Anthem has shocked insureds in six states: Georgia, Indiana, Missouri, Kentucky, New Hampshire and Ohio.
In recent years, Anthem has begun denying coverage for emergency room visits that it deems “inappropriate” because they aren’t, in the insurance plan’s view, true emergencies.
The problem: 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 to seek help.
The unpaid bills can be shockingly huge.
The Vox reports Brittany Cloyd went to an emergency room 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.
The doctors in the emergency room did multiple tests including a CT scan and ultrasound. They determined that Cloyd had ovarian cysts, not appendicitis. They gave her pain medications that helped her feel better, and an order to follow up with a gynecologist.
A few weeks later, Cloyd received a $12,596 hospital bill her insurance denied — leaving her on the hook for all of it.
Anthem’s new policy mirrors similar recent developments in state Medicaid programs, which increasingly ask enrollees to pay a higher price for emergency room trips that the state determines to be non-urgent.
Indiana implemented this type of policy in 2015, and the Trump administration recently approved a request from Kentucky to do the same. Beginning in July, Kentucky will charge Medicaid enrollees $20 for their first “inappropriate” emergency room visit, $50 for their second, and $75 for their third.
Read more in The Vox.
Read the episode distilled to “8 Things to Know” by Becker’s Hospital Review
Some states have enacted “reasonable person” standards for emergency room / ambulance use. That requires a carrier to pay the bill if “a reasonable person” would have believed it to be an emergency. Colorado has had such a standard for a number of years.
As yet the denial trend hasn’t spread to Arizona.