An ER visit, a $12,000 bill — and a health insurer that wouldn’t pay

Brittany Cloyd was doubled over in pain when she arrived at Frankfort Regional Medical Center’s emergency room on July 21, 2017.
“They got me a wheelchair and wheeled me back to a room immediately,” said Cloyd, 27, who lives in Kentucky.
Cloyd came in after a night of worsening fever and an increasing pain on the right side of her stomach. She called her mother, a former nurse, who thought it sounded like appendicitis and told Cloyd to go to the hospital immediately.
The doctors in the emergency room did multiple tests including a CT scan and ultrasound. They determined that Cloyd had ovarian cysts, not appendicitis. They gave the pain medications that helped her feel better and in order to follow up with a gynecologist.
A few weeks later, Cloyd received something else: a $12,596 hospital bill her insurance denied — leaving her on the hook for all of it.

“We have a mortgage, we have bills, we have student loans,” says Cloyd, who works for the Kentucky government and has a 7-year-old daughter. “There is absolutely no way I could pay a $12,000 bill. I don’t even have $1,000 sitting around.”
Cloyd has her health insurance coverage through her husband’s job. His company uses Anthem, one of the country’s largest health insurance plans. In recent years, Anthem has begun denying coverage for emergency room visits that it deems “inappropriate” because they aren’t, in the insurance plan’s view, true emergencies.
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, like in Cloyd’s case.

The policy has so far rolled out in four states: Georgia, Indiana, Missouri, and Kentucky.
“We cannot approve benefits for your recent visit to the emergency room (ER) for pelvic pain,” the letter that Cloyd received from Anthem stated, which she shared with Vox. “Emergency room services can be approved ... when a health problem is recent and severe enough that it needs immediate care.”
The Anthem letter goes on to list “stroke, heart attack, and severe bleeding” as examples of medical conditions for which ER use would be acceptable.

Anthem’s new policy mirrors similar recent developments in state Medicaid programs, which increasingly ask enrollees to pay a higher price for emergency room trips that the state determines to be non-urgent.
Indiana implemented this type of policy in 2015, and the Trump administration recently approved a request from Kentucky to do the same. Beginning in July, Kentucky will charge Medicaid enrollees $20 for their first “inappropriate” emergency room visit, $50 for their second, and $75 for their third.
All of these policies suggest a new and controversial strategy for reining in health care costs: asking patients to play a larger role in assessing their own medical condition — or pay a steep price.
Vox looked into Anthem’s practice of denying emergency room visits as part of a year-long project on emergency room billing. The series has previously explored rising emergency room prices. It relies on a database of readers’ own emergency room bills. If you have one to share, you can submit it here.

Anthem initially agreed to an interview on its new policy and Cloyd’s case, but a spokesperson canceled the day before it was scheduled to take place. Instead, the insurer provided a statement and declined to answer more specific follow-up questions.
“Anthem’s goal is to ensure access to high-quality, affordable health care, and one of the ways to help achieve that goal is to encourage consumers to receive care in the most appropriate setting,” the insurer said in its statement.
Emergency room doctors and patients argue that these new policies can often deprive patients of needed care and deter them from using emergency services in the future. They worry that other insurance plans may follow the lead of Anthem, a giant in the industry with more than 40 million members.
Members of Congress and state regulators are pressing Anthem for additional information about how the policy works and which type of visits no longer receive coverage.
“There is real and justified concern about this,” said Renee Hsia, a professor of health policy studies at the University of California San Francisco and practicing emergency physician. “It’s certainly possible other insurers will pick it up, and might do it intentionally because it deters other kinds of care.”

Anthem tells patients: “save the ER for emergencies — or you’ll be responsible for the cost!”

Jonathan Heidt learned about Anthem’s new policy last June. He’s the president of the Missouri chapter of the American College of Emergency Physicians and was at the group’s monthly meeting when Anthem representatives came in to make a presentation.
“Anthem came to the state chapter and told us they had a new policy they were getting ready to roll out,” Heidt said. “At the time when we met with them, they said they had a significant number of patients who were going to the ER for conditions that could be seen in other, lower-cost settings.”
The Anthem denial policy would not cover “non-emergent ailments” seen in the emergency room. It would, however, exempt patients younger than 15, visits that occur over the weekend, and visits from patients who live 15 miles or farther from an urgent care center.
“For non-emergency ailments, ERs are an expensive — in many instances 10 times higher in cost than urgent care — and time-consuming place to receive care,” Anthem said in its statement to Vox explaining the policy. “Treating these non-emergency ailments in ERs increases the cost of health care for consumers and the health care system as a whole.”
A month earlier, in May 2017, Anthem had sent a letter to its thousands of Missouri members warning of the change.
“Save the ER for emergencies — or you’ll be responsible for the cost,” the letter, first reported by St. Louis Public radio, stated in big blue letters. “Starting June 1, 2017, you’ll be responsible for ER costs when it’s NOT an emergency.”

source: vox