Becker's Hospital Review

23 CFO / FINANCE Anthem's Discretionary ED Policy Lands Patient With $12k Bill: 8 Things to Know By Morgan Haefner A Kentucky resident received a $12,596 bill from Frankfort (K.Y.) Regional Medical Center aer her insurer, An- them, deemed her trip to the hospital's emergen- cy department nonemergent, according to Vox. Here are eight things to know about the bill. 1. Brittany Cloyd went to Frankfort Regional's ED July 21, 2017, aer experiencing increas- ing pain on the right side of her stomach. She feared her appendix had ruptured. 2. ED physicians at Frankfort Regional ad- ministered several tests, including an ultra- sound and CT scan, to determine the problem. Physicians diagnosed Ms. Cloyd with ovarian cysts and not appendicitis, prescribing Ms. Cloyd pain medication and a follow-up with a gynecologist. 3. Frankfort Regional billed Ms. Cloyd for $12,596 a few weeks later aer Anthem de- nied the hospital's claim. 4. Across six states — Missouri, Georiga, Ken- tucky, Indiana, New Hampshire and Ohio — Anthem has recently decided to stop covering emergency department visits it deems unnec- essary for policyholders. e policy, which has several exceptions, aims to steer Anthem members with nonemergent ailments toward a primary care physician or an urgent care provider instead of costly ED visits. 5. Anthem uses a list of diagnostic codes to identify nonemergent visits to the ED. How- ever, Vox notes Anthem's denials are based on physician diagnoses, not the symptoms pa- tients present to the ED — such as Ms. Cloyd's intense stomach pain. 6. Anthem, which covers 40 million-plus members, initially said it would speak with Vox about Ms. Cloyd's situation. Anthem later declined an interview and gave the fol- lowing statement: "Anthem's goal is to ensure access to high-quality, affordable health care, and one of the ways to help achieve that goal is to en- courage consumers to receive care in the most appropriate setting." 7. Following Vox's interchange with Anthem — and two appeals from Ms. Cloyd — An- them reversed its decision to not cover the bill. "We deeply regret if we caused Ms. Cloyd any concern," Anthem told Vox. "Anthem has made, and will continue to make, enhance- ments to our ER program to ensure more effective implementation of this program on behalf of consumers." 8. Several groups, including the American College of Emergency Physicians, have criti- cized Anthem's discretionary ED policy and even questioned its legality. n Aetna Grows Profit by 75.5% in Q4: 3 Things to Know By Morgan Haefner A etna recorded a 75.5 percent increase in fourth quarter profit in 2017 despite revenue declines. Here are three things to know about the payer's results. 1. Aetna, which is slated to be acquired by CVS Health for $69 billion, posted net income of $244 million in the fourth quarter ended Dec. 31, 2017. That's up from $139 million recorded in the same period the year prior. Aetna primarily attributed the increase to low- er restructuring and transaction costs and continued growth in its government business. 2. In the fourth quarter of 2017, Aetna cut its expenses by 7.3 percent year over year to $14.3 billion. At the same time, Aetna saw revenue fall 5.6 percent year over year to $14.9 billion. The insurer said the decrease was primarily due to lower premiums in Aetna's health- care segment because of its decision to exit the ACA individual marketplaces in 2017. 3. Aetna's full-year net income took a hit from the ter- mination of its merger with Humana. Aetna posted full- year net income of $1.9 billion for 2017, compared to $2.3 billion a year prior. n Stanford Health Care's Operating Income More Than Doubles in Q1 By Ayla Ellison S tanford (Calif.) Health Care saw revenues and operating income rise in the first quarter of fiscal year 2018, which ended Nov. 30, 2017, according to recently released bondholder documents. The health system reported revenues of $1.16 billion in the first quarter of fiscal year 2018, up from revenues of $1.07 bil- lion in the same period of the year prior. The system's net pa- tient revenue and premium revenue climbed 6 percent and 12 percent year over year, respectively. Stanford Health Care kept expenses in check in the first quar- ter of this fiscal year. The system reported operating expenses of $1.08 billion, up 3.7 percent from the same period a year earlier. The system ended the first quarter of fiscal year 2018 with op- erating income of $74.3 million, more than double the oper- ating income of $28 million it reported in the first quarter of fiscal year 2017. Stanford Health Care is part of Stanford Medicine, which also includes the Stanford University School of Medicine and Stan- ford Children's Health. n

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