Local Anthem policyholders who visit the ER might find themselves paying their bill out-of-pocket. Last month, Anthem implemented a new policy in select states allowing the health care provider to deny payments for visits to the ER they feel could have been taken care of in immediate care instead.
The change originally only applied to policyholders in Georgia, Missouri and Kentucky, and was recently expanded to New Hampshire, Ohio and Indiana. Anthem claims the change will reduce Emergency Room overcrowding and save consumers money by encouraging them to seek care outside of the ER.
The Recorder reached out to Anthem to discuses the policy change and was sent the following statement:
“… Anthem’s ER program aims to reduce the trend in recent years of inappropriate use of ERs for non-emergencies. Emergency rooms generally treat life-threatening situations, and if a consumer feels he or she has an emergency they should always call 911 or go to the ER. But for non-emergency health care needs, ERs are often a time-consuming place to receive care and in many instances 10 times higher in cost than urgent care …”
Many health care providers feel the change will force patients to self-diagnose or avoid the ER altogether. Medical associations such as ACEP and AAEM are fighting back because they believe patients don’t always know what qualifies as an emergency. For example, nausea could possibly be a sign of a heart attack, and back pain may prove to be a kidney stone. Dr. Thomas Richardson with Hendricks Regional Health said these changes could disproportionally impact minorities and low-income patients, who already have numerous barriers to quality and affordable healthcare and are more likely to visit the ER.
“In general, those with lesser income streams are going to be less likely to seek out an urgent care that is harder for them to get to. And face it, urgent cares tend to set up shop in higher income communities,” said Richardson.
According to a report by the Society for Human Resource Management titled Emergency Room Use Varies by Income, Education and Race, Latinos are nearly twice as likely as the general population to go to the ER for nonemergency care (39 percent vs. 21 percent), and a third of black respondents (33 percent) said they would rely on the ER in the event of nonemergency care.
While Anthem’s policy change does not apply to individuals who live more than 15 miles away from an urgent care center, Richardson said socio-economic factors can make getting to an urgent care facility difficult.
“As an example, there are at least four to five of urgent care facilities on the west side in Avon and Plainfield, within 15 miles of downtown, but for someone with low income, that might as well be 100 miles,” said Richardson. “The same applies for primary care providers. And with many of the low-cost clinics that are set up for this population, you can wait a long time for a call back to get clearance to go to the ER, or weeks to get an appointment.”
Barbara Bolling Williams with the Indiana NAACP agrees that low-income patients will be most impacted by the change.
“They don’t go to the emergency room for routine things, when they go its because they believe its an emergency. They are not medical professionals and they do not know (the diagnosis) until after they get there. Maybe its not life threatening, but they are scared. A lot of times, it’s in the middle of the night and if they had a primary health professional their office is closed,” said Williams. “I question the decision to go after people who utilize the emergency room because historically, we people of color are the population that hasn’t had the best health care. We couldn’t go to regular doctor visits to ward off problems that eventually become critical. To deny payment to low income or no income individuals, it’s just going to burden them even further.”
Richardson hopes the public will get involved by writing their state legislators and expressing their concerns, and has tips on what to do if denied payment by an insurance company.
“First, look at why you were at the ER. Was it really an emergency? If you think it was, then call and ask why your bill was declined. You may have to explain why you felt, as a prudent layperson, and use that language, this was an emergency,” said Richardson.
He added that if the insurance company does not explain why the bill was declined to your liking, the patient should ask for the names of everyone that looked at their chart and ask who was involved in the denial process. This is protected under HIPPA. If a physician was not involved, Richardson says they should ask to have it reviewed again. Consumers may also notify the state insurance commissioner.
“While no one in emergency medicine will deny that the ER can be overused, and this leads to over-crowding and other problems, to frighten people, which this does, from going to the ER when they need to is going to cost lives,” said Richardson.
Anthem implemented a new policy in select states allowing the health care provider to deny payments for visits to the ER they feel could have been taken care of in immediate care instead.