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Anthem penalizes patients who seek emergency room care

Written by Diane Archer

Your heart is racing, your head is spinning, you have excruciating stomach pain. Should you go to the emergency room? Even with health insurance, you may end up paying the entire cost of your ER treatment, if it is later determined that you did not need emergency room care. Leslie Small reports for FierceHealthCare that, in select states, Anthem Blue Cross Blue Shield, the largest health insurer in America, does not cover ER care in these circumstances, penalizing patients who are afraid for their health and seek emergency room care.

New Anthem policies now make some exceptions to Anthem’s general practice in Georgia, Missouri, Kentucky, New Hampshire, Indiana and Ohio of denying coverage to patients who seek emergency care when it turns out they did not need it. It will cover care for patients who are directed by their doctors to go to the ER, for patients under 15, for patients post-surgery or testing, and for patients traveling out of state.

On its face, Anthem’s failure to cover emergency care when it turns out not to be needed is unconscionable, even with the new policy exceptions. Adults may not be able to distinguish between a heart attack and heartburn or hundreds of other symptoms that may or may not turn out to require emergency attention. Forcing people to absorb the full cost of their ER care if Anthem deems it unnecessary based on their diagnosis is tantamount to deterring people from using the emergency room when it might be critical.

Most people visit the ER because they believe their condition is serious, but they usually cannot know for sure; they need trained professionals to make that determination. Even doctors in potentially emergency situations may not know whether ER care is needed. Moreover, the idea of needing to reach your doctor for permission to visit the ER, to ensure coverage, in the course of a perceived emergency, is preposterous.

It is completely reasonable to encourage people to get needed care at the doctor’s office or a clinic, where appropriate, and not the ER. But, it is beyond unreasonable to deny people ER coverage altogether based on their ultimate diagnosis as a way to discourage ER use. It may deter them from getting necessary care or may put them at serious financial risk. As it is, through large deductibles and copays, insurers ration care based on people’s ability to pay, putting people’s health in jeopardy and lives on the line.

As Michael Hiltzik writes for the Los Angeles Times, state regulators need to ban Anthem’s anti-consumer ER coverage policy swiftly.

Here’s more from Just Care: 

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1 Comment

  • I would only go to the emergency room if I thought my problem was life threatening and if I couldn’t reach my doctor. So they are playing catch-22 with patients – you can’t use the ER unless you have your doctor’s approval and if you can’t reach your doctor you are out of luck or will have to pay big bucks. I haven’t been to an ER in 14 years and then it was for a separated shoulder joint due to a fall on a Saturday. I’d never have been able to reach my doctor.

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