Patients in six states are getting huge bills for 'unnecessary' ER visits

Yahoo Lifestyle
Surgeon with his team in the operating room. (Photo: Getty Images)
Surgeon with his team in the operating room. (Photo: Getty Images)

On a summer day in 2017 Alison Wrenne, a mother of two, felt a sharp pain in her stomach. Wrenne was in the middle of cooking pancakes, according to local Kentucky station WKYT, but the pain was so severe that it sent her to the ground. After calling her husband to come home, she phoned a friend, who happens to be a physician’s assistant. By then it had been 30 minutes, and the pain was getting worse, so her friend advised her to go to the emergency room.

Severe stomach pain can be a symptom of several life-threatening conditions, including a pulmonary embolism, ruptured ectopic pregnancy, or perforated stomach. Thankfully, in Wrenne’s case, it wasn’t. At the ER, she got good news: She had a ruptured ovarian cyst, a fairly common phenomenon that often requires nothing but pain medicine.

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It was when Wrenne returned home — and the bill arrived a few weeks later — that she learned the bad news. Her insurer, Anthem, was refusing to pay for the visit, meaning she had to cover it out of pocket. In a letter, the company explained to Wrenne that her ER trip was “unnecessary,” and that she should have visited a practitioner instead. She was forced to hand over $4,000 to the hospital in medical fees.

“I feel like I’m a reasonable person who made a decision to seek care, and to get a letter like that is really frustrating,” Wrenne told WKYT of the incident. “If someone else was in that level of pain, I’d totally understand their wanting to seek treatment. And I think it’s a little bit scary to have to sit at home and weigh the costs.”

Unfortunately, stories like Wrenne’s are only likely to increase.

Kentucky is one of six states where Anthem — one of the largest insurers in America, boasting a net worth of $48 billion — has quietly enacted its new policy on emergency room visits. The policy states that unless the situation qualifies (under Anthem’s rules) as a true “emergency,” the medical costs to an emergency room will not be covered. First introduced in Kentucky, Missouri, and Georgia, Anthem’s program expanded to include three more states this January — Ohio, Indiana, and New Hampshire.

The company insists that the program is aimed at providing its members with the best care possible and keeping them from spending long hours in ER waiting rooms. But patient advocates say the move is a thinly veiled attempt to reap more profits, one that’s putting patients’ lives in danger.

In an email to Yahoo Lifestyle, Anthem spokeswoman Joyzelle Davis broke down the program’s specifics. “If a consumer chooses to receive care for nonemergency ailments at the ER when a more appropriate setting is available, an Anthem medical director will review the claim information and medical records submitted by the provider using the prudent layperson standard,” Davis wrote. “In the event a member’s claim is denied, they have the right to appeal.”

The “prudent layperson” standard, which dates back to 1994, is what has been used up until now to protect patient’s when they find themselves in what they believe to be an emergency room-worthy circumstance. The phrase “prudent layperson” was added to the Emergency Medical Treatment and Labor Act (EMTALA) in the mid-’90s as a tool to help clarify what constitutes an emergency medical condition. It defined one as “any medical or behavioral condition of recent onset and severity … that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in placing the patient’s health in serious jeopardy.” In Wrenne’s case, then, Anthem is arguing that a person with an average knowledge of health would recognize severe abdominal pain as a nonemergency and would wait to visit a practitioner.

On a press release on its website, Anthem begins by stressing that actual emergencies require care. “Always call 911 or go immediately to the ER if you think it’s a life-threatening situation,” the statement begins. But it goes on to dissuade users from going to the ER for “non-emergencies,” saying that primary care doctors are “in the best position to have a comprehensive view of their patient’s health status.” It lists examples of “non-emergencies,” as seasonal allergies, athlete’s foot, suture removals, and common cold symptoms.

The company has yet to produce a comprehensive list of what it considers to be an emergency and what it doesn’t. Varied reports from subscribers in different states suggest there may not be one set of criteria, or one list. In New Hampshire, the company reportedly told subscribers it wouldn’t cover ER visits for rashes, itching skin, removal of wound dressings or sutures, and general medical exams.

As for what it will cover? In a letter to another subscriber denied coverage in Kentucky, who ended up forking over $12,000, the company listed stroke, heart attack, and severe bleeding as examples of things that would be covered under the policy.

Anthem’s spokeswoman says the company is revising the policy to include exceptions. She says Anthem will not deny ER claims if the member is sent to the ER by a provider, lives more than 15 miles from an urgent care facility, or visits an ER on a weekend. The company will also cover an ER visit if a member is traveling out of state, receives an MRI or CT, or undergoes surgery. And members under 15 years old are automatically covered, regardless of the diagnosis.

Still, exceptions aside, the news doesn’t sit well with the president of the American College of Emergency Physicians (ACEP), Paul Kivela, MD. The medical society, made up of of 31,000 ER doctors, has released scathing reviews of Anthem’s new policy in recent weeks, writing that it has “deadly serious implications for its patients.”

In an interview with Yahoo Lifestyle, Kivela calls it further proof that the insurance behemoth prioritizes profits over patients. “Anthem and other insurers have had a habit of not paying doctors and putting patients in the middle, but this seems to be far more egregious than their other behaviors,” he says. “Denying care and scaring patients away from the ER is reprehensible. There are reasons there are laws for this.”

Beyond his disappointment with Anthem’s “greed-based” decision, Kivela worries about the long-term consequences of telling people they will have to cover thousands of dollars of emergency medical fees — and says that the company’s decision to deny coverage for flulike symptoms is the most troubling part. “We’re seeing the worst flu season in a decade, with people getting particularly bad cases that are resulting in arrhythmias and heart attacks. So to have major insurers institute this policy, it just shows how little they care for the patients and how important profits are to them.”

Kivela hopes that those reading stories about Anthem’s decision will keep in mind that ERs are there for a reason, and not to hesitate to use one if a medical emergency arises. “They are putting patients’ lives at risk — and for what?” Kivela asks. “The amount of money they’re going to save is very small, and the lives they’re going to put at risk by scaring people away is immeasurable.”

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