We are extremely grateful to Dr. David Heller, medical director of the Emergency Department at Portsmouth Regional Hospital, for sounding the alarm about dangerous changes to health insurance coverage of emergency room services.
Effective Jan. 1, if you are insured by Anthem Blue Cross Blue Shield, the insurance company says it will deny coverage of services received in an emergency room if it turns out you didn’t need emergency care.
In a policy directive to all local hospitals, Anthem wrote: “Effective Jan. 1, 2018, if a member chooses to receive non-emergency care in a hospital emergency department when a more appropriate setting is available, the claim may be reviewed by an Anthem medical director and potentially denied. The member will be responsible for all charges incurred.”
So when you are feeling chest pains, you, as a non-medical professional, will need to decide whether you are really having a heart attack and therefore need to go to the ER, or whether it might be a muscle pull and therefore you’ll wait a bit because you can’t risk getting stuck with an expensive ER bill your insurance company refuses to cover.
“This sets us back many years when this was a standard insurance practice,” Heller told Seacoast Sunday. “A federal law was passed years ago called the ‘Prudent Layperson’ law that says if a prudent layperson feels that their medical condition is an emergency, they cannot be second-guessed by the insurance companies after the fact. This is a dangerous move on the part of insurance companies.”
While “Prudent Layperson” is a federal law, 47 states around the country have also implemented their own state laws to protect citizens from dangerous insurance billing practices. Unfortunately, New Hampshire is one of the three states without a prudent layperson law. We urge state lawmakers to correct this dangerous oversight as soon as possible.
Heller’s concerns are shared by ER doctors around the country.
“Health insurance companies are scaring people away from emergency departments, saying they will decide after the fact what is a real emergency,” said Rebecca Parker, MD, FACEP, president of the American College of Emergency Physicians (ACEP). “If your insurer disagrees with your decision to visit the ER, they may now refuse to pay. These new actions violate federal law and are dangerous, because people with identical symptoms — such as abdominal pain or chest pain — may either have a deadly medical condition or a non-urgent issue. Health insurers can’t expect patients to know the difference between a heart attack and something that is not life threatening.”
Heller notes that often symptoms that are not definitive emergencies, give warning about serious underlying medical conditions.
“People cannot be afraid to go to the hospital,” he said. “I am mortified by this. If a person has a rash, it could be less serious, but it could be indicative of Stevens-Johnson syndrome, meningococcemia, Kawasaki’s disease, toxic shock syndrome. I could go on. These are all rashes that are indicative of conditions that can kill you if not properly identified and treated quickly. This is a very bad move on the part of Anthem.”
Dr. Parker of the national emergency physicians organization voiced similar concerns.
“Nearly 2,000 diagnoses on the list, which Anthem BCBS considers to be ‘non-urgent,’ would not be covered if the patient goes to the emergency department. Some of these diagnoses are symptoms of medical emergencies. For example:
• ‘Chest pain on breathing’ can be a life-threatening pulmonary embolism.
• ‘Acute conjunctivitis,’ if caused by gonorrhea, can cause blindness.
• ‘Influenza,’ which has killed hundreds of thousands of people over the past century, can be an emergency. Thousands of people die from the flu each year.”
“If patients think they have the symptoms of a medical emergency, they should seek emergency care immediately and have confidence that the visit will be covered by their insurance,” Parker said. “The vast majority of emergency patients seek care appropriately, according to the CDC and often times should have come to the ER sooner.”
Anthem is attempting to reduce costs and maximize profit by putting local lives in danger. New Hampshire needs to pass a prudent layperson law as soon as possible and the federal government needs to stop Anthem and other insurance companies from implementing billing practices that help their bottom line at the expense of public health.