In a disturbing healthcare trend, insurers appear to be trying to scare patients away from seeking emergency care by denying coverage retroactively if the insurer—after the fact—deems an ER visit was “avoidable.” This type of dangerous insurer policy —which can leave patients on the hook for thousands of dollars in medical bills—defeats the basic purpose of health insurance and violates federal healthcare standards. This must be stopped by lawmakers at the state and federal levels.
According to a new report by healthcare advocacy group The Doctor-Patient Rights Project (DPRP,) insurers are exploiting language in the Prudent Layperson standard, a provision in law that requires insurers to cover emergency care, to deny patients’ emergency department claims.
Originally devised to reassure patients who might avoid emergency care for fear of a potentially large hospital bill, the Prudent Layperson standard defines a legitimate emergency as a condition that a person “who possesses an average knowledge of health and medicine” believes could result in serious medical harm.
"Hope for the best, prepare for the worst" has long been the ethos of emergency department medicine. Life-threatening conditions and relatively minor health issues often share similar symptoms. Studies have shown a 90 percent overlap in symptoms for emergencies and non-emergencies. It’s only after a thorough exam that a highly trained emergency physician can determine if a patient presenting with a severe headache has a life-threatening brain aneurysm or just a bad migraine.
Difficulty breathing can be a sign of simple anxiety—or a serious heart condition. Stomach pain can mean indigestion—or ovarian cysts, or a ruptured appendix. Lawmakers recognized that the average person can’t be reasonably expected to make such a diagnosis on their ow and created the Prudent Layperson standard to protect patients by requiring insurers to cover reasonable emergency department visits based on symptoms, regardless of the final diagnosis.
Yet in the second half of 2017 alone, Anthem BlueCross/BlueShield denied more than 12,000 emergency care claims in Missouri, Kentucky, and Georgia as part of a limited rollout of their new “avoidable ER policy,” pursuant to wihch Anthem warned enrollees that claims could be denied if the company deemed a patient was treated for what Anthem considers a non-emergency. One challenge with that approach is that no patient has the luxury of hindsight during a health emergency.
The reality is that only 5.5 percent of emergency department visits are defined as nonurgent, according to the CDC. Despite the evidence that nearly all emergency department visits are warranted and beneficial, Anthem expanded their avoidable ER policy to six states, sending policyholders sternly-worded letters with threatening language like “Save the ER for emergencies – Or you’ll be responsible for the cost.” In doing so, Anthem essentially asks patients to play doctor and self-diagnose themselves—without the relevant medical knowledge or resources––right in the midst of terrifying, potentially life-threatening medical emergency.
We at the American College of Emergency Physicians (ACEP) filed suit against Anthem in Georgia to get them to immediately rescind this ill-conceived policy that threatens the health of people experiencing real medical emergencies and, we argue, violates the Prudent Layperson standard.
Additionally, former Senator Claire McCaskill (D-MO) and Senator Ben Cardin (D-MD) have asked HHS and the Department of Labor to investigate Anthem for potential violations of the Prudent Layperson Standard. Missouri recently passed a bill to prevent insurers from unfairly denying coverage for emergency room visits, and Ohio recently introduced their own bill to prohibit such retroactive denial policies. The American Hospital Association and American Medical Association have also condemned Anthem’ s actions.
Educating patients so that they know when it is best to utilize urgent care, primary care or the emergency department is important. But insurance companies must not discourage patients from seeking emergency care when they believe they could have a potentially life-threatening emergency.
Big insurance companies should rescind these initiatives for the good of their customers. State and federal officials must intervene to ban these dangerous practices if health insurance companies will not do so voluntarily.
Vidor Friedman, MD, FACEP, is the President of the American College of Emergency Physicians (ACEP.)
The views expressed in this article are the author's own.