Anthem Blue Cross Blue Shield planned to limit payment of anesthesia claims for some patients, the company announced recently. But then unexpectedly, on Thursday, the company decided to reverse the decision, according to a media statement.
The flipflop was widely viewed as a reaction to widespread criticism of the policy by doctors and others. Reports also speculated that Anthem backed down in view of the fact that the head of the rival insurer UnitedHealthcare was shot dead on a street in Manhattan, amid widespread speculation that he was killed because of UnitedHealth’s policies denying or delaying care for things that doctors had recommended.
The current practice is to pay for billed anesthesia charges, on a per-patient basis. But in announcing its planned policy switch, the company said: “We will utilize the [Centers for Medicare and Medicaid Services] Physician Work Time values to target the number of minutes reported for anesthesia services,” the Anthem announcement said. “Claims submitted with reported time above the established number of minutes will be denied.”
The work time values a physician uses on average are calculated by C.M.S. by collecting data, validating it, surveying specialty societies, running pilot projects and other activities designed to come up with a valid number as a benchmark. The process is subject to oversight and monitored by think tanks and professional groups.
On the ground, anesthesia use is typically gauged by the surgeon and the anesthesiologist to maximize benefit for the patient and the surgical team, using established standards and responding to events. For example, if a complication takes place and a surgery runs longer, it is expected that the anesthesia will be delivered to the patient and paid for by the insurer. Under this new policy, Anthem was saying it wouldn’t pay.
The American Society of Anesthesiologists said the new rule would apply only to Connecticut, New York and Missouri. The society called on Anthem to reverse this proposal immediately.
‘We have decided not to proceed’
Late on Thursday, Anthem replied to our request for comment with this: “There has been significant widespread misinformation about an update to our anesthesia policy. As a result, we have decided to not proceed with this policy change. To be clear, it never was and never will be the policy of Anthem Blue Cross Blue Shield to not pay for medically necessary anesthesia services. The proposed update to the policy was only designed to clarify the appropriateness of anesthesia consistent with well-established clinical guidelines.”
Insurers and providers have long waged a battle in which providers bill for what they think is necessary, and for what services they provided, while insurers fight back by saying “that’s not necessary” or “prove it” or something similar. This new move is a step further in the direction of the doctor saying “yes” and the insurer saying “no,” to the detriment of the patient, who might wake up in surgery in pain for lack of anesthesia — or get socked with a huge bill. Or the anesthesiologist, performing in standard of care medical practice, might not get reimbursed.
Before Anthem flipflopped, the American Society of Anesthesiologists wrote: “Payment for anesthesia services is based on several factors, including the exact amount of time for anesthesiologists to deliver care preoperatively, during the operation, and when transitioning the patient to the recovery unit afterwards,. With this new policy, Anthem will arbitrarily pre-determine the time allowed for anesthesia care during a surgery or procedure. If an anesthesiologist submits a bill where the actual time of care is longer than Anthem’s limit, Anthem will deny payment for the anesthesiologist’s care. With this new policy, Anthem will 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.
“Anesthesiologists provide individualized care to every patient, carefully assessing the patient’s health prior to the surgery, looking at existing diseases and medical conditions to determine the resources and medical expertise needed, attending to the patient during the entire procedure, resolving unexpected complications that may arise and/or extend the duration of the surgery, and working to ensure that the patient is comfortable during recovery.”
“Surgeries often run longer than expected due to unforeseen complications,” Wendell Potter, a former insurance exec and current whistleblower, wrote on his Healthcare Un-Covered Substack. “A study published in the Journal of Medical Decision-Making found that surgeons underestimated surgery durations 32% of the time. Medical procedures exceeding their scheduled times – often due to patient-specific factors like excessive bleeding or complex anatomy and inefficiencies in operating room management – all contribute to patients requiring anesthesia longer.”
Swift reactions
The anesthesiologists’ society quoted its president, Donald E. Arnold, M.D., as saying: “This is just the latest in a long line of appalling behavior by commercial health insurers looking to drive their profits up at the expense of patients and physicians providing essential care. It’s a cynical money grab by Anthem, designed to take advantage of the commitment anesthesiologists make thousands of times each day to provide their patients with expert, complete and safe anesthesia care. This egregious policy breaks the trust between Anthem and its policyholders who expect their health insurer to pay physicians for the entirety of the care they need.”
Will Flanary, an opthalmologist who has a social media following as Dr. Glaucomflecken, posted a video on his TikTok account ridiculing the idea that an insurance executive should overrule a surgeon and an anesthesiologist on the length of a surgery.
Others responded on social media too. On X-Twitter, a man named Bill Davis tweeted: “As an #anesthesiologist, 2 of the most important things we do are putting a patient to sleep and waking them back up. @AnthemBCBS paying for only one of these shows how they devalue patient safety for their own profits. This cannot be tolerated.”
Robert Mittendorf, M.D., wrote on X-Twitter: “”This absurd anesthesia policy is beyond the pale. It is unacceptable from both a patient ethics and patient outcomes perspective, and a nauseating indictment on the failure of leadership in many insurance organizations.”
Potter wrote: “Anthem’s new anesthesia guidelines should be a wake-up call for all of us. This is not just about one company — it’s about a health care system that allows insurers to dictate medical decisions in pursuit of ever-higher profits. Over the past several years, big for-profit insurers have gotten bolder in their refusal to pay for needed medical care. If we don’t push back now, the next patient on the operating table being refused pain relief by their insurance company could be you or someone you love.”
Exclusions: Under 22 and maternity
Anthem said two groups would be excluded from the new policy: Patients under the age of 22 and those receiving maternity-related care.
The society suggested that people concerned about Anthem’s proposal contact their state insurance commissioner or their state legislator.
Anthem wrote initially that the policy would apply to claims filed on or after Feb. 1, 2025, adding: “If you disagree with a claim reimbursement decision, please follow the claim dispute process as outlined in the Provider Manual. Documentation to support your request will be required.
“If you have questions about this communication or need assistance with any other item, please contact your provider relationship management representative.”
