As an Insurer Resists Paying for 'Avoidable' E.R. Visits, Patients and Doctors Push Back

[dalton99a]

https://www.nytimes.com/2018/05/19/upshot/anthem-insurer-resists-paying-emergency-room-visits-if-avoidable.html

As an Insurer Resists Paying for ‘Avoidable’ E.R. Visits, Patients and Doctors Push Back
Guessing wrong on when a condition is a life-threatening medical emergency could mean a large bill. Or worse.
By Reed Abelson, Margot Sanger-Katz and Julie Creswell
May 19, 2018

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, Mr. Burton, a 37-year-old resident of Lexington, Ky., 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.”

[NurseJackie]

1. 😨

[Hugin]

2. Dang. The CFPB isn't even cold yet.

Anthem has always been among the worst.

[progree]

3. An ER visit, a $12,000 bill -- and a health insurer that wouldn't pay --

An ER visit, a $12,000 bill — and a health insurer that wouldn’t pay -- A new insurance policy expects patients to diagnose themselves, By Sarah [e-mail] Jan 29, 2018

Brittany Cloyd was doubled over in pain when she arrived at Frankfort Regional Medical Center’s emergency room on July 21, 2017.

“They got me a wheelchair and wheeled me back to a room immediately,” said Cloyd, 27, who lives in Kentucky.

Cloyd came in after a night of worsening fever and a increasing pain on the right side of her stomach. She called her mother, a former nurse, who thought it sounded like appendicitis and told Cloyd to go to the hospital immediately.

... A few weeks later, Cloyd received something else: a $12,596 hospital bill her insurance denied — leaving her on the hook for all of it.

... In recent years, Anthem has begun denying coverage for emergency room visits that it deems “inappropriate” because they aren’t, in the insurance plan’s view, true emergencies.

...

More: https://www.vox.com/policy-and-politics/2018/1/29/16906558/anthem-emergency-room-coverage-denials-inappropriate

And yes, it was good ol' Anthem who wouldn't pay, because it was determined to be ovarian cysts rather than appendicitus.

She appealed and was again denied. She appealed again -- one week after Vox began digging into this case and asking Anthem about it and it's emergency billing practices -- and was approved for payment.

----------------------------------------------------------------------------------------------

This is just like another issue -- getting fucked with a huge uncovered bill when you have surgery because the radiologist or the lab or the anesthesiologist wasn't in-network. https://www.consumerreports.org/health-insurance/beat-a-surprise-medical-bill/

[ProudLib72]

5. That's just disgustingly wrong

My wife complains about Kaiser's healthcare. Reading about this shit from Anthem makes me glad I don't still have them.

[HeiressofBickworth]

6. Cases like this are proof

that we need Medicare for all. I agree that it seems like ins cos are requiring people to have the medical knowledge to decide what pain is critical and what pain must be endured until an office opens.

I had my own episode a while ago. Terrible lower belly pain. My grand daughter took me to the ER. Good thing I went as I was admitted for bowel blockage. I dreaded getting the bill for the five-day stay. Fortunately I have Medicare and a suppliment. I don't recall the exact amount, but I do recall that it didn't bankrupt me.

So why can't the rest of the country have Medicare? Or is that a dumb question.

[kairos12]

7. They can also deny ambulance service payments when they deem it not necessary.

Uber is their preferred method I guess.

[progree]

8. Consumer Reports on emergency responders / dispachers ordering AIR ambulances ($30,000)

even when not necessary.

Air ambulance - the average ride is $30,000.

Special Report
Air Ambulances: Taking Patients for a Ride
For-profit air-ambulance companies too often pick up people who don’t need air transport—and leave families with huge bills that insurance won’t pay

https://www.consumerreports.org/medical-transportation/air-ambulances-taking-patients-for-a-ride/

Jennie Stout, a nurse in Ocala, Fla., was finishing an afternoon shift when she got a panicked call from home. Her 13-year-old daughter, Ashlyn, had tripped and fallen into smothered embers left over from burning leaves in their backyard, scorching her hands, knees, and shins.

Ambulance paramedics on the scene when Jennie arrived said that Ashlyn should be sent by helicopter to a burn center in Gainesville for fast treatment.

Jennie was surprised: The hospital was only about 40 miles away and the burns didn’t seem extensive to her. But in that situation, she recalled, “I’m a mom first,” so she didn’t question the decision.

... $24,000 not covered by insurance

http://consumersunion.org/surprise-medical-bills/

[area51]

10. Yes, Medicare for All

FAQ on single-payer health care

[Hekate]

9. My brother felt a sharp pain around his shoulder blade as he was lifting things from his truck...

It persisted and he kept working for awhile. Finally drove himself to the doc-in-a-box, thinking he'd sprained something.

They did a quick EKG and immediately put him in an ambulance to the hospital. It was a heart attack. He's still alive.

Letting actuarial accountants and clerks practice medicine is a recipe for death.

[area51]

11. Scary.

I'm glad he's all right now.

[Demsrule86]

13. Glad he is ok. I have a $5000 deductible and hesitate to go to the ER. I have had shoulder pain

and left arm pain and always am conflicted...I don't want a huge bill but I don't want to die either.

[Demsrule86]

12. This is not new. I had an insurance called PruCare ...and PPO which routinely denied coverage for

the ER...if they deemed it as not essential. Anthem Blue Cross sucks...had it at hubs last job...terrible plan. They once informed me that rabies treatment for an animal bite was not covered as the medicine was a vaccine and thus preventative. They eventually paid the claim but it took some work...the last plan we had with them had an $8000 deductible and a copay after that. Anthem was already denying ER care in Ohio some years ago.