake’ to not consult anesthesiologists
“There was no consultation with the anesthesiology community as they were considering this change to their payment policies, which I think was a mistake,” Gordon Morewood, MD, MBA, FASA, FASE, vice chair of the American Society of Anesthesiologists (ASA) committee on economics, told Healio.
In a statement released Nov. 14, the ASA called Anthem’s proposal an “unprecedented” decision, noting the insurance company would not pay anesthesiologists “for delivering safe and effective anesthesia care to patients who may need extra attention because their surgery is difficult, unusual or because a complication arises.”
The ASA met with the insurance company hoping to better understand the proposal. Morewood noted that although Anthem said its original goal was to decrease the amount of “fraudulent claims” for extra time reported in anesthesia billing, “the way they were going about it was completely irrational.”
“I don’t think there was any competent, knowledgeable opinion on Anthem’s side that led them to think that this change would reduce fraudulent billing practices,” he said, “nor that this would bring them closer into compliance with normal billing practices.”
According to Morewood, Anthem failed to understand how anesthesiology claims are filed and how CPT codes work. Further, start and stop times for anesthesia during surgery are decided from the medical records and billing companies.
“There’s no opportunity for anyone involved with the clinical practice of anesthesia to alter the clinical time that is being submitted associated with the anesthesia care,” he said. “They seemed completely ignorant of the fact that the anesthesia CPT codes we use are not specific to any single surgery, but each one may be associated with dozens or hundreds of different surgical procedures which require different times to complete.”
According to Anthem, the decision to no longer proceed with its plan stemmed from “misinterpretation” of the policy change first announced on Nov. 1.
In its retraction, Anthem wrote that the policy update was “only designed to clarify the appropriateness of anesthesia consistent with well-established clinical guidelines. Any medically necessary anesthesia would have been paid under the update.”
The company also noted that if anesthesiologists surpassed the clinical guidelines, they would have been able to provide medical documentation to “support accurate payment.”
‘Intrusion of business’ into medicine
Anthem’s proposal was not only strongly opposed by the ASA but also by health care providers performing surgical procedures.
“I am unable to identify any rational, logical, ethical or humane basis for a businessperson to interfere in the practice of a surgical or gastroenterological procedure,” Joshua Katz, MD, a practicing colorectal surgeon in Memphis, Tennessee, told Healio.
He added, “The imposition of arbitrary anesthetic limits interferes with the sacred relationship that physicians have with their patients — on the ward, in the endoscopy suite and in the operating room. It is a vile intrusion of business into the practice of medicine and is morally abhorrent.”
Katz noted that while there may be variation in procedure duration, that can be assessed on a case-by-case basis and by peer review and should not be decided by an insurance company.
Time limits would not only deny anesthesiologists payment for complications that may arise during surgery, but it also forces surgeons, anesthesiologists and gastroenterologists to “assume risk and liability for a complex procedure” without being compensated, Katz said.
Despite Anthem’s claims that physicians can appeal caps on anesthesia care time, Katz said it will only create “deliberate” administrative burden to discourage clinicians from appealing. The proposed policy change would “completely change” surgery, he added.
“If we are placed on a time clock, it will hurt everyone,” Katz said. “Mostly it will hurt the patients, because it will place a burden on our back that will inevitably affect our judgment and our practice.”
Katz urges those in the insurance industry to “stop making decisions without physician and clinician input” and allow providers to educate them on “issues that pertain to the health, safety and well-being of our patients.”
References:
- Anthem Blue Cross Blue Shield won’t pay for the complete duration of anesthesia for patients’ surgical procedures. https://www.asahq.org/about-asa/newsroom/news-releases/2024/11/anthem-blue-cross-blue-shield-will-not-pay-complete-duration-of-anesthesia-for-surgical-procedures. Published Nov. 14, 2024. Accessed Dec. 6, 2024.
- Update to anesthesia billed time units policy. https://providernews.anthem.com/connecticut/articles/update-to-anesthesia-billed-time-units-policy-23311. Published Dec. 5, 2024. Accessed Dec. 6, 2024.
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