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Major Insurance Company’s Payment Decision Angers ER Doctors

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It hurts when you take a deep breath. Is it a heart attack? A blood clot in the lung? An infection?

Emergency room doctors are questioning letters that have gone out to some Anthem Blue Cross/Blue Shield members in three states that threaten a crackdown on reimbursements.

“Save the ER for emergencies — or cover the cost,” reads a letter sent last month to Blue Cross and Blue Shield of Georgia members.

“Going to the emergency room (ER) or calling 9-1-1 is always the way to go when it’s an emergency. And we’ve got you covered for those situations,” it reads.

“But starting July 1, 2017, you’ll be responsible for ER costs when it’s NOT an emergency. That way, we can all help make sure the ER’s available for people who really are having emergencies.”

Similar letters have gone out to members of plans owned by Anthem, Inc. in Missouri and Kentucky.

Anthem, Inc. said it’s trying to steer patients to proper care. “What we are really trying to do is make sure that people are seeing their doctors first,” said Joyzelle Davis, communications director for Anthem, Inc.

She said patients are inappropriately showing up to emergency departments with itchy eyes and other non-emergency symptoms.

Dr. Becky Parker, president of the American College of Emergency Physicians (ACEP), said it’s about money.

“The insurance company is not on the same plane. They are not here to take care of people. They are here to make money. It’s clear that the insurance companies are looking to make money. It is about the dollar. It is not about high quality care,” Parker said.

“Our concern is that the insurance industry is trying to push this nationally.”

The 2010 Affordable Care Act lays down strict rules for covering emergency room visits. ACEP said the insurance industry is taking advantage of the Trump administration’s disregard for the ACA to push the boundaries.

“Health plans have a long history of not paying for emergency care,” Parker said.

“For years, they have denied claims based on final diagnoses instead of symptoms. Emergency physicians successfully fought back against these policies, which are now part of federal law. Now, as health care reforms are being debated again, insurance companies are trying to reintroduce this practice.”

Davis denies this. “It is reinforcing language that has been in the contract that has not necessarily been enforced before,” she said. She said policies still apply what is known as the “prudent layperson” standard.

Anthem defines it in the letter:

“Emergency” or “Emergency Medical Condition” means a medical or behavioral health condition of recent onset and sufficient severity, including but not limited to, severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that not getting immediate medical care could result in: (a) placing the patient’s health or the health of another person in serious danger or, for a pregnant woman, placing the woman’s health or the health of her unborn child in serious danger; (b) serious impairment to bodily functions; or (c) serious dysfunction of any bodily organ or part. Such conditions include but are not limited to, chest pain, stroke, poisoning, serious breathing problems, unconsciousness, severe burns or cuts, uncontrolled bleeding, or seizures and such other acute conditions as may be determined to be Emergencies by us.

But Parker said the letters and the new policies have a chilling effect on patients and could leave some with bills in the thousands of tens of thousands of dollars.

“The ‘prudent layperson’ standard requires that insurance coverage is based on a patient’s symptoms, not their final diagnosis,” ACEP said.

“If patients think they have the symptoms of a medical emergency, they should seek emergency care immediately and have confidence that the visit will be covered by their insurance.”

Blue Cross and Blue Shield may potentially deny a claim from someone who shows up with chest pain, ACEP said. Davis said a sharp pain with a deep breath could be a symptom of the common cold, and is not an emergency.

Parker said it’s not reasonable to expect a patient to know the difference. “I don’t know and you don’t know if that is a heart attack, a blood clot, or a collapsed lung unless I see you in the emergency room,” she said.

The last thing a doctor wants is for a potentially dying patient to hesitate, worried about a bill.

“It’s really dangerous for our patients,” Parker said.

“I had a woman the other day who was in her early 40s who came in for having a stroke,” added Parker, an emergency physician at West Suburban hospital in Oak Park, Illinois.

“She had had severe dizziness, vertigo symptoms.”

The patient had waited until office hours to come in because the co-pay on her health insurance plan to see a primary physician was $50 but it was $250 for an ER visit. The patient missed an important early window for treating her stroke, Parker said. “She told me, ‘I can’t believe I risked my life for $200.'”

Dr. Howard Forman, an expert in health policy and medical imaging at Yale, said both sides are right.

“To me, this is a problem of the system,” Forman said. “This is not about bad actors.”

Doctors want to work 9 to 5 and patients have few other choices outside of those hours, he said.

“There are a lot of people who go to emergency rooms for things that are not true emergencies,” Forman said.

Many may simply go because they are anxious. “That incurs a significant cost to the healthcare system,” he added.

“I don’t believe insurance companies hold down costs so they can make more profit,” Forman said. Many insurance companies simply manage programs for employers who are self-insured, meaning they pay their employee health costs themselves.

That said, Forman added, ACEP has a point.

“It is really difficult to know in advance which patient is really having an emergency,” he said. “Doctors aren’t even great at predicting which patients have something terrible.”

And you cannot blame patients for using ERs. “The emergency room has become the multi-specialty clinic of the 21st century,” Forman said. “You can go to the emergency room with blood in your stool, which for most people is not an emergency, and four hours later not only be diagnosed with colon cancer but you could have already met with the oncologist,” he added.

“We provide a level of service in the ER now that is extraordinary.”

And that drives up costs. What the insurance companies say they want to do is direct people to less expensive and more appropriate options.

“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,” the Anthem letter advises.

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