Claim Denied!

We recently ran a blog that looked at how patients in several states are finding out the hard way that one of the nation’s largest insurers won’t cover  an ER visit if the company decides it wasn’t really an emergency. The company in question is Anthem and at the time of our original story, wrote,

“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.”

Bottom line, according to a report in LA Times, “Over the last few months, Anthem, the nation’s biggest health insurer, has informed customers in several states that if they show up at the emergency room with a problem that later is deemed to have not been an emergency, their ER claim won’t be paid.”

Just yesterday, three of the nation’s largest medical groups, the American Hospital Association (AHA), American College of Emergency Physicians (ACEP), and the American College of Radiology (ACR) wrote a joint letter that again asked Anthem to rescind its new policy.

Below are excerpts from that letter. Click here if you would like to read it in full.

“Our organizations represent the physicians and hospitals who care for Anthem enrollees, as well as other individuals who need our care. We have each met with you and your team separately to express our concerns about Anthem’s coverage policies for emergency care and outpatient imaging, which we believe adversely impact the quality, safety and coordination of care for patients. We write to urge you to rescind these policies, and to express our belief that there is a better way to ensure that patients access the right care, in the right place, at the right time. We invite you to work together with us on these efforts.

“Patients do not have the full set of knowledge and tools to assess the level of care they may need. In fact, most clinicians cannot make a diagnosis with confidence without the support of a wide range of tools and tests. That is why the prudent layperson standard is so important – it protects those who seek emergency medical care when they believe there may be risk of serious impairment to his or her health. The changes to the policy announced by Anthem last week do not address the underlying problem of putting patients in the potentially dangerous position of having to decide whether their symptoms are a medical emergency before they seek emergency care, or risk paying the entire bill if it is not. Only full rescission of the policy will ensure the safety of our patients and your enrollees.

The letter end with this, in bold letters, “We ask that Anthem rescind these policies and work with us to design programs to educate patients about the appropriate use of health care services and improve the coordination of care among providers, while increasing transparency requirements surrounding patient out-of-pocket cost responsibility.”

Share your thoughts on Anthem’s decision to stop covering non-emergency visits in some states. Do you believe it puts too much pressure on patients to decide if what they are experiencing is a true emergency? Driving these types of conversations around the health stories making headlines is another way we are working toward our long-term goal of one day making Arizona the Healthiest State in the Nation!

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