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Medical Justice

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Patients to Be Dinged by Insurance If ER Visit Not Emergent

02/20/18 2:44 PM

Anthem rolled out a new policy holding patients directly responsible for the ER bill if it is later deemed non-emergent. And who will decide whether the visit was emergent or not? You guessed right.

Anthem’s policy is in place in Georgia, Kentucky, and Missouri. Next up is Indiana.

Anthem just sent notice to enrollees in Missouri stating “Save the ER for emergencies – or you’ll be responsible for the cost.”

The notice continued:

“Going to the emergency room or calling 9-1-1 is always the way to go when it’s an emergency. And we’ve got you covered for those situations. But starting June 1, 2018, you’ll be responsible for ER costs when it’s NOT an emergency (this isn’t a change to your benefits plan).”

The AMA asked Anthem to rescind the policy in states where it has been put into effect. The AMA also asked that it not be implemented in any other states.

The AMA and American College Emergency Physicians argue the new policy might violate the “prudent layperson standard” codified into state and federal law. The standard defines an emergency medical condition as one that manifests itself “by acute symptoms of sufficient severity” that a prudent layperson could reasonably expect that the absence of immediate medical attention could place their health in serious jeopardy. 

Anthem counters this is much ado about little. The first state the policy was implemented in was Kentucky in late 2015. They note that only 1% of ER claims have been denied for being an avoidable visit. But, this stat does not include patients who may have avoided going to the ER in the first place for a bona fide emergency.

Asking patients to second guess an emergency is wrong. Patients should be able to err on the side of caution and not have to choose between their life and a giant unexpected bill.

What do you think? Use the comment box below to share your thoughts. 

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Posted by Medical Justice | in Legal | 4 Comments »
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dennis thrasher
dennis thrasher

Are they going to be upset with their physician if she/he directs them to the ER after regular office hours.

Ron Lichtenstein
Ron Lichtenstein

In Israel, it is the patient who decides by his actions whether or not he believes that the visit is for a bona fida emergency. If a patient leaves the ER before the full evaluation had been completed, he is telling the insurance company that in his own mind he did not really believe it to be an emergency. He is therefore responsible for the bill. Makes sense.

Susan Hughes Office

anthem needs to be controlled by AMA and or government
if they get away with this, other insurance companies will follow
I agree running out of eye ointment isn’t a reason to go to the er, but those type of patients are made to wait longer than real emergencies
susan m hughes, md

Kenneth Licker
Kenneth Licker

The purpose of triage in the ER is to determine the urgency of the problem that a patient presents with. If the ER were set up with a emergency section and an urgency section, and if the triage officer does a good job, patients could be directed to get the most efficient care possible. That is not to say that mistakes can’t be made, but having worked in an ER with such a system, I know that it is a viable system. Holding the patient responsible if his “emergency” is deemed not emergent after the fact is arm chair coaching… Read more »