Anthem drawing hard line on what emergency room visits it will cover

An Anthem Blue Cross Blue Shield policy allows the insurance carrier to decide, after they see a final diagnosis from an emergency room visit, if they are going to cover the claim.

“That says they’re going to look at the final diagnosis when you come to the emergency department and use that to determine if they refuse it saying it was a non-emergent event,” WKYT Medical Contributor Dr. Ryan Stanton said.

Stanton has been working as an emergency department doctor for twelve years. Stanton went on, “The biggest concern I have is that people are going to use this as a reason not to go to the emergency room for true emergencies or when they think they have an emergency.”

Alison Wrenne was home cooking breakfast for her two children last summer, when pain in her abdomen became so severe, she fell to the floor. “Just instantly, I was in really horrific pain all in my abdomen,” she explained to WKYT’s Miranda Combs. She thought she was going to pass out.

Her husband came home and after waiting to see if the pain would subside, they were told by a physician’s assistant friend that she should go on to the emergency room. Wrenne had an ultrasound to confirm that it was an ovarian cyst that had ruptured. It was not life-threatening, but her doctor assured her there was no way for her to know that.

“A couple of months later, I got a bill from the hospital and a letter from Anthem saying they had rejected my claim and that I should have sought the emergency room and that I should have visited my local practitioner,” Wrenne said. She owed more than $4000.

“Is Anthem’s move not to pay a slap in the face to what you thought was an emergency?” Combs asked.

“Yes,” Wrenne replied.

Dr. Stanton said this policy flies in the face of the prudent layperson standard. He explained, “Prudent layperson is established and says that if you feel like you have an emergency, then you have the right to go to the emergency room and you have the right for that to be covered by your insurance company.”

According to Stanton, Kentucky is one of just a few states where they are pushing the policy. He says Anthem claimed the policy has been around since 2015. However, Stanton just started seeing refusals in his ER from Anthem this summer.

On Thursday Anthem released a statement to WKYT, “Anthem’s goal is to ensure the broadest access to high quality, affordable health care, and one of the ways to help achieve that goal is to encourage our members to receive care in the most appropriate setting.”

Anthem tells WKYT’s Miranda Combs that the company is simply trying to cut back on care that is not normally perceived as an emergency such as “itchy eyes from seasonal allergies, treatment for ingrown toenails and suture removal”.

“Emergency rooms treat life and limb threatening situations, and if a member feels he or she has an emergency, they should always call 911 or go to the ER. But for non-emergency ailments, ERs are an expensive and time-consuming place to receive care. Primary care physicians should always be the first medical professional members see with non-emergency medical concerns, with urgent care, telemedicine, retail clinics and Anthem’s free 24-7 nurse lines available to assist members in after-hours situations.”

Anthem goes on to say they will continue coverage to anyone that is directed to the emergency room by another medical provider and if a patient thinks they are in an emergency situation Anthem says they still highly suggest going to the hospital or calling 911.

Anthem says they will cover services if they were provided to a child under the age 14, if there isn’t an urgent care or retail clinic within 15 miles or if the visit occurs between 8 p.m. Saturday and 8 a.m. Monday or on a major holiday.

They say all visits will be reviewed by the hospital’s layperson before the insurance company makes a decision on the coverage of the visit.

Source: Anthem drawing hard line on what emergency room visits it will cover