Sunday, March 11, 2018

Insurance Company Denial of Emergency Care - Part 2

Last week, I opined about a decision by Anthem to deny paying for Emergency Room (ER) care that it deemed to be non-emergent.  My point was that insurance companies should not be obligated to pay for routine, non-emergent care, recognizing that we need a fair and reasonable method to define a medical emergency.   In my view, payment should not be denied to a patient who reasonably believes he needs ER care, even if the symptoms are (hopefully) found to be innocent after a medical evaluation.

For example, if a patient develops chest pain at 10 o’clock p.m., and is worried about an acute cardiac issue, he should call 911.  If the ER determines that chest pain is simple heartburn, it would not be reasonable for Anthem to deny payment for this ‘non-emergent’ condition.   We’re all a little smarter after the fact once we know the outcome.

Some medical complaints, however, are never medical emergencies.  If you want ER care for a runny nose, a cough or a sore knee, and you proceed to the ER, explain why you think your insurance company should pay for this. 



Coronaviruses Cause the Common Cold 
True Emergency?

Emergency Rooms must accept every patient who seeks care there by law.  A patient cannot be turned away regardless of how trivial the medical issue is.

One approach would be for every ER to have two tiers of service – Tier 1 for true emergencies and Tier 2 for all the rest.  Some ERs have such a system, but I think this should become the standard of care.  The Tier 2 facility could be equipped to provide efficient, low cost care for appropriate medical issues.  ER personnel are already highly skilled in triaging patients and could direct incoming patients toward the correct Tier. 

Here are the benefits.
  • Patients with minor complaints would be seen without waiting for hours while ER personnel attended to truly ill individuals.
  • Tier 2 facilities would be designed to provide lower cost care.
  • Tier 1 could operate more smoothly since patients with routine medical issues would be siphoned off.
  • There would likely be an overall cost savings to the health care system.
Ohio legislators are already threatening legislation to attack Anthem’s ER denial of care policy.  As a gastroenterologist, this craven political grandstanding nauseates me.  Politicians, who spend a career spending other people’s money irresponsibly, aim to lecture a private company who wants to exercise reasonable cost restraints.  Give me a break.

Would Anthem and her sister companies cover Tier 2 care?  Could they assert that since the patient was determined in the ER to have a non-emergent condition that the care should be on the patient’s dime?  I’m not answering this question, I’m merely posing it.  I do think that the present system when a patient expects or is entitled to any ER care being covered needs to be reformed.

When insurance companies pay millions of dollars for unnecessary care, guess who’s really paying for it?

3 comments:

Anonymous said...

I unfortunately have Anthem. Recently my husband went to a hospital-associated urgent care for respiratory symptoms, including burning bronchial pain upon coughing, that he gets most winters and his former PCP always labeled "pneumonia." He made the mistake of saying, "I have pneumonia." They sneeringly asked why he thought THAT. (Though well educated, he is fat and looks lower-class.)

They took a chest x-ray, as they always demand, and it was negative. Instead of saying he just had bronchitis, the head "provider", not an MD, instructed us to rush him to the corp's ER for a Cardiac Workup. When I said, okay, maybe this is always just bronchitis and his [idiot] PCP was wrong, or maybe it's been nipped in the bud this time, they were dismissive. Having already decided that his opinion was valueless, they rejected his ability to recognize familiar symptoms. The med student shadowing her pompously assured me that angina could feel exactly like bronchitis. Should you go to the ER for a Cardiac Workup every time you get bronchitis? She admitted that she was covering her *zz, called me a liar for saying that I would not sue if he later had a heart attack, grudgingly wrote a steroid prescription, and gave us a discharge sheet claiming that patient had been instructed to go to the ER for complaint of chest pain and pressure. (A lie, because he never spoke of pressure.)

We ignored the threats and went home. We then read just days later that we were in a state where Anthem will not pay for needless ER care. Though we hadn't fully realized it, our entire life savings were on the line, and a good decision was made. Urgent care midlevels can NOT be trusted to care whether your life is ruined by their advice - they have fannies to cover, after all, and maybe corporate profits to maximize.

Anonymous said...

Anonymous ER physician here again, I also opined on your first post on this subject.

Overall, I agree or have no major objection to what you write in your second post. Prima facie, if I were an insurer I would not want to pay exponentially more for care when the same care could have been dispensed at a fraction of the cost elsewhere.

Dr. Kirsch, I would love to hear your opinion on the following scenarios:

1. Should an ER physician get paid to take care of someone who comes to the ER with a minor complaint that is not paid for by their insurance? What if the patient cannot afford the bill? The average person makes $55,000 / year, and the average ER bill is probably $2,000. $2,000 is a tremendous amount of money for the average person.

Note that EMTALA is an unfunded federal mandate. If EMTALA were funded this question wouldn't even need to be asked.

2. Should Anthem (and other providers) ensure the ability to obtain timely access to outpatient physicians? We see patients who say "I called to make an appointment to see my doctor and an appointment isn't available for 4 weeks. So I came to the ED."

3. Should insurance providers pay the ER bill if the primary care office told the patient to go to the ER? There are several variants on this question:
a. the office secretary or staff tells the patient to go to the ER over the phone or in person;
b. the office RN tells the patient to go to the ER;
c. the doctor sees the patient, and tells the patient to go the ER;
d. the afterhours nurse on the phone tells the patient at 11 PM to go to the ER;
e. the afterhours doctor on the phone tells the patient at 11 PM to go to the ER.

4. A patient has a minor injury at work, and work will not allow that person to return without a note from a doctor. Their primary care doctor is not available by appointment for 3 weeks. They need a doctor now so they can go back to work tomorrow.

5. A patient gets a routine lab draw as an outpatient and the K+ is 5.9 (abnormally high) and is immediately told to go to the ER. Repeat K+ is 4.5 (normal). The patient actually never had high potassium, it was a lab error. Who should pay for this ER visit?

6. A physician wants their patient to be directly admitted to the hospital, but the hospitalist tells the patient (and maybe even the doctor) to instead get checked in through the ER. Who pays for this ER visit?

I could go on and on. There is vast nuance, subtely, and minor variations on common themes that we see every day.

Michael Kirsch, M.D. said...


@anonymous # 1, I could not clearly follow your narrative, but appreciate your comment. It sounds like you endured quite an ordeal.

@anonymous ERMD, I will offer some brief responses to your inquiries – all sound and rational.

(1) If a pt seeks ER care that is not a covered benefit, he or she should expect a bill. Uninsured should also expect a bill, although the hospital and the physicians may devise a lenient policy for these patients. It is unconscionable that hospital bills for uninsured are much higher than reimbursed charges by insurance companies. This abominable practice should end yesterday.

(2) Anthem may already require that its clients have a PCP. This physician is already obligated to see the ER patient when it is medical necessary to do so, a subjective decision. I have seen pt’s a day or two after an ER visit because they were advised to do so, when such an expeditious visit was not truly needed. Ideally, the ER physician and primary care (or coverage after hours) can discuss the appropriate timing of a f/u appt.

(3) I can’t respond to all of your hypotheticals, but in general, I think the care should be covered if a medical professional (not office staff) advised ER care.

(4) I do not think this is an appropriate ER referral. This patient will need a physician to address the minor injury, which may be an Urgent Care facility who can clear the patient for work. Or, the patient may need to take the initiative to call physicians’ offices or the local hospital referral line looking for a timely appt.

(5) If the patient is directed to the ER, as you suggest, then the patient should be held harmless for the bill.

(6) I can’t specifically offer an opinion w/o knowing the clinical details. For example, if there is an acute issue, ER care may be appropriate.

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