Health Insurers Refusing To Pay Emergency Room Bills, Doctors Say

Emergency Room Patient
Scott Olsen / Getty Images

The Doctor Patient Rights Project recently published a study which details how many health insurance companies are denying claims for the ER visits of their clients in a concerted effort to make its subscribers — particularly those who are poor or live in rural areas– too afraid to visit an ER lest they be charged for the entire amount of their hospital visit. The study focused on Anthem, which through its related networks is the largest health insurance provider in America, but notes that other providers are following suit.

“The purpose of this program is to spread fear,” said Dr. Ryan Stanton, a critical care and emergency medical specialist in Lexington, Kentucky.

“Anthem is the big boy on the block, but other health insurers are picking up on it,” said Dr. Stanton. “They’re like a child getting into daddy’s wallet. They take a few dollars at a time and, if they don’t get caught, keep going.”

According to a CBS News report, about one in five Americans report visiting the emergency room at least one time per year, totaling over 130 million visits. The last estimated cost of just over $1,200 for an ER visit from 2012 is outdated, according to insurers and health professionals, largely due to the recent spike in substance abuse-related cases.

In Georgia, the American College of Emergency Physicians and the Medical Association of Georgia have filed a lawsuit in federal court to force Anthem to “rescind its controversial and dangerous… policy that retroactively denies coverage for emergency patients.” Additionally, Missouri Senator Claire McCaskill sent a letter to both the Department of Health and Human Services and the Department of Labor asking them to clarify if Anthem’s policy violates the Prudent Layperson Standard established by Congress in 1997. The policy was expanded to include group and individual health plans in 2010.

The Prudent Layperson Standard defines an emergency condition as one in which the average person’s knowledge of medicine and determination of the severity of their own symptoms would dictate a visit to the ER. Anthem’s policy leaves individuals in the predicament of risking either severe health consequences by not going to the ER or the possibility of their health insurer denying their claim if they do go to the ER.

“Patients should never be in the position of correctly diagnosing their … emergency” McCaskill said in her letter.

In a letter to companies insured by Anthem, the company notified its network that it didn’t want individuals insured under Anthem policies to seek “care right away” at an ER when they could just as easily be treated by a primary care physician or a health clinic. Anthem contends that nearly a quarter of its emergency room claims could be treated elsewhere, and consequently cut Anthem’s health care costs by $4.4 billion per year, about a billion of which would be saved by Anthem’s network companies.

Americans spend over $3 trillion in the health care system annually. Anthem contends that five percent of patients who visit the ER are discharged with no treatment whatsoever, and the CDC confirms that the number is at least three percent. Also, the CDC reports that only 43 percent of emergency room visits result in hospital admissions.

“Anthem’s Emergency Department Review aims to encourage consumers to receive care in the most appropriate setting,” said Anthem spokesperson Joyzelle Davis. “Anthem’s review [of claims] aims to reduce the trend in recent years of inappropriate use of emergency departments for non-emergency use.”

Patients denied a claim by their insurer have a right to file an appeal. Patients should first file an appeal with the insurer, and if the insurer returns a written denial explaining the reason for not honoring the claim, the patient should submit documentation and justification for why the ER visit was necessary.

If the patient receives a second denial, they can request an external review by an independent party, such as a state insurance regulator. The process is labor-intensive for the patient, and the insurer is likely to make the patient jump through all the hoops in the hope that the patient will quit out of frustration. However, the Affordable Care Act makes it clear that the patients have the law on their side should they be able to prove the visit stemmed from a true emergency, and insurers cannot require patients to get prior approval for ER visits.

Over 50 percent of retroactive coverage denials by insurers were overturned after an independent review.