As an Insurer Resists Paying for ‘Avoidable’ ER Visits, Patients and Doctors Push Back

Jim Burton was lifting a box in his garage last August when he felt a jolt in his back.

“It dropped me to my knees instantly,” he said. He thought he’d slipped a disk. His friend, an emergency medical technician, urged him to go to the hospital.

At the emergency room, Burton, a 37-year-old resident of Lexington, Kentucky, was found to have a back sprain, with no signs of other serious injury, and was sent home.

He soon got another surprise. His health insurer, Anthem, refused to pay medical bills totaling $1,722, saying his care in the emergency room had not been needed “right away to avoid a serious risk to health.”

To rein in emergency medicine costs, Anthem is reviving an old, contentious tactic: pushing back on patients who visit the emergency room for ailments deemed minor.

Anthem denied thousands of claims last year under its “avoidable ER program,” according to a sample of emergency room bills analyzed by the American College of Emergency Physicians. The program, which Anthem has been rolling out in a handful of states in recent years, reviews claims based on the final diagnosis of patients.

Emergency room physicians say that, last year, the company did not routinely request medical records for denied patients, and therefore could not review the symptoms that brought them to the emergency room. Anthem says it is now reviewing such records before issuing denials.

The company says the policy goal is to reduce use of the emergency department, one of the most expensive places to receive medical care. Anthem recommends that patients with sprains and upper respiratory infections instead consider a visit to a primary care doctor or an urgent care center.

“The costs of treating non-emergency ailments in the ER has an impact on the cost of health care for consumers, employers and the health care system as a whole,” Jill Becher, a company spokeswoman, said in an email.

But doctors and consumer advocates argue that the policy forces patients to diagnose their own illness, and may discourage people with serious problems from seeking care. Patients, doctors and hospitals have been pushing back in the form of opinion pieces, political lobbying and even humorous videos ridiculing the idea that people can be their own doctors. Members of Congress have written to Anthem expressing displeasure, and state lawmakers have drafted bills to bar the practice.

The criticism seems to have had an effect: For now, Anthem appears to be denying fewer claims — though it also expanded its policy to several more states.

So-called avoidable visits are the latest conflict among doctors, hospitals, insurance companies and patients over emergency rooms. And the Anthem policy is just one way that patients seeking emergency care can be stuck with unexpected costs. Some doctors, who fail to sign contracts with insurance companies, are sending patients direct bills for their services.

“It’s the place where the incentives in health care break down,” said Zack Cooper, a health economist at Yale University, who has studied patterns in out-of-network bills. “You’ve ended up with this death struggle between insurers, hospitals and emergency room physicians, and patients get caught in the middle.”

The emergency room, which functions as the front door to most hospitals, contributes a substantial portion to the nation’s enormous health costs. The program by Anthem, the nation’s second-largest insurer, tries to reduce those costs by changing patient behavior. Other insurers are watching carefully. Anthem points to estimates that as many as 5 percent of visits are unnecessary.

“ERs are often a time-consuming place to receive care and in many instances 10 times higher in cost than urgent care,” Becher said. Anthem began testing its policy in Kentucky in 2015. That’s when Jason Salyers, now 32, who works in the financial aid office of a community college, started having episodes in which he couldn’t breathe. When he went to the emergency room, he was treated for a panic attack. Two days later, he returned, fearful he was having a heart problem.

His pulse, he recalls, was above 150 beats per minute.

“I thought I was dying and I needed to go to the ER,” he said.

His second visit was covered because his diagnosis was breathing trouble. Anthem denied payment for his first visit, classified as a panic attack. He appealed, and eventually Anthem paid.

Under federal law, insurers can’t limit coverage of emergency care if a “prudent layperson” would think he or she were experiencing a medical emergency. That standard was established in the 1990s, and the Affordable Care Act expanded the standard to apply to all workplace and individual insurance plans in 2010.

Nearly every state has a similar standard. But the definition of the rule may be a little murky, said Mark Hall, a professor at the Wake Forest University School of Law, who studied the state laws in 2004. So far, state insurance commissioners have received some complaints about the Anthem policy, but no enforcement actions have been taken. Anthem says it follows the standard.

“I could see how this approach could easily start to violate the spirit of the law,” Hall said. “But on the other hand, there has to be some system in place to make these determinations.”

Consumer advocates argue that Anthem’s approach of reviewing the final diagnosis — even if most bills end up being paid — could cause lasting harm by making patients hesitate to seek treatment.

Karen Englert, the government relations director at the Missouri branch of the American Heart Association, said her organization has worked for years to teach women to look for early, unconventional signs of a heart attack, like indigestion, nausea or arm pain. “For some women, those are absolutely the precursors to a heart attack,” she said. “We can’t look inside ourselves to know this is what I have. And patients shouldn’t be expected to — they aren’t doctors.”

Englert, who uses Anthem insurance and is a heart patient herself, says she vividly recalls opening a letter from Anthem notifying her of the policy.

Last summer, Anthem expanded the program into some of its plans in Missouri and Georgia.

In 2016, Sandra Rivera of Jackson, Missouri, had a series of small strokes during an operation to repair her aorta. Last year, she woke up in the middle of the night with chest pain and heart palpitations, and drove herself to the emergency room.

It wasn’t a heart attack, it turned out. Anthem sent her a letter, saying the visit would be covered, but if she went back again with a similar complaint, it wouldn’t pay the bill.

“I’m a heart patient, and it’s not like I was having a stomachache,” said Rivera, 48. Still, the letter worked. Worried about another bill, she said that she had a few more episodes of chest pain in the following months that she didn’t have checked out at the emergency room. “That’s pretty scary,” she said.

Burton, the man whose claim was denied after his back sprain, kept fighting his bill. Anthem eventually paid.

Anthem’s new policy appears to still be in flux.

At the start of this year, Anthem announced it would begin making more exceptions: Patients who live far from an urgent care facility, those who are under 15, those who receive certain treatments in the emergency room and those admitted to the hospital, for example. These people will automatically have their visits covered, even if they have an “avoidable” diagnosis. In Kentucky and Missouri, data from emergency room physicians show that last year’s spike in denials has been followed by a rapid decline. But Anthem has expanded the policy to four more states — Indiana, Ohio, New Hampshire and Connecticut — and has sent letters to affected customers notifying them of the change. Anthem said it could not comment on the data provided by the doctors.

In Missouri, the state legislature passed a bill Friday to shield patients from the dysfunction of the emergency department. The legislation will prevent insurance companies from rejecting bills solely on the basis of a final diagnosis. The bill will also force doctors who didn’t sign insurance contracts into binding arbitration with insurers, to avoid surprise bills.

“The whole idea is just to protect the consumer,” said Paul Wieland, the chairman of the state Senate’s insurance and banking committee. “Because the consumer does not need to be caught up in the fight between the insurance company and the providers.”