Your insurance may not cover that emergency room visit

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Study finds new healthcare policies put more patients at risk of a claim denial

A change in emergency coverage announced by Anthem Blue Cross Blue Shield earlier this year means fewer visits to the emergency room are covered.

A study published in the JAMA Network Open contends that one in six ER visits wouldn't be covered by insurance if all carriers adopted this policy.

Patients head for the ER for all sorts of treatment, from broken arms to heart palpitations. Anthem has begun to deny coverage for ER visits if the patient's condition turns out not to be an emergency.

Some other providers have adopted similar policies, as has the federal government. In July, the American College of Emergency Physicians (ACEP) and Medical Association of George sued the Department of Health and Human Services, claiming the new policy is impeding ER doctors from getting paid for all of their services.

At the moment, Anthem's policy is active in six states -- Indiana, Kentucky, Missouri, New Hampshire, Ohio, and Georgia. If it expands to all 50 states, the study's authors conclude that nearly 16 percent of ER visit claims would be denied.

'Unreasonable and dangerous'

The goal of the policy is to discourage patients from using ER services to treat non-emergency conditions. But Dr. Vidor Friedman, president of ACEP, says it's both unreasonable and dangerous to ask patients to self-diagnose what's wrong and whether a trip to the ER is justified.

"Insurers cannot expect a patient to know in advance whether a headache is a migraine or an aneurysm, or if abdominal pain is indigestion or something far worse. In addition to sticking patients with large medical bills, this policy could deter people from going to the emergency department in a situation where they need immediate medical attention," Friedman said.

The study found it is often hard to tell whether a condition is an emergency or a non-emergency symptom since the two have been shown to overlap nearly 88 percent of the time.

Risk of coverage denial

"Our results demonstrate the inaccuracy of such a policy in identifying unnecessary emergency department visits,” the authors wrote. “This policy could place many patients who reasonably seek emergency care at risk of coverage denial."

The Urgent Care Association of America (UCAOA) advises patients to use good judgment when suffering a condition that may or may not be an emergency. If the condition is serious or life-threatening, you should immediately head for a hospital ER.

If there is doubt, visiting the nearest walk-in clinic or urgent care facility will allow qualified medical personnel to evaluate the condition and make the call.

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