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Consumers Run Into Road Blocks With Anthem Policy

Anthem’s controversial emergency department policy added confusion to the nation’s already confusing health care system. The policy, which CQC has previously reported on, allowed Anthem to retroactively deny coverage for consumers’ ER visits if the insurer determines the situation was not actually an emergency.

While Anthem said the policy was designed to reduce unnecessary ER visits, How Stuff Works highlighted some of the complications that consumers faced when dealing with the policy.

To avoid surprise emergency room denials, the Anthem policy required consumers to decide whether they should first go to their primary care physician or an urgent care center for treatment. However, it could be difficult for consumers to quickly get an appointment with a primary care physician or specialist.

When Amanda Gorman was suffering from kidney stones, she knew better than to go to the ER for the issue. However, she found her other options limited.

"I was almost forced to go to the ER [emergency room] this week [early February 2019] because of [a] kidney stone, and couldn't get a new appointment with a urologist," she recalls via email. Gorman is a nurse practitioner married to a physician and was trying to go to the hospital where her husband works. "So if we're having trouble navigating this, I can't imagine the struggles for regular patients," she says.

Ultimately, Gorman decided to visit an out-of-network urologist, a decision that carried additional possible out-of-pocket expenses. She said the current state of health care coverage means that she would rather avoid the ER all together.

While Gorman has the experience to know that she could avoid the ER, many consumers did not. Experts warned that the policy forced consumers to diagnose themselves, which could be dangerous and even fatal. Dr. Ryan Stanton, a spokesperson from the American College of Emergency Physicians, said the policy put profits over patients and could “lead to injuries and deaths.”

"I have talked to a number of people that were denied and the common theme was how upset they were, but more importantly, they are now afraid to go to the emergency department, even if they feel they have an emergency."


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