Emergency Room Claims – Self-Diagnose or Pay the Price?

While most of us know that emergency room (ER) care is more expensive that non-emergent care, you may not have realized just how much more. In some cases, you could be responsible for the entire cost of your hospital ER visit.

We’re hearing an increasing number of stories from patients who are being billed for the entire cost of their emergency room visit (think thousands of dollars) because their insurance plan didn’t consider their case a “true emergency.” The concept of “true emergency” is not new to us – it has been a common theme that insurance companies don’t want members using the ER for services that could reasonably be rendered by an urgent care facility or even a doctor’s office, which makes sense in the grand scheme of things.

But in recent years, one insurer has begun to deny ER claims in Kentucky, Georgia, Missouri – and as of this year in Indiana, New Hampshire and Ohio – because of the ultimate diagnosis, instead of basing their determination on the symptoms that caused the member to seek emergency care. Anthem BlueCross BlueShield has defended its policy and says their review of ER claims takes into account “prudent layperson” laws, which are present in a majority of states and built into federal law – including the Affordable Care Act. The “prudent layperson standard” requires that insurance coverage of emergency visits be based upon a patient’s presenting symptoms and complaints – not final diagnosis.

Picture this; you wake up in the middle of the night with a terrible pain in your abdomen and you’re thinking “could this be my appendix?” so, you head to the ER knowing that a ruptured appendix could be fatal if not treated quickly. After a few hours of being poked and prodded it turns out the piercing pain that had you doubled over was simply trapped gas in your digestive tract and you are given a few over-the-counter digestive aids and sent home.

A few weeks later you get the notice in the mail that the insurance company isn’t covering your visit to the ER because trapped gas in your digestive tract is not a “true emergency” and all you can think is “how was I supposed to know that it was gas?” While I consider myself to be intelligent, I know I can’t diagnose my own medical problems. But it seems that is what we will be asked to do if insurance companies such as this one have their way.

Anthem has recently amended their policy to make exceptions under specific circumstances after receiving some serious backlash from lawmakers, the medical community and consumers alike. But many aren’t satisfied with the changes – this will certainly be interesting to follow.

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  1. avatarlarry Gagnon says

    The third paragraph is confusing. Is the author saying that Anthem is NOT complying with the prudent layperson laws? If so, at a minimum, last sentence of that paragraph should begin with “But” and some indication of Anthem’s other justifications given.

    • avatarCraig Hasday says

      We agree – it does seem confusing. And we are sure that the legislatures in the affected states are going to seek better clarification from Anthem and other insurers who are denying these claims.

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