A publication of the Kentucky Center for Public Service Journalism

Critics say new insurance policy denying ‘non-essential’ ER visits expects patients to self-diagnose

Anthem, one of the country’s largest insurance companies, is increasingly denying coverage for emergency room visits it deems inappropriate–i.e., not true emergencies. The policy, which has been implemented in Indiana, Kentucky, Georgia and Missouri, exempts patients younger than 15, weekend visits, and patients who live 15 miles or father from an urgent care center. Other patients can be left on the hook with huge ER bills though.

Cloyd with her daughter (Vox photo by Luke Sharrett)

That was the case with Brittany Cloyd of Frankfort, after she went to the ER for severe abdominal pain that she thought could be appendicitis. She was diagnosed with ovarian cysts, and was prescribed pain medication and told to make a follow-up appointment with her gynecologist. Anthem refused to pay the $12,596 ER bill because it deemed pelvic pain not severe enough for immediate care. In the refusal letter, Anthem listed “stroke, heart attack, and severe bleeding” as examples of acceptable medical conditions for an ER visit.

“Anthem’s new policy mirrors similar recent developments in state Medicaid programs, which increasingly ask enrollees to pay a higher price for emergency room trips that the state determines to be non-urgent,” Sarah Kliff reports for Vox. “Indiana implemented this type of policy in 2015, and the Trump administration recently approved a request from Kentucky to do the same. Beginning in July, Kentucky will charge Medicaid enrollees $20 for their first “inappropriate” emergency room visit, $50 for their second, and $75 for their third.”

Anthem argues that it’s trying to cut health care costs and keep people from using the ER inappropriately. But critics say the policy effectively forces patients to practice medicine and diagnose themselves. “It’s not fair to expect the patient [to come] in knowing their diagnosis. If they did, they wouldn’t come in and wait for ours,” said Renee Hsia, a practicing physician and professor of health policy studies at the University of California San Francisco.

Anthem denied Cloyd’s bill twice, but approved it after Kliff contacted Anthem for an interview.

From Kentucky Health News

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