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INSURER SETS TIME LIMITS ON ANESTHESIA DURING SURGERIES  
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Helen Santoro
December 4, 2024
The Lever
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_ A surprise medical bill could be waiting for you when you wake up
in the recovery room. _

A patient receives anesthesia before surgery., AP Photo/Richard Drew)


 

_Editor’s Note: On Thursday, Dec. 5, following _The Lever_’s
initial reporting, an Anthem Blue Cross Blue Shield representative
notified our reporting team that it would no longer be pursuing its
new anesthesia policy. The statement came after Connecticut’s State
Comptroller announced that Anthem’s policy would not take effect in
Connecticut._
 

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
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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
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New York
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Missouri
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“The federal government has clarified
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multiple times that insurers must cover the full cost of medically
necessary anesthesia services” for preventative colonoscopies,
according to health policy foundation KFF
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and a recent federal rule
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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
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“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.”

According to Arnold, the new “arbitrary time limit
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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
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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
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for anesthesia services following surgeries if insurance fails to
pay.   

Elevance Health, Anthem’s parent company, brought in more than $170
billion [[link removed]]
in revenue last year. CEO Gail Boudreaux’s total income, including
her base salary, stock awards, and other compensation, was nearly $22
million
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In 2018 alone, the federal health insurance program Medicare, which
serves more than 65 million Americans
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$2 billion for anesthesia services. Private insurers, which are
charged significantly more
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for hospital and physician services, paid about 3.5 times more than
that, according to a 2020 report
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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
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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
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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.  

“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
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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
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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
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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
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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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