Denying Payment for ER Visits Can Spell Death
How do you know if that terrible headache that feels like an emergency and just won’t go away is an unexpected, intense migraine or a life-threatening aneurysm? Severe headaches are tough ailments to self-diagnose. As a result, often at the urging of loved ones, many people go to the emergency room to make sure they treat it responsibly.
Recently, a patient in Indiana went to the emergency room after severe abdominal pain caused her to collapse in front of her children. She went only at the urging of a neighbor who is a physician assistant. It didn’t matter to the health insurance company — they refused to pay because they considered the final diagnosis of a ruptured ovarian cyst to be a non-emergent condition, with no apparent consideration of the mechanism of injury or the patient’s existing medical history.
In real life, people in the midst of a severe or sudden health issue often don’t know whether to grin and bear it or go to the emergency room. Neither does the doctor until the patient receives a medical screening exam. Choosing the emergency department is often the right choice for the patient’s health, mind and, sometimes, his or her life. Patients should not be punished if it turns out that their condition was not life-threatening.
Unfortunately, for many patients with an Anthem health plan, the price of this difficult decision can be costly. This year, a number of plans under Anthem — the second largest health insurer in the United States — informed their members in several states via letter that if they go to the emergency room with a health issue that the insurance company later qualifies as a non-emergency, the company will not cover the visit. Since such determinations aren’t made until well after their ER visit, impacted patients then face an unexpected bill that they must pay entirely out of their own pocket. Anthem says it has physicians on staff to first perform a “medical review” of a case before it denies payment, but the very limited information the insurer receives via codes in a claims submission from an ER visit lacks a full picture of the patient’s presenting symptoms and is, therefore, inappropriate for basing a determination on. The policy is currently enforced by Anthem plans in Georgia, Kentucky and Missouri, while Indiana, New Hampshire, and Ohio plans are set to follow beginning this month.
In a quest to maximize profits, insurance companies have long been pushing the boundaries on paying for emergency room visits. However, due to the enactment of the Affordable Care Act and work by patient advocates like emergency physicians, stricter rules were laid out to ensure emergency room coverage. These protections included prohibiting insurers from denying payments for emergency care simply on the basis of a patient’s diagnosis.
With the enactment of its policy, Anthem is testing the waters of what is permissible under the law, and other insurers are sure to follow suit if they are not challenged. It is also threatening patient welfare.
By denying these payments, Anthem plans are forcing patients to self-diagnose. As a result, patients may forego life-saving emergency care for symptoms that can confound the best medical professionals. Severe abdominal pain can be caused by food poisoning, an ovarian cyst and other conditions that are usually not life-threatening, but it’s also the hallmark sign of appendicitis or a ruptured ectopic pregnancy. This is not for patients to determine. If they go to the ER with abdominal pains that turn out to be harmless, they should not be punished by their insurance company or, worse yet, die at home because they are afraid of a high bill and tried to “wait it out.”
As health-care advocates who have come together to speak up for patients and health care consumers, we urge Anthem and other insurance companies contemplating this switch to stop putting patients’ lives at risk by denying payments for emergency room visits. Pretending to be a doctor is fine for child’s play, but adults should leave medical care in the trusted hands of professionals who interact with the patient — that means emergency physicians, not insurance companies like Anthem Blue Cross Blue Shield.
Donna Christensen is a physician, board member of Consumers for Quality Care, and former Member of the U.S. House of Representatives, where she represented the U.S. Virgin Islands from 1997 to 2015, and Paul Kivela, MD, FACEP, is president of the American College of Emergency Physicians and a practicing emergency physician in California.
