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Insurer doesn't want to pay for non-emergency ER visits

Posted at 4:30 AM, Oct 25, 2017
and last updated 2017-10-25 07:40:34-04

CINCINNATI -- Being rushed to the emergency room can be a scary thing, especially for anyone who doesn't know what's wrong.

Some patients have gotten another scare: a bill for the cost of the visit that wasn't covered by insurance. That's because of a major policy change that has some health care providers worried.

The general expectation is that insurance will cover costs for emergency medical issues, Dr. Ryan Stanton, spokesperson for the American College of Emergency Physicians, said.

But Anthem Blue Cross and Blue Shield has a policy denying some emergency room claims if they believe the visits weren't actual emergencies.

The policy is not new, according to a statement from the company. The policy is already in place in several states, including Kentucky and Indiana. Anthem said it's set to take effect in Ohio in January.

"Claims for inappropriate use of emergency rooms may be reviewed...and could be denied," the statement said. The company also said it believes primary care doctors are the first medical professional patients should see for non-emergency medical concerns. 

There's also a cost issue: The average cost of an ER visit is about 10 times the cost of a visit to a primary care doctor, urgent care or retail clinic, according to Anthem. 

The company also said patients visiting the ER with non-emergency issues could end up waiting for hours as more serious cases are treated first. 

"Despite education campaigns to inform the public about the risks and costs of going to the ER for non-emergent care, inappropriate use of emergency rooms continues to be a problem," a company spokesperson wrote.

Bill Banks, the vice president of managed care for St. Elizabeth Healthcare, said both patients and hospitals can appeal an insurance company's decision to not cover an emergency room visit.

"The bigger concern is, it's going to keep out some people that really need to be in the emergency room," Stanton said. "And we're trying to attack this before people get hurt and die."

Anthem sent the following statement to Cincinnati-based WCPO:

"Anthem is committed to providing access to high quality, affordable health care. As part of that mission, we are committed to promoting care delivery in the most appropriate clinical setting; for non-emergent care, generally this is the patient’s primary care provider. Anthem believes that primary care doctors are in the best position to have a comprehensive view of their patient’s health status and should be the first medical professional patients see with any non-emergency medical concerns.
 
"If a member can’t get an appointment with their primary care doctor, most non-emergent medical conditions can be easily treated at retail clinics, urgent care clinics or 24/7 telehealth services such as LiveHealth Online. Those alternatives typically are much less expensive and have lower member cost sharing than the emergency room. If a member chooses to receive care for non-emergency ailments at the ER when a more appropriate setting is available, their claim will be reviewed using the prudent layperson standard and potentially denied. The review by an Anthem medical director will take into consideration the presenting symptoms that brought the member to the emergency room as well as the diagnosis.
 
"It’s important to note that Anthem’s 24/7 nurse line and online tools are always available to help members find the right care option for their neighborhood. Anthem will cover non-emergent ER visits if a member was directed to the emergency room by another medical provider, if services were provided to a child under the age 14, if there isn’t an urgent care or retail clinic within 15 miles of the member or if the visit occurs on a Sunday or major holiday."

St. Elizabeth's said they're trying to work with Anthem and patients, but the policy leaves them in the middle.

"We can't really go to war with Anthem over emergency room care," Banks said. "But, I can't allow this to continue. We can't just have Anthem deciding, 'Well, that's going to be paid for and that won't be paid for.'"

Anthem said there are some exceptions, such as a patient under age 14, or if the ER visit is on a Sunday or major holiday. 

Experts advised that anyone who gets a denial try appealing it, or negotiating a lower bill with the hospital.