Man Denied ER Coverage As A Result Of Controversial Anthem Policy

By Consumers For Quality Care, on February 8, 2019

When Paul Sweatman’s left ankle swelled to three times its normal size in 2017, his first stop was an urgent care clinic. The urgent care said that the case was more complex than they were able to handle and sent him to Atlanta Medical Center. The hospital’s staff discussed the possibility of amputation. Fortunately, they were able to treat Sweatman’s swollen ankle, stemming from a mysterious bacterial infection, over a three-day hospital stay. When he left everything seemed resolved, Atlanta Journal Constitution tells.

Unfortunately the swelling returned. Since he had unsuccessfully tried urgent care the first time, Sweatman returned to the emergency room. An insurance agent himself, Sweatman confirmed that Atlanta Medical Center was in his insurer’s network.  The emergency room physicians gave Sweatman more IV medicine and prescribed more antibiotics; he left the ER cured.

He said he was sure the ER was the right place to go, especially since urgent care sent him to the hospital originally and the potential consequences were so serious.

His insurer, Anthem, argued that Sweatman should have returned to the cheaper urgent-care unit. Because he hadn’t, Anthem refused to pay Sweatman’s second hospital bill.

Sweatman says that the process to appeal the denial was so laborious that he eventually gave up.

The company forced him to write and mail documents, he said, then would not acknowledge receiving them.

“I’ve never had a late bill in my life,” he said. “Every time I tried to follow up on my appeal I was passed around to different departments, some people couldn’t find my appeal, some people could find my appeal. I know I was hung up on at least two or three times. Eventually you just get frustrated and quit fighting.”

Sweatman said he tried to pay the bills but stopped with about $500 left, due to other looming expenses. Now, he is receiving collection notices from an attorney’s office. He hopes his tax return will allow him to finally pay the balance.

According to Atlanta Journal Constitution, Sweatman is one of thousands who have been denied emergency department coverage as a result of a 2017 Anthem policy change. The policy states that if a patient’s condition is retroactively not deemed an emergency, they reserve the right to deny the coverage.

A report by then-U.S. Sen. Claire McCaskill of Missouri showed that in the six months after the initiative launched in 2017, Anthem denied 12,200 of its customers’ claims for emergency room care in Georgia, Kentucky and Missouri, 3,500 of those in Georgia alone. In those beginning months Anthem admitted it was wrong to do so in the majority of cases where the customers appealed, reversing its decisions more than half the time.

Politicians, physicians, and consumer advocates say that insurers are putting profits before consumers by expecting them to make complex medical decisions out of fear that they will be denied coverage.

“This affects Georgians and quite frankly people across this country,” said state Rep. David Knight, R-Griffin, who is trying to bring attention to the issue and is critical of Anthem. “They act with complete immunity. Once you’re in there they can do whatever they want.”