By Consumers for Quality Care, on February 13, 2018
More and more consumers are finding themselves saddled with expensive emergency room bills as a result of Anthem’s decision to stop covering visits it deems to be non-emergencies. That’s exactly what happened to Kimberly Fister-Mesch.
According to Consumer Reports, Fister-Mesch woke up in the middle night with a severe headache. She took Motrin and Tylenol, but neither helped. With persistent pain and an elevated blood pressure, Fister-Mesch worried that she might be having a stroke. Her husband rushed her to the emergency room.
At the ER, a CT scan revealed that she was not having a stroke. Instead, doctors found she had a serious but treatable form of an ear infection called a bacterial mastoiditis. Fister-Mesch left the ER with prescriptions for a pain killer and antibiotic, feeling fortunate that the pain had not been caused by something more serious.
Fister-Mesch’s feelings of fortune faded when she received a bill totaling $4,300. Anthem said it would not cover the visit “because her condition didn’t meet the company’s definition of a true emergency.”
While Anthem says that the emergency room policy change was implemented to combat the overuse of ERs for minor issues, like rashes and colds, it disregards the symptoms that prompt individuals to seek treatment, often forcing patients to self-diagnose.
But a growing chorus of medical experts object to Anthem’s new policy. “It’s inappropriate and dangerous to ask patients to determine whether chest pain is just indigestion or a heart attack,” says David Barbe, M.D., president of the American Medical Association. Anthem’s policy, he says, “is a threat to a patient’s health and threatens them economically too.”
Fister-Mesch feels that is what Anthem is asking her to do.
That includes Fister-Mesch, who paid her bill and filed an appeal with Anthem to reimburse her. “I felt like I needed immediate in-person medical attention,” she says. “It was 4 a.m. and there was no other place to go.”
To help other consumers who may find themselves in a similar position, Consumer Reports has compiled a list of tips to help avoid denials to begin with and contest them when they do. The steps include:
- Understanding what your insurance covers, including the “emergency service benefits”
- Appealing the decision, with notes from the physicians that treated you
- Filing a complaint with your state insurance regulator
- Negotiating with the hospital’s billing department
Consumer Reports’ full list of advice can be found here.