Can an Insurance Company Label an ER Visit 'Avoidable'?

A U.S. insurance companies has started cracking down on expensive emergency room visits by labeling some 'avoidable' and kicking the bills to the patients. Learn more in this episode of BrainStuff.

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Episode Transcript

Speaker 1 (00:02):
Welcome to brain Stuff from How Stuff Works, Hey, brain Stuff,
Lauren Bogle bam here. Navigating the health care system is
already pretty dicey, and a new program put forth by
insurance giant Anthem is muddying the waters even more for some.
Known as the Emergency Department Review, the company's program launched
in teen with the intent of reducing unnecessary visits to

(00:24):
the nation's emergency rooms. In and of itself, the idea
isn't such a bad thing, since emergency departments are sometimes
ill used. Report found thirty eight billion dollars per year
in wasteful spending thanks to emergency department over use. However,
per Anthem's policy, if a person goes to the emergency
department with symptoms or a condition that turns out to

(00:44):
not be life threatening, they could wind up holding the
bag for a whole lot of money. We spoke with
Christina Gaines, communications director for Anthem Incorporated, via email. She
said if a consumer chooses to receive care for non
emergency conditions at the emergency department, when a more appropriate
setting is available, Anthem will request more information, including additional

(01:04):
medical records from the hospital and a statement from the
consumer as to why they went to the emergency department.
Then an anthem medical director will review the additional information
using the Prudent lay Person standard, and the claim might
be denied as not a covered service. In the event
of consumers claim is denied, they have the right to appeal.
Much of the controversy surrounding this program lies with that

(01:26):
Prudent lay person standard, Gains mentioned. The standard was enacted
by the US Congress back in with forty seven states
opting to work it into state law as well. It
was done to add a layer of protection for healthcare
consumers so they can seek care without working up a
huge emergency department bill. We also spoke via email with
Dr David Farcie, president of the American Academy of Emergency Medicine.

(01:49):
He said the Prudent lay Person standard requires health insurance
companies to cover visits based on the patient's symptoms, not
the final diagnosis. This means if a patient has chest
pain but turns out to have a non urgent medical
condition such as gastritis or muscular pain, the insurance company
must still cover the visit. We have a duty to
safeguard patients and cannot expect our patients who have little

(02:09):
to no medical training to be doctors and know the
difference between a minor or life and death medical condition.
Anthem is forcing the patients to be doctors in completely
disregard federal and state laws to protect patients. Anyone who's
ever been in a potential emergency situation knows that sometimes
the most logical choice isn't always the most obvious. This
is further convoluted by a health care system in which

(02:31):
it's often difficult, if not impossible, for a person to
see a primary care physician or specialist in a timely manner,
hence emergency department visits that could have been handled elsewhere.
Such was nearly the case for nurse practitioner Amanda Gorman.
She recalled, I was almost forced to go to the
emergency room this week because of a kidney stone and
couldn't get a new appointment with a urologist. Gorman is

(02:53):
married to a physician and was trying to go to
the hospital where her husband works. She said, so if
we're having trouble navigating this, I can't badge of the
struggles for regular patients. Gorman ended up finding an appointment
with an out of network specialist, potentially costly risk in itself.
She estimated that it was about six times as expensive
as an e R cope would have been, but she
didn't want to deal with the hassle of an e R.

(03:15):
Many emergency medicine experts don't mince words about the potentially
damaging effects of the plan. We spoke with Dr Ryan Stanton,
a Lexington, Kentucky based emergency physician and spokesman for the
American College of Emergency Physicians the a c e P.
He said this will harm people and lead to injuries
and deaths. The goal of this program is not the denials,
it's about the fear people will be afraid to seek

(03:37):
emergency care. A CEP feels this policy is incredibly dangerous
and puts people at risk in the name of profits.
I've talked to a number of people that were denied,
and the common theme is how upset they were, but
more importantly, they are now afraid to go to the
emergency department even if they feel they have an emergency.
Many conditions present with similar symptoms, whether they wind up
being benign or truly life threatening. Stanton said, chess pain

(04:00):
can be a heart attack or heartburn. Abdominal pain can
be a pendicitis or gas. A headache can be a
ruptured aneurysm or a hangover. The challenge with medicine is
that it deals in shades of gray and rarely black
or white. The key is that if you feel your
life or health or at risk, go to the e ER.
Not everyone thinks Anthem's program is completely off base, though.

(04:21):
Lindsay Artola is a health policy expert with Sage Health
Strategy who supports some type of penalty for unnecessary use
of the emergency department. She said via email, the emergency
room is by far the most expensive way to get healthcare,
and with the advent of urgent care centers, nurse triage lines,
and other alternatives, it's a poor use of health system
resources for folks to use the e R as a
primary care office. I think a financial penalty for misuse

(04:44):
of health system resources isn't necessarily a bad idea. So
how bad is the problem of misusing the e R?
Statistics very widely? A study using data from e ER
visits from two thousand five eleven found that only three
point three percent of e R visit were avoidable, which
is in line with the CDC statistic of five point

(05:04):
five percent. Meanwhile, Truven Health Analytics, drawing on insurance claims
data from said that seventy of e R visits were
unnecessary and avoidable. Clearly, the word avoidable has different meanings
for different people. Anthem spokesperson Gains said consumers who reasonably
believe that they are experiencing an emergency medical condition should
always go to the emergency room or call nine one one.

(05:27):
She points out that Anthem will always cover emergency department
visits under certain conditions. For example, if a consumer was
directed to the emergency room by provider, including an ambulance provider,
if the patient is under the age of fifteen, if
the patient's home address is greater than fifteen miles from
an urgent care center, if the visit occurred during off
hours that's between eight p m Saturday and eight am Monday,

(05:49):
or on a major holiday. If the patient received surgery
I V fluids, I V medications or an m R
I or CT scan, or if the patient had conditions
such as chess pain, difficulty breathing, convulsions, fainting, or was
experiencing a drug overdose. Many of these exemptions were added
in January eighteen after public objections to the original policy

(06:09):
it gains. Adds that Anthem's Emergency Department program is currently
in effect in five states Missouri, Georgia, Ohio, Kentucky, and Indiana,
with no current plans to extend its reach. Today's episode
was written by Elliot Hoyt and produced by Tyler Clang
for iHeart Media and How Stuff Works. For more on

(06:30):
this and lots of other topics, visit our home planet,
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