Anthem among health insurers refusing to pay ER bills, doctors say

[pmac]

For those of you looking into Health Insurance for 2019, definitely give this article a read. The bottom has helpful tips on how not to get screwed over by the health insurance companies for ER visits.

https://www.cbsnews.com/news/anthem-among-health-insurers-refusing-to-pay-er-bills-doctors-say/

[MilesTeg]

The article, for those that it's tldr; is about Anthem denying claims for ER visits that Anthem deems as not "emergencies". The specific example in the article is a woman with severe abdominal pain thinking she might have an acute appendicitis but really "just" had ovarian cysts (painful, but not life threatening).

It's important for people to seek care at an appropriate venue. Going to the ER for an ear infection or flu is a big waste of resources. That said, Anthem is playing a dangerous game here. How is a layperson supposed to know the difference between a "real emergency" and something else? What happens when the reverse of the example happens and someone dies because they are afraid to get a huge ER bill if Anthem denies their claim?

It appears Anthem is trying to define "emergency" based on diagnosis rather than symptoms. This is really, really stupid. You can't discourage people with emergency scale symptoms from going to the ER.

[Aelias]

This is exactly it -- in the moment, how is the average person supposed to know what will or won't be classified as an emergency by some insurance provider after the fact?  And are you sure enough about it to risk your life on it?

I took my son to the ER recently for an asthma attack.  He seemed relatively fine by that evening, but they decided to admit him to the hospital for observation. Unfortunately, the only place with enough nursing staff to administer the medicine every 2 hours was the pediatric ICU.  He seemed fine to me--too sick to go to school, but eating and sleeping and playing and generally looking fine--but, hey, I'm not a doctor.  We ended up in the ICU and then the general pediatric ward for 4 days for a grand total of about $45K.

Later, we got a letter from our insurance company saying they had reviewed the bill and deemed it medically necessary.  Well, good, I guess. But what if they had NOT deemed it medically necessary?  Or had only deemed part of the stay medically necessary?  How could I have known that ahead of time?  I didn't exactly want to check my son out of the ICU against medical advice on the "eh, he looks fine" theory.

The more I interact with the US healthcare system, the angrier I get.  It's inhumane. It gets everyone and their weakest moment, and it's hardest on the most vulnerable people. It violates the Hippocratic oath to "do no harm."

[EnjoyIt]

It is physically impossible for the average person to know what constitutes an emergency.
Is my abdominal pain gas or appendicitis?
Is my cough and fever that won't go away just a simple cold or pneumonia?
Is my chest pain a heart attack or just indigestion?
How long should person wait and find out before they deteriorate further?

If the insurance companies want to play that game they should have a phone number for the patient to call and tell them what to do.  And if the response is go to the ER.  They should pay for it.  And there should be 0 wait times for that call.  God forbid someone is staying on hold for 30 minutes while having a heart attack waiting for permission.  Ohh, if the insurance company was wrong and the patient has complication, morbidity or death they should pay out their ass for it.

Fact is, on the phone companies that offer such a service more often than not hedge on the side of caution and send people to the ER.

I am a doctor and embarrassed with our healthcare industry.

[mm1970]

The article, for those that it's tldr; is about Anthem denying claims for ER visits that Anthem deems as not "emergencies". The specific example in the article is a woman with severe abdominal pain thinking she might have an acute appendicitis but really "just" had ovarian cysts (painful, but not life threatening).

It's important for people to seek care at an appropriate venue. Going to the ER for an ear infection or flu is a big waste of resources. That said, Anthem is playing a dangerous game here. How is a layperson supposed to know the difference between a "real emergency" and something else? What happens when the reverse of the example happens and someone dies because they are afraid to get a huge ER bill if Anthem denies their claim?

It appears Anthem is trying to define "emergency" based on diagnosis rather than symptoms. This is really, really stupid. You can't discourage people with emergency scale symptoms from going to the ER.

It depends, really, on the time of day and the amount of pain.

I went to the ER for an ear infection.  I'd suffered all night long, it was 6 am, and I literally could not take the pain anymore.  It was more painful than childbirth (for the record: this ear infection was AFTER the "with epidural" childbirth and BEFORE the "not enough time for an epidural" childbirth.  So it was true at the time!)

Urgent care was not open.
The ER was empty.

I'm really glad they paid that bill.

[hops]

Some related articles:

https://www.vox.com/2018/2/27/16936638/er-bills-emergency-room-hospital-fees-health-care-costs

[nessness]

I agree with PPs that this is a dangerous road to go down. A much better way of avoiding unnecessary ER costs is to have more combined UC/ERs. I took my kid to one and it was great - a DOCTOR decided what level of care she needed and they billed accordingly. That makes so much more sense than expecting patients to diagnose themselves.

[Tyson]

I agree with PPs that this is a dangerous road to go down. A much better way of avoiding unnecessary ER costs is to have more combined UC/ERs. I took my kid to one and it was great - a DOCTOR decided what level of care she needed and they billed accordingly. That makes so much more sense than expecting patients to diagnose themselves.

That's genius. 

[TexasRunner]

I agree with PPs that this is a dangerous road to go down. A much better way of avoiding unnecessary ER costs is to have more combined UC/ERs. I took my kid to one and it was great - a DOCTOR decided what level of care she needed and they billed accordingly. That makes so much more sense than expecting patients to diagnose themselves.

This needs to become a thing everywhere...

Especially if the clinic and ER share triage resources (as they generally have offset busiest times, or so it seems).

[honeybbq]

I see both sides of the argument.
I'd be nice if there was some flow chart where someone could self-triage and figure out if ER vs UC vs waiting would be best. I know people who use the ER like it's their primary care doc; and it does help deplete resources for those who do truly need it.

But I think undiagnosed, sudden, debilitating pain is definitely an ER thing. She was right; a burst appendix could have killed her. Anthem is disgusting in their treatment of this poor woman. If you need 12k worth of tests, clearly the ER knows you belong there and need medical care.

Routine medical care and physicals would be best for everyone as well and would also eliminate the over-use of ERs.

[Abe]

There is no way for the insurance company to know a priori that a person with severe pain does not have a life-threatening emergency. Many times I don't even know until the patient's been seen by someone in the ER. It's hard to diagnose these things over the phone, even with significant medical knowledge. Two solutions being considered: ER nurses are good at triaging and that is the appropriate branch point in the decision making, not sitting at home writhing in pain. Another part of this is the appropriateness of urgent care billing for a higher level of care than a primary care for the same visit. That's worth negotiating between hospitals and insurance companies.

Anthem is conflating this issue with a separate issue of people coming to the ER for non-emergencies because they don't want to have to sit in a urgent care or wait until the next day to see a primary physician. Some would argue that's just laziness. The converse argument, however is that every person has a different tolerance for discomfort, and the perceived severity of suffering after the fact is not a fair yard-stick. In the end it comes down to intent: did you come to the ER because you thought there was something seriously wrong, came because you didn't want to wait in line in a non-emergency setting, or (a major driver of ER costs in most cities) just wanted somewhere to be other than the streets for a few hours?

In a non-cruel system, we'd focus more resources on decreasing these latter problems with better social services and mental health care. This would drive costs down enough that a person coming to an ER would pay the same for equal services as someone coming to an urgent care. This would eliminate the incentive of insurers to engage in bullshit 20/20 hindsight analyses.

[DaMa]

20 years ago I worked at an insurance company that routinely denied ER claims.  When patients called to question they would be sent a form that requested information -- illness or accident and if accident were you injured in a car accident, at work, at home, and what's the associated insurance info. If you didn't return the form the claim remained denied. 

Over the years, I have had 3 ER claims denied for not being emergencies -- two for chest pains and one for severe abdominal pain (suspected appendix) which turned out to be other things.  In every case, the hospital billed with discharge diagnosis rather than admit diagnosis.  The insurance paid after the hospital rebilled.  I've seen the same thing with ambulance claims.

So much of this is based on computer programming.  Insurance company denies based on codes submitted then provider bills patient.  A person doesn't even look at it.  Then it's up to the patient to figure it out -- the one person who is most likely to have the least knowledge and ability to get it fixed.  Just one more way the US system is screwed up.

[WhiteTrashCash]

Insurance companies are doing this because customers are going to the ER for absolutely everything. They just increased the copay for ER visits on my insurance plan, because other employees at my job were going to the ER every time they got the sniffles instead of going to urgent care.

It's like what happened with L.L. Bean's return policy. They used to allow unlimited returns no matter the age of the item, but some folks got greedy and started buying thrift store items and returning them for new replacements. So L.L. Bean changed the policy to only allow returns one year from purchase with receipt. A few idiots ruin things for everybody else.

[Unique User]

I agree it's a dangerous road to go down, but I see the result they are trying to get.  ER bills are absolutely crazy and how insurance deals with them is equally crazy.  I just got the finally corrected bill for DH's very first ER visit this week, it happened in March.  The hospital was in network, but the physician was not, I spent at least four/five phone calls with insurance and the hospital over that.  $4,500 bill versus $225.  Just nuts.

[Bucksandreds]

Based off the "Prudent Layperson Standard" discussed in the article, I'm smelling a 9 figure class action lawsuit against Anthem.  They're playing with fire and need to be taught a lesson.

[SKL-HOU]

The problem is there is no alternative to the ER in the middle of the night. Urgent Care's close at midnight at best. I took my son to a 24/7 "Urgent Care" on a sunday night for what turned out to be an ear infection. That was me being responsible and not going to the ER for two reasons, not to tie them up (and wait) and to avoid the crazy bill (high deductible plan). It turns out the reason UC we went to was open 24/7 was because it bills like an ER! I got 2 bills, $2500 for the doctor, $2550 for the facility for a 10 minute visit. My insurance denied the claim. They reduced the bill to $250 and $300 respectively.

[Daisy]

Going to the ER for an ear infection or flu is a big waste of resources.

Not true. I hardly ever go to the ER. I did once go for an ear infection because it was incredibly painful. My ear canal had totally clogged up from the infection and the ear drops I had were not even going in.

I went to an urgent care for the flu and the next day ended up in the ER after losing consciousness and ended up in a coma. I probably should have gone to the ER directly, but thought it wasn't necessary.

[chasesfish]

Oh boy I've had some experience with this and have two comments:

The prevalence of stand alone "ERs" in some states really blew this issue up.  Places in Texas would setup private, stand alone Emergency Rooms and take urgent care cases, lie them down in the hospital bed, hook up an IV, and charge $7,000.   There had to be some accountability and this is a result.

That being said, I can't stand codes driving reimbursement.  An ER doc labeled my wife "other headache disorder" when her actual industry was tearing her <insert four letter words > spinal cord.  There were multiple unproductive ER trips while she was in crippling pain before we got to the root cause.   I don't blame the doctors directly, it was on the rarer side of diagnoses, but "other headache disorder" code would get an ER trip declined by insurance for something that is absolutely an emergency.   

ER doctors are generalists and their code is not the end all, be all diagnosis