INDIANAPOLIS (AP) -
Alison Wrenne was making waffles for her two young children one morning when
abdominal pain forced her to the floor. A neighbor who is a physician
assistant urged her to go to the emergency room.
according to her health insurer. Wrenne was diagnosed with a ruptured
ovarian cyst, but Anthem said that wasn’t an emergency and stuck her with a
“How are you
supposed to know that?” said the 34-year-old from Lexington, Kentucky. “I’m
not a doctor ... that’s what the emergency room is for.”
In an effort to
curb unnecessary and costly ER visits, the Blue Cross-Blue Shield insurer
has told customers in a few U.S. states to go to the hospital only in a real
emergency such as a heart attack, stroke and major bleeding - or they could
wind up footing the bill.
nation’s second-largest insurer, wants patients to consider alternatives
like drugstore clinics, nurse advice hotlines or telemedicine. Insurers for
years have been raising ER co-payments to try to deter unnecessary - and
expensive - visits, and Anthem’s policy marks another round in this
Even doctors agree
the ER - an important revenue source for hospitals - isn’t the best option
for minor complaints like sinus infections, rashes or ankle sprains. They
say it’s better in those cases to see a family doctor who knows a person’s
But some also worry
that Anthem’s clampdown will scare patients away from the ER in an actual
emergency, especially in cases where major problems may not seem serious at
“I think it’s
completely unfair to patients,” said Dr. Jesse Pines, who teaches emergency
medicine at George Washington University. “It runs the risk of really
hurting some people.”
Missouri and Georgia received letters earlier this year from Anthem warning
them that minor complaints should be checked out at places like clinics or
urgent care centers, where visits can cost $85 and $190, respectively. By
comparison, Anthem says a typical ER visit costs around $1,200.
The ER should be
used “as it was designed - to treat life-threatening illness,” said Dr.
Craig Samitt, Anthem’s chief clinical officer. “This is in no way meant to
compromise a member’s determination of whether they’ve got an emergency.”
The push began in
2015 in Kentucky and will expand to Indiana next year and possibly other
states that have seen a rise in unnecessary visits. Those involve “common
medical ailments” that the average person knows should not be seen in an
emergency room, according to Samitt.
Anthem Inc. says it wants to steer patients into using the right locations
for their care. It has a similar policy for MRIs that pushes some patients
away from getting scans at more expensive hospital locations.
There are many
exceptions to the ER rule: Patients won’t get dinged when there isn’t an
urgent care center nearby, if they need help on a Sunday or major holiday,
if a doctor recommends going to the ER or if someone is under age 14.
Samitt also said
Anthem isn’t simply rejecting every non-urgent ER claim it receives. The
insurer has a physician review a case before issuing a denial, and will
consider a patient’s circumstances. Anthem said it may cover a patient who
arrives with chest pains that turn out to be indigestion instead of a heart
officials in Missouri say many of Anthem’s reviews haven’t been this
thorough. The insurer has rejected some claims in only a couple days and
hasn’t requested patient records before making a decision, said Daniel
Landon, a senior vice president with the Missouri Hospital Association.
department visits are expected to climb to around 150 million this year, up
from 141.4 million in 2014. The rise is due partly to coverage expansions
under the Affordable Care Act, an aging population and an increase in opioid
overdoses, according to the American College of Emergency Physicians.
Other insurers also
review ER use but not as aggressively as Anthem, said Laura Wooster of the
emergency doctor group. The group has asked Anthem to stop immediately.
“I would hope that
other insurers would take a look at this ... and realize it’s a dangerous
enforcement mechanism to consider,” she said.
Joyzelle Davis said the insurer has met with representatives of the doctor
group, but it has no plans to stop its program.
Anthem said it has
seen a drop in unnecessary ER visits in Kentucky since it started its review
there and has rejected only around 1 percent of all claims as avoidable.
In Wrenne’s case,
the letter from Anthem said: “We do not believe that a person with an
average knowledge of health and medicine would think that this needed care
right away” to avoid a serious problem. The insurer said she could have been
treated safely in a doctor’s office or clinic.
whittled Wrenne’s bill down to several hundred dollars. But now she’s
nervous about using the ER again.
frustrating to be a reasonable person and have to weigh the cost of ...
going to the ER or not because you have no idea what the bill would be,” she
Judy Kurtz also is
worried about future emergency care. The 62-year-old Maysville, Kentucky,
resident was hit with a $1,600 bill a couple years ago after the insurer
rejected an ER visit.
A doctor had told
her to seek emergency help after an antibiotic reaction made her throat and
face swell. She said Anthem eventually paid the claim. But it took about a
dozen phone calls and six months to get the insurer to change its mind.
The retired school
teacher doesn’t want to go through that again and has set a high bar for
going to the ER.
“It would have to
be terribly life-threatening if I were to go,” Kurtz said. “I would probably
have to be (unconscious) and someone would have to carry me out.”