Insurer making patients question visit to the ER
INDIANAPOLIS — Alison Wrenne was making waffles for her two young children one morning when abdominal pain forced her to the floor. A neighbor who is a physician assistant urged her to go to the emergency room.
Wrong decision, according to her health insurer. Wrenne was diagnosed with a ruptured ovarian cyst, but Anthem said that wasn’t an emergency and stuck her with a $4,110 bill.
“How are you supposed to know that?” said the 34-yearold from Lexington, Ky. “I’m not a doctor … that’s what the emergency room is for.”
In an effort to curb unnecessary and costly ER visits, BlueCross BlueShield has told customers in a few U.S. states to go to the hospital only in a real emergency such as a heart attack, stroke and major bleeding — or they could wind up footing the bill.
Anthem, the nation’s second-largest insurer, wants patients to consider alternatives like drugstore clinics, nurse advice hotlines or telemedicine. Insurers for years have been raising ER co-payments to try to deter unnecessary — and expensive — visits, and Anthem’s policy marks another round in this long-standing fight.
Even doctors agree the ER — an important revenue source for hospitals — isn’t the best option for minor complaints such as sinus infections, rashes or ankle sprains. They say it’s better in those cases to see a family doctor who knows a person’s medical history.
But some also worry that Anthem’s clampdown will scare patients away from the ER in an actual emergency, especially in cases where major problems may not seem serious at first.
“I think it’s completely unfair to patients,” said Dr. Jesse Pines, who teaches emergency medicine at George Washington University. “It runs the risk of really hurting some people.”
Customers in Missouri and Georgia received letters earlier this year from Anthem warning them that minor complaints should be checked out at places like clinics or urgent care centers, where visits can cost $85 and $190, respectively. By comparison, Anthem says a typical ER visit costs around $1,200.
The ER should be used “as it was designed — to treat life-threatening illness,” said Dr. Craig Samitt, Anthem’s chief clinical officer. “This is in no way meant to compromise a member’s determination of whether they’ve got an emergency.”
The push began in 2015 in
“I think it’s completely unfair to patients. It runs the risk of really hurting some people.”
– DR. JESSE PINES, GEORGE WASHINGTON UNIVERSITY
Kentucky and will expand to Indiana next year and possibly other states that have seen a rise in unnecessary visits. Those involve “common medical ailments” that the average person knows should not be seen in an emergency room, Samitt said.
Indianapolis-based Anthem Inc. says it wants to steer patients into using the right locations for their care. It has a similar policy for MRIs that pushes some patients away from getting scans at more expensive hospital locations.
There are many exceptions to the ER rule: Patients won’t get dinged when there isn’t an urgent care center nearby, if they need help on a Sunday or major holiday, if a doctor recommends going to the ER or if someone is under age 14.
Samitt also said Anthem isn’t simply rejecting every non-urgent ER claim it receives. The insurer has a physician review a case before issuing a denial, and it will consider a patient’s circumstances. Anthem said it may cover a patient who arrives with chest pains that turn out to be indigestion instead of a heart attack.
However, hospital officials in Missouri said many of Anthem’s reviews haven’t been this thorough. The insurer has rejected some claims in only a couple of days and hasn’t requested patient records before making a decision, said Daniel Landon, a senior vice president with the Missouri Hospital Association.