By Consumers for Quality Care, on February 1, 2018
As a part of Vox’s dive into emergency room billing, Sarah Kliff recently reported on how Anthem’s new emergency room policy – which essentially requires patients to diagnose themselves in order to ensure their condition is serious enough to be deemed an emergency by Anthem, and therefore covered by their insurance – is impacting consumers. This change in policy, which Consumers for Quality Care has highlighted previously, will likely mean that patients will delay or go without emergency care rather than risk getting a surprise medical bill after an insurance company decides their situation wasn’t truly an emergency.
Birttany Cloyd and her family are now grappling with the realities of Anthem’s policy change. The 27-year-old mother recently went to the emergency room after severe abdominal pain:
Cloyd came in after a night of worsening fever and a increasing pain on the right side of her stomach. She called her mother, a former nurse, who thought it sounded like appendicitis and told Cloyd to go to the hospital immediately.
When Cloyd arrived at the hospital, she was immediately wheeled to a back room, where the doctors began running a number of tests. Her doctors discovered the pain was coming from ovarian cysts, not appendicitis. She was given medication and told to consult with a gynecologist.
Despite being insured through her husband’s employer, Cloyd received a staggering $12,000 bill for her trip to the ER. Anthem informed Cloyd that they would not be able to cover her visit, stating that ER services are only covered “when a health problem is recent and severe enough that it needs immediate care.”
Cloyd’s story highlights a fear that many consumer advocates raised when the policy was announced. Renee Hsia, a health policy professor at the University of California San Francisco and practicing emergency physician, points out some of the policy’s shortcomings:
These denials are made after patients visit the ER, sometimes based on the diagnosis after seeing a doctor, not on the symptoms that sent them, like in Cloyd’s case….
“If you look at insurance claims data, you have diagnoses but you don’t have what the patient came in with,” Hsia said. “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.”
Because Cloyd ended up not having appendicitis, it is seemingly irrelevant that she believed she did when she entered the ER and she was stuck with a bill she couldn’t pay.
Emergency physicians like American College of Emergency Physicians Missouri chapter president Jonathan Heidt and hospitals in the affected states began seeing denials within days of the policy change :
Emergency room doctors started to notice the change quickly. Heidt, who attended the summer meeting, says that his hospital “was receiving denials within days. We discussed that with [Anthem]. They said they were thinking of looking at medical records, but all of the denials at that point were coming off the claims.”
Vox reports that at this point, there are no estimates of how many consumers Anthem’s policy has affected.
After two appeals, Cloyd was covered for her emergency room visit. However, she still says her experience will have long-term health care ramifications:
The experience completely changed how Cloyd thinks about the emergency room. She would still take her 7-year-old daughter in case of emergency, but she says she no longer thinks she’d ever seek emergency care unless forced by a medical provider.
“I have numerous health issues, and it’s upsetting and scary to think that I don’t have that option, but it’s just not worth the stress,” she said. “I told my husband, I’ll go to primary care, and they’ll have to force me into an ambulance to go to the emergency room.”