JACKSONVILLE, Fla. – One Monday last September, Kimberly Fister-Mesch woke up in the middle of the night from head pain so severe she thought she might be having a stroke. Taking Motrin and Tylenol did nothing.
When she took her blood pressure and found it spiking to 190/120 (normal for her is 120/90), she had her husband race her to the emergency room a few miles away from their home in Lexington, Ky.
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Fister-Mesch was relieved when a CT scan at the hospital found she wasn’t having a stroke but suffering from bacterial mastoiditis, a serious but treatable inner ear infection. The 54-year-old was given pain killers, an antibiotic prescription, and sent home.
But her relief was short-lived. A few weeks later, she got a letter from her insurer, Anthem, saying that it wouldn’t cover the $4,300 ER bill because her condition didn’t meet the company’s definition of a true emergency. Instead, they said she should have called the insurer’s 24/7 online doctor service or have gone to her doctor’s office or to an urgent care center.
That’s when Fister-Mesch learned that Anthem, one of the nation’s largest insurers, had changed how it determines whether something is an emergency it will cover. The company isn't factoring in the symptoms that prompt you to go the ER, as most insurers have long done, but rejecting claims based on the final diagnosis reached only after tests and a doctor’s exam in the hospital.
The company has rolled out that new policy in several states over the past two years, starting in Kentucky in 2015, then Georgia and Missouri last summer, and in Indiana, New Hampshire, and Ohio last month.
Anthem told Consumer Reports it is simply trying to rein in the overuse of ERs for minor problems such as colds, rashes, and ingrown toenails. The insurer says the ER is a time-consuming and costly place to get care that could be handled elsewhere.
And it notes that the policy has many exceptions, including when a patient is under 15 years old, was told to go to the ER by a doctor, lives more than 15 miles from an urgent care center, is traveling out of state, or goes to the ER on a Sunday or holiday when other medical facilities may be closed.
But a growing chorus of medical experts object to Anthem’s new policy. “It’s inappropriate and dangerous to ask patients to determine whether chest pain is just indigestion or a heart attack,” says David Barbe, M.D., president of the American Medical Association. Anthem’s policy, he says, “is a threat to a patient’s health and threatens them economically too.”
Indeed, hospital officials in states affected by Anthem’s new policy say claim denials for thousands of consumers are piling up, often sticking people with huge medical bills.
That includes Fister-Mesch, who paid her bill and filed an appeal with Anthem to reimburse her. "I felt like I needed immediate in-person medical attention,” she says. “It was 4 a.m. and there was no other place to go.”
- Know when to go. There are no hard-and-fast rules on when to go the emergency room, but the ER is clearly justified if you or someone you’re with is unconscious, bleeding heavily, can’t breathe, or has an obviously broken bone or sudden unexplained dizziness, or fainting. When you need treatment for an illness or injury that isn’t life-threatening but needs to be addressed quickly, such as sprains, cuts, or a sore throat, an urgent care office or your primary care doctor (if she has walk-in visits, as many do) is more appropriate and likely to be faster. Your doctor or a retail health clinic, like CVS’s Minute Clinics, are also appropriate for routine care, say for a rash or a flu shot. If you’re uncertain and don’t feel in immediate danger, most insurers have a 24-hour nurse line you can call for guidance.
- Understand what your insurance covers. Check your insurer’s “emergency service benefits” coverage to see how it defines an emergency and what your plan will and won’t cover. Most offer general guidelines as to what constitutes an emergency, and list common conditions like heart attack or stroke but don’t limit policy holders to specific injuries or illnesses.
- Appeal the decision. The claim denial letter from your insurer will give a deadline for submitting an appeal. To bolster your case, ask first responders, the ER doctors who treated you, or your primary care doctor for a letter stating that your ER treatment was medically necessary. A good resource: the Patient Advocate Foundation’s "Your Guide to the Appeals Process," which includes sample appeal letters. Once you file, the insurer must make a decision within 60 days; if you’re denied, you can appeal one more time. If you're denied, appeal again. Many insurers offer a second level of appeal, which is reviewed by a medical director not involved in the claim denial.
- File a complaint. Lodging a complaint with your state insurance regulator could give you more bargaining power and ensure an independent review of your case. It will also alert the regulator to a pattern of problems he or she should address with the insurer. To find out where to file a complaint in your state, go to Consumers Union’s End Surprise Medical Bills site.
- Negotiate. If your appeal fails, try negotiating with the hospital billing department. The bill you received is for the sticker price and doesn’t reflect the rate the insurer would have negotiated with the hospital. Pricing transparency websites such as Healthcare Bluebook can give you an idea of how pricing for the same service varies at different facilities, and can be a great tool to use when you negotiate.
Those strategies helped Kimberly Fister-Mesch win her appeal with Anthem. She sent a letter to the insurer, along with her medical records, and filed a complaint with her state’s insurance regulator at the same time. At the end of January, Anthem reversed its decision.
Still, Fister-Mesch says she’ll think twice before going to the ER again. “I’m too scared to get another bill,” she says.