An ER visit, a $12,000 bill — and a health insurer that wouldn’t pay
A new insurance policy expects patients to diagnose themselves.
By
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 a
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 her pain medications that
helped her feel better, and an 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.
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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!”
“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.”
The letter suggested going to an urgent care center for
“back and joint pain” and visiting a retail clinic for “minor allergic
reactions, bumps, cuts & scrapes.” It also advertised Anthem’s own
online doctor visits and 24/7 nurse hotline.
Emergency room doctors started to notice the change
quickly. Heidt, who attended the summer meeting, says that his hospital
“was receiving denials within days. We discussed that with [Anthem].
They said they were thinking of looking at medical records, but all of
the denials at that point were coming off the claims.”
An Anthem spokesperson said that the health plan uses both diagnostic codes as well as medical records in their review process.
Anthem’s policy appears to be targeted toward pushing patients not to
go to the emergency room when they have an injury or illness that could
be treated elsewhere. That can hold down premiums for everyone, as
emergency room visits are expensive — and, as the last story in this series revealed, prices in emergency rooms have increased rapidly in recent years.
In some states, the list of reasons to reject a claim is confidential
It is hard to know how many visits are “avoidable” or “non-emergent.” Studies have estimated that anywhere between 4.8 and 90 percent of emergency room visits are “avoidable,” depending on the criteria and methods used.
Emergency physicians tend to cite the lower numbers,
arguing that unnecessary trips to their department are few and far
between. Insurers, however, often gravitate to the higher numbers that
indicate they’re massively overpaying for routine care that could be
delivered elsewhere.
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.
The topic can be especially difficult to study because it
often requires understanding initial symptoms — chest pain, for
example, could be a heart attack or indigestion. Many studies, however,
only rely on the final diagnosis.
“If you look at insurance claims data, you have diagnoses
but you don’t have what the patient came in with,” Hsia said. “It’s not
fair to expect the patient [to come] in knowing their diagnosis. If
they did, they wouldn’t come in and wait for ours.”
Anthem appears to use a list of diagnostic codes — which
indicate the patient’s final diagnosis upon leaving the emergency room —
to screen for non-emergency visits. A version of the diagnosis codes
that would trigger review in Indiana from early January 2018 includes
“pain in extremities” and “low back pain.”
A list of codes from Missouri is significantly longer,
with more than 1,900 diagnostic codes that could indicate non-emergency
visits. The list includes multiple types of “unspecified injuries” and
“chest pain on breathing.” When asked about the Missouri list, an Anthem
spokesperson said the latter diagnostic code regarding chest pain has
since been removed from the list, which has been updated and revised.
In other states, the list of diagnosis codes remains
confidential. Georgia insurance regulators have asked Anthem to provide a
copy of that state’s list, but so far, that hasn’t happened.
There are no current estimates of how many patients the
Anthem policy has affected, or what results it has achieved for the
health insurance plan in deterring unnecessary visits. Anthem declined
to provide such figures, only saying denials represented a small
percentage of claims.
Congress, however, has begun to get interested in those
questions. On December 20, Sen. Claire McCaskill (D-MO) sent Anthem a
letter stating, “I am concerned Anthem is requiring its patients to act
as medical professionals when they are experiencing urgent medical
events.”
McCaskill has requested that Anthem provide “all
complaints received by Anthem from any entity relating to coverage of
emergency room care in Missouri, Kentucky, or Georgia” and “all internal
communications ... relating to the company’s decision to clarify its
policies regarding emergency room care utilization.”
“I’m currently sitting with a $12,000 debt over my head because I thought my appendix had ruptured”
Cloyd was shocked when she received the denial notice. She immediately got to work appealing the decision.
“I consider myself intelligent and generally knowledgeable about my own health,” she wrote in a letter dated August 22. “I am not a
doctor, which is why I immediately sought experienced medical care when
I felt my symptoms could be dangerous and potentially lethal.”
Anthem reviewed Cloyd’s appeal two months later and, once again, denied coverage for the visit.
“Based on a review by a medical doctor ... we’ve
evaluated your appeal of denial of ER services,” the letter stated. “We
cannot approve coverage for your emergency room visit.”
Anthem wrote that it did not have sufficient medical
records from her hospital. The hospital told Cloyd they had sent the
health plan all the necessary documents. Cloyd made a second appeal.
“The claim has caused unnecessary stress, which certainly
hasn’t improved any of my other medical conditions,” she wrote on
December 27. “You can easily review my claims and note that I do not
overuse the emergency room or hospital services in any capacity! I’ve
been covered by Anthem for several years and have never overused or
misused any benefits.”
The letter continued, “I’m currently sitting with a $12,000 debt over my head because I thought my appendix had ruptured.”
One week after Vox interviewed Cloyd about her emergency
bill and inquired to Anthem about its emergency billing practices, Cloyd
received a letter stating that the denial would be reversed — she had
won her second appeal.
“We deeply regret if we caused Ms. Cloyd any concern,”
Anthem said in a statement to Vox. “Anthem has made, and will continue
to make, enhancements to our ER program to ensure more effective
implementation of this program on behalf of consumers.”
Emergency room physicians are currently exploring what
options they may have to push back against Anthem’s new policies. A
meeting between the health plan and the American College of Emergency
Physicians took place in Washington last December but yielded few
results.
“There were a couple of questions I had but couldn’t get
answers to, like what does success look like? And how many patients are
actually being denied?” said John Rogers, president-elect of the
American College of Emergency Physicians, who practices at a hospital in
Macon, Georgia. “They may have the answers to them, but I didn’t hear
them.”
Rogers said his group is looking at possible lawsuits or legislation, at either the state or national level.
Right now his group is focused on collecting patient stories to get a sense of what the denial policy looks like on the ground.
“Hospitals are starting to talk to patient advocacy
groups, asking whether they’re aware of the situation,” he said. “We’re
starting to sit down with legislators to say, ‘This is happening, we
don’t think it’s a good idea, and these are other, better solutions.’”
The experience completely changed how Cloyd thinks about
the emergency room. She would still take her 7-year-old daughter in case
of emergency, but she says she no longer thinks she’d ever seek
emergency care unless forced by a medical provider.
“I have numerous health issues, and
it’s upsetting and scary to think that I don’t have that option, but
it’s just not worth the stress,” she said. “I told my husband, I’ll go
to primary care, and they’ll have to force me into an ambulance to go to
the emergency room.”
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