Emergency department denials after-the-fact due to situations not deemed emergencies.
Some insurers are instituting policies that would force policy-holders to pay for an emergency room visit if they later deem it a non-emergency. These policies, which essentially require patients to diagnose themselves in order to ensure their condition is serious enough to be deemed an emergency by their health insurer, are harming customers while reducing costs for the insurers implementing them.
Though many denials are reversed after consumer complaints, the practice will likely mean patients will delay or go without emergency care rather than risk getting a surprise medical bill after an insurance company decides their situation wasn’t truly an emergency. In the meantime, insurers report hundreds of millions of dollars in earnings each quarter.
In Missouri, Sandra Rivera, who underwent a previous heart operation with some complications, went to the emergency room after waking up with chest pain and heart palpitations. Fortunately, she did not have a heart attack, but Anthem sent her a letter informing her this visit would be covered, but any subsequent visits with similar symptoms would not be. Rivera is understandably worried about the next time she may experience similar symptoms and the choice she will have to make in trying to avoid a bill.
In Frankfort, Kentucky, Brittany Cloyd went to the hospital with a fever and strong pain on the right side of her stomach at the advice of her mother, a former nurse, who suggested it might be appendicitis. It turned out Cloyd had ovarian cysts and Anthem denied the $12,596 bill, leaving her to cover the full sum.
What you can do:
Consumers should note which insurance companies are implementing this policy and in which states. Anthem Blue Cross/Blue Shield is the insurer that appears to be following through on this policy the most. If you select a plan with this policy in place and encounter issues with emergency department coverage, many of the affected states have established hotlines through their insurance commissioners to file complaints.
We know these denials have occurred in Georgia, Indiana, Kentucky, Missouri, New Hampshire and Ohio, and likely other states as well. If you encounter an issue with an emergency department denial, your best first step is to contact your state’s insurance commissioner. Contact information for insurance commissioners in these states can be found here.
Notably, insurers have overturned many ED coverage denials when pressed, so we encourage consumers to appeal. However, patients should not be forced to deal with red tape and bureaucratic appeals to get the coverage they already pay for.
58: Percent of Americans who find it frustrating when insurance does not cover emergency room or urgent care visits.