My insurance company has a 24 hour nursing phone line. For obvious emergencies I just go to the ER, but for those with the slightest doubt call the 24 hour line and get it on record that the insurance nurse told you to go. You don’t have to personally make the call (your spouse or someone else can) but that starts a paper trail. And sometimes the nurse will call the ER to say you are coming. That helps move you up on the triage list.
My sister was out of state with me once and got very ill. She didn’t want to go to the ER because she was afraid she wouldn’t be covered. I took her to a drug store walk-in clinic and the nurse there immediately sent her to the ER with a document showing she went to the walk-in first. Because she was referred by a health professional her insurance paid 100% (minus copay) for the visit.
Always use the system or the system will screw you over.
34
What kind of problem did Jim Burton think he had with his back that required him to go the emergency department? A slipped disc is an ambiguous term. Even for people with truly herniated discs, which occurs in less than 2% of back pain, there is no medical emergency unless there is loss of sensation or weakness in the legs or loss of bowel or bladder control. Apparently none of those were present.
Why didn't he simply call his physician and ask what he should do and if he needed to go the emergency department and if he didn't have a physician, there are ambulatory care centers.
11
1). What if he didn't have a physician? Millions don't. Read up on the shortage of PCPs .
2). Most PCPs say rather than coming into the office to go to the ER because you need some kind of diagnostic test to RULE OUT something serious
3). Urgent care centers are rarely open 24/7
4) MOST consumers do not have the medical knowledge you obviously have.
42
My insurer -Blue Cross - tried to deny charges for an ER visit. I had severe poison ivy reaction, eyes swollen shut ( on Memorial Day ) and needed steroid shot. I reported them to Insurance Commission and they paid up.
We need better ( Federal , Universal ) laws NOW! Health Insurers are rapacious, heartless , stone cold capitalists - why are they the financial gatekeepers of our HEALTH ??? Medicare for All , bring it on .
53
So strange that human beings can accomplish so much such as space travel and splitting the atom and yet here in the United States, we are, as a society, unable to take care of one another through providing accessible, affordable health care to all. The movement of shifting costs through higher deductible and co-pay limits is having a devastating affect on many in the middle class. This ER policy is not unique to Anthem and is just another example of attempts by insurers to control health care “consumer” behavior resulting in people choosing not to obtain medical care or being hit with unexpected bills that are beyond their means to pay. A one payer system appears to be the only way out of this morass of greed and shortsightedness. America, vote accordingly.
34
2 Years ago Humana denied my trip to ER for Anaphylaxis. In the denial, put in writing, a ‘medical specialist’ held steady to the denial thru repeated requests for review and explanation for 6 fill months. The bill in question was $7500. They paid the claim without comment after I filed a grievance with the State Insurance regulator, with copies to Humana’s CEO. I dont believe the claim was ever reviewed by a medical expert..I think it was a senior clerical level staffer, who didnt take the time to figure out what anaphylaxis even is. They kept repeating in writing, that Anaphylaxis is “not a medical emergency” and that I should have gone to Urgent Care. I sent them documentation from the 3 closest Urgent Care facilities stating they dont treat Anaphylaxis. Humana still stood by their decision. In fact according to the hospital, no one at Humana ever requested the records or comments from my visit. I saved them the cost of an ambulance because the hospital was close, and I had someone to drive me, but In the future I would always go by ambulance. Never heard from them at all..no apology, nothing. Just a silent payment after a threat from Dept of Insurance, altho thats all I wanted. Would never use Humana again. Ever.
37
Just another example of the joke of a health care system we have in the United States while the rest of the civilized World has worked out solutions to health care.
29
I would wager good money that almost everyone railing against Anthem also uses Dr. Google to tell their primary care doctors what is wrong. They also complain about dem greedy doctorz and hate on medicine. But don't let them take the ER away!
1
I dont use dr google, nor do i diagnose myself for my PCP. I do, however, expect my insurance company to meet their obligation of paying for true emergency care without playing games, and making me push them to do so. Your comment is unhelpful
28
We have an amazing Urgent Care close by, EXCEPT it is open only 12 hours a day. What is person to do if an apparently serious condion/injury happens outside these hours? We did use the ER once in the last five years when Urgent Care was not open. Luckily the claim was paid but we did get a stern letter afterward. Where we used to live near Bellevue WA, our HMO’s Urgent Care was open 24 hours a day AND co-located with the hospital as suggested by another reader. It was wonderful! ER’s and insurance company’s need to consider what resources were available before denying a claim.
13
Please look at the folks who benefit from denying to pay for care. . .the insurance companies. This is a game of control of the service providers and to prove the remaining thoughtless folks that doctors aren't necessary for anything except a broken bone. How ridiculous is that mindset? It only makes sense for the insurance companies.
While you are at it, please explain to me why doctors, patients, hospitals and the government don't sue these medication and device manufacturers who create garbage that cannot work beyond the 6 week test period or so? Every time I turn on the idiot box, there is one commercial after another trying to persuade me to eat, buy, or procure the next re-invention of the wheel that will cure a new disease or keep me articically skinny, etc. I could go on and on, forever.
7
"Just see your primary care doctor?"
Find one.
Who has an open appointment.
THIS week.
The profit-mongers and execs with million-dollar salaries at Anthem know this is the most disingenuous advice ever.
And FEW Urgent Care Centers are open past 10.
And wasting TIME during a stroke is wasting brain and life.
Their advice is 100% antithetical to what we are advising people to do with possible stroke symptoms.
If they want consumers to be their own diagnosticians then they need to FUND and operate 24-7 call lines with RNs and NPs to guide consumers - - and accept the liability for damage due to wrong guesses!
33
My 5 year old granddaughter had an emergency appendectomy. A few days later she because very ill and her primary care doctor said to take her directly to the ER, where she waited for hours behind a room full of children with colds, coughs and belly aches. These other children were so ill that they played tag during their wait. Your article deliberately chose borderline injuries and illnesses to make your point and ignored the issue that many people visit the ER for obviously minor problems. Unfortunately many of these people are on Medicaid and unlike (the evil) for profit insurers, Medicaid enables their clients to abuse and misuse the system. As long as hospitals are in the business of making a profit, we need insurance companies to provide a check and balance. And we need patients to excercise common sense in choosing medical care.
9
You have NO idea what the payer mix is for ER patients
And the vast majority of hospitals are not for profit - - and even if they weren't, this approach penalizes the patient, not the hospital.
FYI, insurance company CEOs do OK -- paid an average of about $28.5 million per CEO and a median of about $17.3 million per CEO.
20
While not defending Anthem's arbitrary decision process, let's all acknowledge that there are many, many people who clog up the ERs of our nation's hospitals with symptoms any layperson would recognize as non-ER level problems.
I believe many ERs are prohibited by law from demanding proof of medical insurance before treatment.
We all get stuck with the bill for the unnecessary visits.
Hate insurance companies all you want, but believe me, universal unlimited coverage will be paid by those who actually have the money to pay this medical cost.
And there are millions of Americans who will gladly take all the free treatment they can get and do everything possible to avoid paying for it, no matter how little we ask of them.
4
During his finals week, my son had an esophageal spasm that triggered a terrible case of acid reflux. The doctor's visit cost me $245. At 5 am this morning he begs me to take him to the hospital for tests, because he's sure that something is terribly wrong. I tell him we can't afford a visit to the ER, & that he is going to have to wait until his insurance kicks in in June. Going to the ER without insurance is not free, no matter what anyone else says. The hospital demands payment, & all that does is add more debt to our mountain of debt.
I then lecture him about how being poor means that you have to be twice as vigilant about eating properly, getting enough sleep & exercise. The rich can afford to abuse their bodies & run off to the doctor or the ER for a quick fix. The poor cannot.
We don't climb ladders, & are terrified of accidents, for example. We can't afford to engage in excess of any kind. We live in fear of getting sick or being injured, because we are already at the financial breaking point after I had cancer. Another illness could make us homeless. But some hospitals made a lot of money off of my illness! Did they care about bankrupting me? No!
So much of illness is tied to anxiety, & there is nothing like poverty to make you feel anxious. It is a vicious circle, one that no ER can cure.
What would cure this anxiety is universal health care. The Republican party's greed & selfishness is the disease. It is literally injuring - even killing - some of us.
35
We're currently having this exact fight with United Health Care. My husband woke up in the middle of the night unable to breathe and having chest pains, so I rushed him to the ER thinking he was having a heart attack. To our relief, it turned out to not be a heart attack. However, this means that the insurance company decided that we shouldn't have gone in the first place and are now refusing to cover it. We now have a bill for over $4000. It's absolutely ridiculous. What else should we have done? Waited to see if he actually died first and then called emergency services? We are definitely appealing this decision.
43
Many may disagree with doctors or hospitals making excessive charges but, no legislation, be it State or Federal, should force binding arbitration!
How about we have the first room you come to at the hospital be an "emergency care," facility. They can then decide to send the patient into the second room, the "emergency room."
1
The Freedom Caucus will fix this. No Insurance for you !! No Healthcare for you!!
Typical Americans can and should expect less and less for themselves as we go 'forward' (ahem).
8
I was astounded to learn that TriCare Prime, for retired military service members, requires "retroactive preauthorization" for Emergency Room visits from our Primary Care Physician. Yes, that is the term the nice lady on the phone used when I called TriCare to inquire about the large medical bill's I had received for my wife's visit to the ER for sudden onset of chest pain and difficult breathing. "Retroactive preauthorization."
7
Here is a quote from a 76-year-old traditional Balinese healer, about whom the Times has another article. Our greed-driven society needs to think about this:
"He considers part of his practice healing mostly local patients, who donate what they can afford in exchange for treatment. 'People that come and see me are sick and are already having problems, and if you force them to pay, you make their situation worse,' he said. 'And that’s not healing.'"
6
I would hope that Anthem would spend as much effort in keeping hackers from my data as they do reveiwing ER claims. Sorry, but I feel Anthem is such an incompetent company. Although I understand it is difficult for Amthem when so many run to ER for very minor issues. Still, Anthem and the industry have so many other problems
3
Insurance companies exist to make money. If they pay every claim they can't make the desired money. So let's see. The insurance company denies your claim. The government tells the doctor what he can and can not prescribe. No wonder we are all sooooo healthy. What an idiotic system we live under.
11
Awful, awful insurance companies. They are there for OUR health, in theory, but we all know they are there to profit. When that profit comes at our expense, as it too often does, they need to be regulated. Or more. Single care never looked so good.
11
What an astounding lack of common sense in these comments that wail "oh but but I can't tell if I really need treatment right now!"
(1) Basic first aid class
(2) Where you learn to take a temperature, check a pulse (or heart rate if you have a cheap stethoscope at home as I do for the animals), count respiration & see if it is normal or shallow & more stuff
(3) If you still need help to figure out if it is super-serious, try google. Gawd knows you all use for everything else!
For example, lifting box & sudden back pain....gee maybe you pulled a muscle & need to get some linament & heat on it & massage? Go off to the ER & even IF it is a disc, they will send you home with aspirin & tell you to lie down with some heat.
VOX has been wailing about this. One story was the parents who were trimming the toddler's nails, cut too close & it was bleeding. DO they do the sensible thing of cold water, pressure & elevate & then a bandaid? NO - off they go to the ER for a bandaid & then whine about $629 bill. Trust me - the cut finger was a LONG WAY from the kid's heart & she wouldn't die from it.
You CAN learn to triage at home. Learn to take a temperature & the steps to lower it (NSAID, cool water in tub etc) Learn to take a pulse/heart rate & what is normal. Buy a $25 stethoscope. Learn to count respiration & whether normal, shallow or labored. Learn how to tell shock (dilated pupils, gum refill time etc)
I do it ALL the time with the large & small animals & ourselves
6
Diagnosing a stroke requires an MRI
Got one of those in your basement?
And glad you have taught yourself what doctors spend four plus years learning. Do you do your own dental work and cut your own hair?
And first treatment for back pain is ICE. Heat makes inflammation worse Back to Google for you
23
Death panels? I thought that required socialism.
8
This country needs only one insurance company: Medicare from cradle to grave. Compared to 11 countries that have single-payer, the US ranks last in quality, outcomes and access. Unfortunately our elected "representatives" represent the interests of corporations, not the people that elected them. Single-payer will lower health care costs in this country dramatically and actually improve health care.
Teddy Roosevelt was the first US President (and a Republican!) to advocate for single-payer. We need to elect a President and a Congress with his ideals and integrity. We need to end Citizens United that allows corporations to fund campaigns. And we need to educate our children to use good judgement when they are of age to vote in order to prevent the corruption and incompetence we now have in Washington.
16
Having to second-guess whether something is life threatening is NOT what we should be doing. Even Medicare is pushing back on paying for ER visits, and yet when I go to an urgent care facility, they bring me to the ER because I'm over a "certain age".
It's especially problematic for those who live alone, who have no one to watch over them to see how they fare when they're not well and may not be able to get help.
What kind of a country is this?
16
Wait till they start cutting Medicare, to pay for the tax cuts.
10
Several years ago, a relative went to the ER with a severely
swollen hand & arm. Since the final diagnosis was poison ivy, the insurance company denied the claim. When the patient
sought medical treatment, he didn't know that he was ALLERGIC to poison ivy!
A female neighbor went to the ER by ambulance because she knew she was having a heart attack--she had already had a previous heart attack. As mentioned in this article, her symptoms were different from male heart attack symptoms. Because she didn't include the words "chest pain" to describe her symptoms, the ambulance paramedics
wrote up a report that resulted in Medicare's denying the claim for the ambulance bill! Medicare said that the ambulance ride was "not medically necessary." The irony was that Medicare paid for the ER visit & a hospital stay
because my neighbor WAS diagnosed with a heart attack!
Medicare's explanation for the difference in payment was
that a different contractor processes ambulance claims from the contractor that processes ER & hospital claims!
11
This is a slippery slope. Last month I had abdomen pain (and at my primary care doctor’s recommendation), went to the ER. Three hours later had an appendectomy.
I think a ‘reasonably prudent’ person would agree that chest pain and/or trouble breathing is a reasonable basis for a trip to the ER.
I’m sure the new rule is pushing back on the fairly large number of people who treat the ER as an urgent care. A good friend who is a paramedic in a wealthy Chicago suburb has endless stories of people who call 911 for clearly non-life threatening complaints (and the paramedics are required to transport them).
I guess we should just consider there are 2 sides to this story.
10
A better question perhaps is why are ambulances and ER treatment so outrageously expensive in the USA?
I live in the Cayman Islands. Not a cheap place to live and certainly there is no socialized medicine.
A few years ago I collapsed while having lunch with friends at a restaurant.
An ambulance arrived and took me 20 minutes away to the hospital. I was seen quickly in the ER and kept for a couple of days.
My total bill was about $2,000.
The following year I passed out in my home in Florida. An ambulance arrived and too me 15 minutes away to the hospital.
The bill for that ambulance ride ALONE was $1,800.
The USA has great doctors and hospitals. But wow are they expensive!
15
When I developed a fever but no other obvious symptoms, i called my internist. She sent me to the ER, where I was subjected to a chest X-ray, blood tests, and urinalysis, in that order. The cause of the fever? An asymptomatic urinary tract infection. My proposal: stop sending patients to the ER as a first resort. The UTI could have been quickly and cheaply diagnosed at the doctor’s office. Once the patient is in the ER, start with the least costly test. That would save both time and money for everyone.
7
I had Anthem for two years. They continually made it more difficult to access medical services. They dropped urgent care centers, until the closest one to me was 8 miles away. Searching for a hospital, the website told me there was no hospital on my plan within a 20 mile radius. Really? This is Los Angeles! The practice that my primary care physician worked out of was no longer on the list of providers - dropped by Anthem. All the physicians listed on their website were no longer accepting new patients. What to do? I ended up NOT seeing a primary care physician for two years. I used the urgent care they listed, which was horrible and in a bad part of town. Or I went to the urgent care near me and paid cash.
I have had Kaiser for three years, thanks to the ACA, and, after a total knee replacement, am completely satisfied with the care I receive there.
18
Yes. Time for single payer with Kaiser as the model. My family, which includes 2 kids, have been Kaiser members for more than 30 years with not a single serious complaint.
13
Last year, I had to take my 14-year old to the ER for suspected appendicitis. His symptoms were indistinguishable from early appendicitis, and even his RN stepmother agreed that it was wise to take him in. Thankfully, it turned out to be a strep infection that was causing abdominal pain and fever. But I'm on the hook for $1500 either way. This is unfair and stands in between patients and good healthcare. What are we paying for if all that's ever covered is routine preventive care?
15
Your article failed to mention that many times people cannot get prompt appointments to see their family physicians. Mine (at a facility with multiple physicians), routinely directed patients to go to the hospital emergency room or an urgent care facility instead.
Anthem's policy refuses to acknowledge the realities of getting healthcare from family physicians.
23
If the docs who participate in Anthem keep sending patients to the ED for no good reason, then it should kick them out of the program.
I doubt whether this country will ever move to a single payer system or even see legislation that imposes serious regulation on the health insurance industry until the majority of physicians refuse to continue to do business with the insurance companies or practice in hospitals affiliated with them. It amazes me that physicians continue to allow medical decision making policies to be dictated by an insurance company's bottom line.
12
The continuum of doctor's office - urgent care - emergency room can't easily be navigated by a layperson unaided. If insurers want to penalize patients for choosing the wrong point on the continuum it is incumbent upon them to provide tools to assist the patient in making the right choice. These tools need to be easily navigated, understandable, fast and accessible. These policies seem likely to discourage more than the 5% of visits labelled as unnecessary.
9
When the urgent care clinic sent me to the ER because they were afraid there was a life-threatening condition that could need hospital care, but it was a mistake. They had the ability to treat me, but instead I got an ambulance ride and a bill for multiple thousands of dollars.
If the doctors at a clinic sometimes don't get it right, why should we let insurance companies make decisions based on second-guessing doctors? We truly live in a money-driven idiocracy.
23
I just found out that someone I know went to the emergency room, and her insurance wouldn't cover it. She's unable to pay. Of course she's now more or less unable to obtain any further medical care, which is needed.
I understand that a recent study indicates that not too many Americans face bankruptcy due to medical bills. But financial catastrophe clearly happens.
14
Aetna and Cigna have long had a policy to deny all original requests for coverage. It makes one wonder what business they are really in and who they really work for.
It appears that they work for share holders, rather than their customers who have little medical education and feel that their life and family finances are in the balance.
19
They are a for profit company, right?
1
My last urgent care cost was $800 for a scratched cornea. Although we don't know the medical facts regarding Melania's stay, it appears to look like a 5 day stay for what is typically an out patient or overnight stay. I just watched them send my sister home the next day with a knee replacement and hypertension. I was told that in 6 months time knee replacement will be handled as a totally outpatient procedure with patients going home the day of surgery. Clearly the average consumer paying $12K plus per year for insurance is the loser in this racket.
24
How is being explicitly advised by a doctor/urgent care center to go to the ER not grounds for presumptive coverage? Our six-year-old recently fell and hit/badly cut his face. Our pediatrician told us to go to our well-respected children's hospital ER and not to an urgent care center given the location of the cut/stitches. We got a huge bill from the hospital. Was I to second-guess the doctor?
25
People who are hampering to have the AHA overthrown because of the higher costs in some states don't realize
what they are throwing away.
There is a reason hospitals and the doctor's offices ask for health insurance cards and or the ability to pay even before one is allowed to see a doctor.
Even more so, they ask if you have an HMO or PPO.
And another thing to think about, there is a reason why all of these hospitals are now being incorporated into these groups and doctors are now part of these groups.
In some countries, if one doesn't have the means of some sort to pay for 'living', you are sent home....to probably die or suffer.
I see the same happening in this country.
The only thing that might save us is a universal health care system, but that would mean paying more in taxes like they have in say, Canada, England, and Sweden.
So what's it's going to be America.
12
In those other countries you would pay more in taxes BUT an ethical employer would pay you higher wages because the employer would no longer need to pay for your health insurance.
23
US is a Third World Country with a dictator. What do you expect?
21
This article while well written and factual misses one major problem.
Those whom have coverage from private insurance are those whom pay the tolls for everyone else who does not. I am an ER physician and routinely see 60-70% patients who have no emergency issues or need medical attention; some recent cases in point, a minor sunburn, poison ivy, a toe that had been stubbed, fingernails too long, and those faking injury to obtain narcotics. These types of patients severely jam up the system for those people with life threatening injury or illness and cost the hospital and tax base millions.
15
ERs may need a better triage system and provide referrals to a non-medical social work group. One problem cities are facing is an un-insured population without work-related insurance. They often lack transportation, time and money to use the 'proper' system.
Many cities are in the early stages of implementing person-centered systems centered around schools, nutrition, health service centers
12
Hey ER Doc,
What’s the solution? UTCs attached to ERs? Stronger support for triage nurses to direct patient care to Family Medicine, UTC, ERs? Denial of service? I’m all for sitting down and finding sensible solutions. I just don’t know what that looks like? What’s your solution being that you are on the front line?
-Jim
3
and the major point you intentionally ignore is that the use of the ER for "common" complaints is what the uninsured had no choice to do before the ACA. The trend started towards moving people to primary care doctors before the R's took over Congress and the White House. With their constant drive to cripple the ACA the pendulum is swinging back towards the ER being the only primary care some people know.
It takes time to change behaviors and certainly many primary care docs refused to take Medicare/Medicaid and other low-reimbursement insurance plans created under the ACA. Those poor uninsured people were, as a group, moving towards primary care, now as a group more will move away from it.
And people like you are to blame for it.
6
Urgent Care Centers are everywhere and apparently aren't where they are MOST needed - right at the hospital. Just build them on the hospital campus and the prospective patient could get triage right there, close by a hospital in case you need to go there.
The health insurance industry not only increase our premiums every year (has raised mine every year for the past 40 years). They've raised our deductibles to exorbitant amounts, and now they want us to diagnose our EMERGENCY situation and decide (rightly or wrongly) which place we need to go.
What if we make the wrong decision?
30
The most needed remedy is requiring everyone, even those with Medicaid/Medicare to have and routinely see a family physician.
1
I have worked in health care for for 30 years. One winter day I slipped on the ice and injured my ankle painfully. But I knew the "Ottawa rules" for deciding if an xray was warranted, and determined it was not. I got a ride home, rested, iced the ankle and took ibuprofen. When I hobbled into work the next day, every nurse and physician who asked me what happened was horrified that I had not gone to the ER. Damned if you do, damned if you don't...
23
The problem (at least with Anthem) is not just the ER. Try to get them to pay for what treating doctors consider to be necessary mental health care. You'll find that Anthem's experts, who have never met the patient, overrule those who have. The appeals process is onerous: the first 2 (!) appeals are internal to Anthem. How convenient for them.
We need universal health care, not universal health insurance, where access is controlled by for-profit companies. The incentives are all wrong. It's a warped and dysfunctional system that's unique to the USA.
24
The medical insurance is becoming a bigger racket each day. They will try to get anyway with anything and everything they can. I just found out the hard way that my $2,400/month policy doesn't fully cover "radiology." I used to worry about making sure I stayed in network but this is not enough. You now have to a carry around a cheat sheet to confirm coverage. This means that while you are at the doctor's office wincing in pain after paying your co-pay, you have to call the insurance company before treatments and tests to avoid surprise bills. They said you have to read and memorize the insurance fine print. How unreal is this but this was what I was told by the insurance customer service. They blamed this on AHC. I can't believe how little $2,400/month gets you now. Make sure to fully understand your policy, including what is covered under "radiology," before you mozy on over to your in network doctor's office. Personally, I was told ultrasound was not covered under annual exam. They said this is clearly printed in the policy and I should have known this. Shame on me for not knowing radiology does not include ultrasound. Totally out of control.
25
In addition, in-network hospitals will knowingly assign out-of-network physicians to emergency patients and will refuse to formally admit a patient for more than 24 hours, thus forcing patients to pay extra for the physician and for the hospital stay because it is treated as out-patient care and thus triggers a higher deductible. As if a patient in an emergency can pick and choose doctors and hospitals...
12
now i know why er kicked me out so quickly even though i complained of pain and nauseau when i had kidney stone. i begged to stay a little longer bc i didnt feel well enough but it was to no avail. unreal. i paid over 250k so far and luckily no medical problems but its been never pleasant the few time i had to rely on it. wish i could get some of premium back.
Why bother passing laws against it when some enterprising DA can just charge the executives that developed the policy after the death of an insured? Hard case, but it might teach them a lesson.
4
I guess from Anthem's vantage point, anything less than a gunshot wound is not deemed worthy of treatment via an ER physician.
15
Reality check the homeless dont have health insurance so doctors can refuse treating them . Dentist can refuse treating person with out insurance. Affordable health care is for those who healthy dont need it . Insurance companys made billions on healthy people now tha tit manditory.
2
Emergency rooms must treat all who come in claiming an emergency without regard to whether they have insurance or can pay. That's federal law. At a minimum they must stabilize you. After that you're on your own.
2
Im a doctor and Anthem is right. Even if you felt you had 'slipped a disc' there is nothing special an ER could do. Analgesics and a day or two rest and gentle mobilization. Americans run to the ER at an alarming rate, and unsurprisingly, pay for it.
10
YOU have an MD. The person with an injury does not and so doesn't know what to do
YOU need to re-read the oath you took!
17
Easy for you to say bc ur a dr but how does a layperson know this?
8
If you see the cases I see daily in the ER you may alter your opinion. People come into my ER for toothaches, minor poison ivy, or simply to seek narcotics. People abuse the ER and in turn have to pay for it. Our society is too dependent on everyone else having the answers instead of taking a personal assessment and a moment to analyze your own situation.
The system is broke and inefficient only benefiting those whom do not have a copay or simply use the ER as a catchall on some sort of subsidized federal insurance program.
If your medical condition is non-emergent then do not come into the ER and refer to your family physician.
3
Health Care system in US is a malignant blight indeed disease on our society, the closest I can come to describing is not cancer but AIDS - an autoimmune disorder where the very system that is supposed to be protecting the host (body) instead turns on it, and corrupts and poisons it from within. As it is inseparable from the host it supported the entire corpus dies - rot from within. The weight of this bloated, self-gratifying, self-justifying system overtaxes whatever remains healthy and the entire enterprise just collapses. Absolutely the most complicit specialty is psychiatry where freedom of choice is to a large part removed, right to refuse treatment (i.e. medication) is denied in practice, and the resulting co-morbidities are the primary generative engines for the rest of what is essentially a giant Ponzi scheme. This Ponzi scheme, unhappily, works because the principle of caveat emptor cannot apply, thus giving new meaning to the words "bottom feeders". Gut yuntif.
13
Stunning metaphor.
3
I hit my head in a skiing accident. It seemed minor. At dinner a few hours later I collapsed. Above my protestations I was taken by ambulance to an emergency room. A few hours later it was declared a simple concussion and I was discharged. The insurer, an HMO, refused to pay because it was not a serious injury, and I was hounded by phone for months by this poor hospital in Glens Falls NY . . . . This was in the mid-1990s, the heyday of HMOs. That particular HMO, called HIP of NY-NJ, eventually went bankrupt. Fast forward to 2018: The names have changed but the game hasn't. The patient is still stuck. Either you're too sick or not sick enough.
16
The "problem" can be boiled down to the phrase "profit driven."
19
The Glaring Big Elephant in the Room is that US hospitals need to post their prices, clearly and prominently, where EVERYBODY can read them. In fact!!! PRINT THEM on a flyer, and drop the price list in every single mail box in the the hospital cachment area. If the hospital won’t do it, the patients need to do it. Where else in the world do you find out about prices after you incur the cost?
5
And THEN what???
You are having chest pain but you stay home? Go to an ER 3 hours away?
No one risks life because of costs
8
So, the Insurance Co gets to "Monday morning quarterback" a lay person's decision???
14
i went to my doctor with bit of chess pain. He instructed me to go to ER immediately he will not examin me. The ER folks wanted me to stay for 2 nights, as rhe scanner was ubder maintenance. 4 weeks later I received $4500 bill, for heart scan, Blue cross refused to pay because the scan shows no sign of heart distress, therfore the procedure was not necessary!! i end up negotiating a reduced fee but vlie would not pay. this practice is not new and is very common
11
Insurance companies are agents of death.
They make money when you do not get medical help.
The people who decide you fate have bobble heads on their desk constantly saying no.
For the health of the nation health insurance companies need to go.
Medicare for all!
19
This situation only occurs in the United States, the only country in the developed world without universal health insurance.
16
Traditional Medicare for All.
14
And doctors need to be required to accept it. I just had to change from a specialist I have been seeing for over 20 years. I went on Medicare. He doesn't accept Medicare. He won't treat people over 65. To my mind, that should not be legal.
11
Medicare and Medicaid literally reimburse pennies on the dollar compared to private insurance. Medical practices actually loose money on those visits! So those that don't get extra government funding (those that aren't Federally Qualified Health Centers) almost always have to limit the number of these patients they can take in order to keep the practice afloat. These also tend to be sicker patients who need a lot of care, further exacerbating the problem.
You all the need to find a better health care system in the US. If you are an average middle class Joe, you would be way better off, and have peace of mind too, with a Canadian type system.
The only argument made against such system is that the US system has higher quality care. That is disputable, except for some really exceptional cases. But anyways, what good is it if a profit motive entity managing your health care from a spread sheet denies you that supposedly superior healthcare!?
The average Joe can’t win in the US system. And guess what !?....Trump ain’t gonna help.
10
This is only part of the story; please make public how much this “insurer” lobbies congressmen! Please!!! Rip off the consumer so you can continue to buy off and corrupt government so you can continue to rip off the customer and skim off the top. This is how big business in America works-we should call it the American Model.
13
We need a US Attorney General and President who understand that tactics like Anthem’s are dangerous and ruinous to our social fabric and worthy of a federal investigation and rebuke from the White House.
9
This is not about patient concern or quality.
This is about reducing expenses and protecting profits.
Aren't patient deductibles enough?
Patients are in no position to assess their health risks.
What this should prompt is single payer or a system that approximates this.
What this should prompt is mass law suits against Anthem.
What this should prompt is patients switching to other insurance carriers.
12
My last ER visit involved symptoms of a panic attack. I went to the ER because I previously had a heart attack and it was late at night. I wasn't treated immediately even though I told the admitting nurse of my heart condition for which I was treated at that very hospital. The doctors claimed they couldn't diagnose my condition. One doctor thought I might have blood clots in my lungs, which I thought unlikely as at that time I was feeling better. He suggested an MRI. I asked him if my insurance covered his services and he didn't know. I asked him the cost of the MRI. He didn't know and couldn't find out. My refusal led to extreme pressure by the doctor and my family to get the MRI. The insurance company paid the MRI but the doctor was not in the network even though the hospital was.
Can a patient demand in network doctors at such a hospital? Why would a hospital have out of network doctors?
17
They subcontract
6
Most doctors, especially in the emergency dept, of community hospitals (those that aren't at a university) don't work for the hospital. They work for large physician groups that contract with the hospital.
5
My guess is that most people who show up in emergency don't really have an emergency, but they don't know it. Something is wrong, it's the middle of the night, and they want to make sure it doesn't kill them. So they go to the only place that's available.
The solution might be a simple as adding an urgent care facility to the emergency system and letting the admitting system perform triage to direct patients to one or the other. If the triage gets it wrong, the urgent care personnel can correct the mistake and send them to Emergency, or the Emergency personnel can send them to Urgent Care, because both functions are co-located. Also, the urgent care facility could help handle the overflow in the case of a widespread emergency.
15
Thanks for this article, but it fails to note an issue that, frankly, makes it grossly incomplete.
The vast majority of Americans have their health insurance through their employment. All of these policies, less those for government employees and religious institutions, are subject to a massive Federal law, the Employees Retirement Income Security Act of 1974, or "ERISA". It preempts ALL state laws relating to health insurance policies within its reach. The many, many safeguards against insurer avarice, deeply engrained in state statutes and common law, were blown clean out of the water when Gerald Ford signed ERISA into law. ERISA is the boss, and if your insurer denies a claim, in whole or in part, your only remedy is ERISA.
First intended to ensure people with health insurance would receive the benefits they were paying for, the Supreme Court, through a series of decisions starting with Bruch v.s Firestone, has completely upended it. Passed as a consumer protection law (Senator Javits, hailed it as the greatest development in the life of the American worker since Social Security), it is now a sword in the hands of insurers. Everyday they hide behind it to deny claims. The remedies ERISA creates look fine on paper, but the Supremes have utterly gutted them, stating often that only Congress can "fix" it.
But it won't. Every few years they discuss it and then do nothing.
Any discussion of the health insurance industry that fails to note and explain ERISA is vastly incomplete.
16
The emergency room, which functions as the front door to most hospitals, contributes a substantial portion to the nation’s enormous health costs.
Please define "substantial" and provide data.
9
Are insurance companies such as Anthem licensed to practice medicine? From the evidence, they are making more and more medical care decisions while physicians and patients remain mute. It will not change until victims realize that power is always taken, seldom given.
As a result, witness how Anthem folly follows when attention is not riveted toward patient interests.
12
Another problem RE urgent care vs. ER. My adult son who lives about 80 miles away and had Kaiser HMO insurance in a metro area fell from a ladder onto concrete, badly scraping his back against a brick wall on the way down. It was a Saturday. I took him to an urgent care but the receptionist was not able to confirm that the practice accepted the Kaiser insurance and recommended we go to the ER. It was his first claim of the year so his high deductible meant he had to pay the exorbitant $1500 bill for x-ray and wound care. If we had known he had no head or spine damage, he could have saved a lot of money by staying at the urgent care for wound treatment. I had in mind that emergency care was always covered without a deductible so I wasn't thinking of the cost at the time. Why the heck does getting the care you need when you need it in the United States of America have to be such a major hassle? I'll tell you. Because we don't have a single-payer insurance system. I'm sick of the whole mess!
23
This is the problem with for profit healthcare. A company that made 2.5 billion last year has to find ways to make more. This is why we pay more than any other country for healthcare and do not get the best. What about the stress these companies put on their "customers"? I am certain that is good for them.
22
Anthem is behaving poorly, but so are the ERs. My daughter had a minor gymnastics injury that led the local urgent care facility to refer us to the local ER. She was seen by several physicians, each of whom was out of network though the ER is supposedly in network. The doctors must have looked at us as a nice little money pump. The bill was appalling: more than $3,000 for a 30-minute visit and a diagnosis that nothing was really wrong.
This type of behavior happens all the time in ERs nationally. We've heard from friends in Arizona, California, and Minnesota with similar experiences as our in Brooklyn. Here's a simple equation for healthcare today:
For-profit hospital + for-profit insurer = unmitigated disaster
On most economic issues I lean (1990s) Republican. However, on healthcare, I am 100% for single-payer nationalization. The current system is broken beyond repair, and it's a question of "when" not "if" it will be dismantled and relegated to the dustbin of history.
21
This story actually proves the point Anthem is trying to make. Sounds like this was a situation where the urgent care should have told you to go home and put some ice on it instead of to the ER. People present for complaints that they themselves call "minor"!
Emergency care is extremely expensive because it has to be open, fully staffed, and 100% prepared for disaster 24/7/365. Also, most ER physicians don't work directly for the hospital they're in, they're subcontractors. And less than 20% of US hospitals are for-profit, the problems are system-wide.
1
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.”
If it was so obvious that his condition wasn’t serious, why did it take $1,722 worth of health care to prove it?
27
MBA's running health care. What could possibly go wrong?
17
Universal coverage is needed. At the least, no for profit health insurance companies with their vile medical loss ratio should be allowed. A heavily regulated system system like a utility would work, similar to Switzerland.
12
Why are we blaming the insurance company when most of the problem is the absurd amount of money emergency rooms charge. An ER visit should be no more than an emergency visit from a plumber on a weekend, and if there is a need for further treatment then standard hospital fees should kick in. People really do need to be trained to recognize panic attacks, so they do not waste the time of medical personnel because so many ER visits are obviously time consuming and a waste of human resources. Humans are such hypochondriacs.
3
A few years ago, I had the basement sewer back up -- horrifying -- and the bad luck that it occurred on Memorial Day weekend. Not only weekend overcharges, but DOUBLE charges for a HOLIDAY weekend (even though Memorial Day is hardly Christmas!). I called dozens of plumbers and was quoted prices to come and clear the drain of $1000 to $1500 AND UP for about 15 minutes of work. So....my husband and I gritted our teeth, and got our shop vac, and pumped what we could out of the basement, so we could survive (barely) for two days until we could call a plumber out at regular rates. Instead of $1500, we paid $200 -- but we had to live in utter filth and misery for that weekend. But we were never in danger of DYING, just uncomfortable. When it is YOUR HEALTH or that of your loved one....what choice do you have? To let them bleed? have a heart attack? a stroke? while you wait for medical care, since you cannot afford the greedy ER?
4
Medicare for all, but if you like your Health Insurance Company you can keep it.
5
Who is going to pay for Medicare For All? I note you are conveniently in Australia.
Medicare is not free, cheap and also does not cover all medical costs unless one has a supplemental plan.
Many people think Medicare is the be-all end-all for health insurance in the US and that is not necessarily the case.
3
I believe we should have universal and non-profit health care, but I know that the E.R. is the most expensive possible place to ensure this. We are, or should be, our own best first line doctor. Everyone has a responsibility to society to know how to lift a box and the consequences if you mess it up, and to know those consequences are painful but not life threatening. That’s a glib example, but we should all know the symptoms of a heart attack, a stroke, uncontrolled bleeding, etc. We should all have a plan in place for appropriate medical care. Those who routinely use the E.R. as a first line of care are costing us all not just money, but also social and political capital.
4
How can lay people be expected to correctly diagnose their medical problems when sometimes even specialists get it wrong? The list of conditions that warrant an ER visit is long and the list of symptoms (which can vary widely from one person to another) is much longer. My brother nearly died because he waited so long to go to the hospital, incorrectly thinking his symptoms were not serious. I had a neighbor who mistook pain from kidney disease for a strained back.
15
Way too many people are going to the emergency room for minor ailments--this is a good idea. If you are having chest pains that is another thing altogether. Some people will sit in the emergency room for six hours when you can go to an urgent care center and be seen immediately.
Urgent care is a rip-off perpetuated by the health industry. I have been to urgent care sites 4 times. None of those times did they treat me in any way. Twice they sent me to the ER. Once they actually took an X-ray. The last time, they shrugged and said “Sorry, don’t know what’s wrong.” They are useless. They are just another stick for insurance to beat poorer people with.
11
Why don't ER's turn away people? Because it's ludicrous to diagnose anyone without an evaluation. So professionals wouldn't "self-diagnose" but lay-people should. This is Insurance companies baiting a "tragedy waiting to happen". Doing so by gauging profits vs pushback from consumers and legislators by muddying the contract language; in their favor.
8
The ER cannot turn people who present for care away.
This is Federal Law, meant to offer any person seeking care the ability to see a trained healthcare provider without regard to their ability to pay.
From the Centers for Medicare and Medicaid.
"In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay. Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual's ability to pay. Hospitals are then required to provide stabilizing treatment for patients with EMCs.
"
3
I thought that Donnie Trump was going to solve the health care crisis in terms of the costs of medications by negotiating as Canada, the UK, and France do for what government providers will pay for the most common drugs recommended by a physician. Some deal maker. Ah well, bait and switch again.
5
It took Obama 5 years to implement lousy, worthless Obamacare -- but you only give Trump 16 months?
3
Obviously, use of the ER for personal scheduling convenience is abuse.
The question is how to avoid that, without killing people.
Without sending every patient to medical school, the requirement for accurate self-diagnosis is absurd.
If a problem that doesn't actually require an ER visit should have been obvious to the patient, why should the ER's workup be priced at $3K? If it was so obvious, shouldn't it be obvious to the ER to evaluate instantly at low cost? The problem is the law -- a visit to the ER exposes both ER physicians and the hospital to liability that force them to do what's often more legally defensible that clinically reasonable. When a patient is killed by an inaccurate self-diagnosis, no one suffers other than the patient.
For a long time, a rational approach to this problem has been achievable through software triage. Especially with voice interfaces, patients can be questioned using capable hand-tooled expert systems (and, over time, by machine-learning system).
Triage to the ER should guarantee coverage no matter what the ultimate diagnosis. But to make that acceptable to hospitals, the law has to be changed to shield the deployers of such systems from potentially overwhelming liability. This will mean that some patients will be incorrectly triaged, but it's a whole lot better than self-triage that will lead to disaster more frequently.
3
How about this? a REAL health care reform, that required all hospitals to have both Urgent Care and true ER care....with an initial consultation with a triage nurse, who would then direct the patient to the most appropriate care. ALL such facilities would be open 24/7 and required to treat everyone regardless of insurance status, and to ONLY CHARGE the trust cost of care, not some inflated B.S. "chargemaster" price -- the true cost being determined by MEDICARE standards (or Medicaid, or a combination of both). Then everyone would know where to go, and real medical personnel would decide if you had indigestion -- or a massive heat attack -- and NOBODY would be charged $4000 and up for a 10 minute consultation. OH and no doctors out of network ever.
3
Once again we have non medical professionals making important decisions regarding health. I don't want an administrator making a choice about whether chest pain is indigestion or an MI
11
Anthem is directly going against medical advice. This policy is 20/20 hindsight by bean counters. A percentage of all ER visits are precautionary, The patient must go there to find out if it is an emergency. The folks on the phone when I called for a possible emergency were very clear - they cannot diagnose over the phone. People must go to the ER to find out if it is an emergency in many cases. Anthem's policy WILL kill people. This policy is just plain wrong and must be outlawed.
13
Since the republican Congress could care less, state insurance commissioners or state legislatures should subpoena the Anthem CEO to a hearing and cross-examine the son-of-a-gun to expose his company's conduct to the public. And some legislator should tell him, on film, that no one in their right mind should choose to be covered by
an Anthem policy as long as they interpret their policies this way.
4
A conundrum. I’m not a doctor, but my health insurance wants me to self diagnosis prior to heading to an ER? Couldn’t I sue myself and the insurance company as a co-conspirator for medical negligence when things go inevitably wrong? Oh, wait - I’m not an attorney either!
13
These heart rending anecdotes mask the fact that most users of the emergency room are abusers and costing working families real money. They need to lose weight and get jobs so they can pay their fair share. I pay work and pay my bills; I don't want to pay theirs too.
2
Agree, But there are also people who have gamed the system for a lot of money. There are also people who think Ers are their PCP, also people who wait till midnight who wait until midnight to go to the E.R. for a cold. E.Rs are very expensive,
What to do??
2
Denied ER visits are the logical outcome as insurers are forced to maintain (or decrease) premiums while expanding what's covered when consumers no longer are required to purchase health insurance (Obamacare mandate). So insurance must choose where they can deny claims without facing medical liability.
Is this action by Anthem morally reprehensible? Yes.
Is it unreasonable for a lay person to determine if an ER visit is truly warranted? Yes.
Is basing payment decisions on the results after the tests are done blatantly unfair? Yes.
Is it legal? Apparently.
3
RE: "may discourage people with serious problems from seeking care. "
Isn't that the point? People will just stay home and suffer which won't cost them anything or they'll die which will cost someone else some money. Win - win.
For those who will say that there is no incentive for an insurance company to put off treatment which will result in more expensive care later, poppycock. US companies are famous for this period bottom line decisions, what looks good this period, next period is someone else's problem. Lack of long term view is a hallmark of our system of our financial expectations.
6
CIGNA has this same absurd and dangerous policy, and they require that insured patients pay at higher out-of-network rates, typically 40% deductible, if CIGNA, in their review determines the ER visit was non-life threatening. This can only lead to more people dying from heart attacks, asthma attacks, strokes and undiagnosed cancers. It's a greedy policy.
I personally experienced similar issues when struck with an emergent kidney stone. To avoid the ER, due to Cigna's new rules, I instead called my urologist, told him I was in agony, and he advised me to come to his office for a CT scan.
CIGNA then balked at preauthorizing the CT scan, as I was desperately waiting in the waiting room, hoping the next wave of writhing stone agony would not come. I chewed them out thoroughly over the phone and told them I'd sue them for damages if I had an attack due to their absurd dithering.
Turned out they had a new policy and wanted me to go to get cheapest CT scan in my area, failing to recognize it was an emergency. Later, I found out that my urologist did have the cheapest cost after all. They just didnt check.
The point is that no patient should have to suffer in agony, or risk death or severe injury, due to the incompetent bureaucracy and rampant greed of health insurers like CIGNA and Anthem. We need stronger enforcement of laws to protect consumers from these abuses.
12
How do you regulate greed? There isn't enough profit in doing what makes sense. Until then we'll continue to write our fat monthly checks to health insurers, think very carefully about who gets our votes, and/or hope to make it to sixty-five.
7
Thank heavens for Conservatives that tell us we should all be responsible for ourselves and our lives. It simply does not matter that such thinking is totally devoid of real world considerations. Only ethical thought experiments are necessary for Conservative thought. People diagnose their own symptoms. Poor people should save more money and open their own businesses.
Women should always want to carry their fetuses to term, regardless of any other circumstance because the Bible says something. Starving kids in broken families should just study harder to get a degree that pays well. Arm the whole population to reduce gun violence. Simple, common sense solutions. MAGA, indeed.
6
The comments critical of Anthem give a window into why a single-payer system will be very, very expensive if implemented in this country. Health care providers (in this case the ER), will be unable to say no to any service demanded by a patient.
3
And I'm sure this insurer provides its services for no monthly fees... Are you kidding me? Health care in the US has gotten completely out of control. I pay $800 a month for insurance (for my self only) that carries a $4000 hospital deductible. That means if I don't go to any doctors I start the year almost 10 grand out of pocket for no service whatsoever. A brilliant product marketing strategy, don't you think? "You give us your 10 grand and we'll give you... NOTHING." Pure genius. This country is broken in so many ways but the biggest is the health care system... Or should I say Healthcare-lack-of-system. Or should I say Healthcare money scam system.
12
My first thoughts with regard to Anthem's policy was 1. What if the incident happens on a weekend?. Doctor's offices are not open. Urgent Care facilities close early and only treat minor illnesses. 2. There's no garantee that you will be able to get in to see your doctor. This recently happened to me.
Admittedly there are those who abuse the system by constantly going to the emergency room. However, punishing people such as those depicted in this article, for the actions of these others, is ridiculous.
Thanks to Trump and our "wonderful" Republican Congress more and more people will end up at emergency rooms because of the elimination of the Individual Mandate for having insurance, buying cheep insurance plans that cover nothing or inability to pay for insurance.
6
Remember: from a for-profit insurance company's perspective, the ideal outcome of any serious medical condition is for the insured to die suddenly without incurring any medical expenses.
6
health care is controlled by the same entities it has always been. Insurance companies, big pharma, hospital corporations, government beuracrats. None of these have "md" or "rn" after their names. It's just another business now. The ACA sold its soul to the devil after getting a few concessions and now the right wants to get rid of those as well. Your care, even after paying those spectacular premiums, is at the mercy of people who's only concern is the bottom line. High premiums- low service= high profits. We've seen what happens when things like wars and environmental protection are moved to the private sector, the same thing has happened to health care.
4
This is a perfect example of how ridiculous it is to entrust for profit private sector companies with our lives. They are not concerned about medical outcomes, they are only concerned about financial outcomes that favor them. We need to catch up with the rest of the developed world and institute single payer healthcare under the control of our elected representatives.
7
Some people who smoke get cancer, wonder if the next step by insurers would be to turn down medical claims for avoidable cancers. Or turn down claims from people who are overweight and develop avoidable diabetes. Maybe the ultimate plan is to insure only healthy people and we can call that plan TrumpCare.
4
This country is divided. Divided by Race. Divided by Income and Wealth. Divided by Beliefs and Politics.
A house divided can not stand. Time to make this the United States again.
3
I am an EMT. This is something you should know about emergency medical service: calling an ambulance does not necessarily mean you get seen faster. We call the hospital on the radio before we get there, and describe your condition in 30 seconds or less. Depending on your condition, you could be triaged to the waiting area where you will sit in a chair until you are seen. If your problem is stable and manageable, and you are ambulatory, consider having someone drive you and avoid a hefty ambulance bill. On the other hand, if you have chest pain, or symptoms of stroke, please, please do not drive yourself. You could put others at risk. Call for help.
9
If the insurance company does not review the records, it has no basis for denying the claim.
Failure to do this is contract fraud, and should be the basis of complaints to the FTC, if not a class action lawsuit.
3
These contract less doctors puzzle me. Who don't they have a contract with? Anthem? Or the ER?
4
The US should maybe try a tested system, in use in nearly every major developed (and even under developed) country, such as ....single payer?
There are just no good arguments to keep healthcare in the hands of for profit companies. There just aren't.
7
It's ironic that insurers won't pay for someone visiting an ER with a minor ailment, but somehow expect someone with no medical experience--i.e., the patient--to be able to diagnose the seriousness of an issue before heading to the hospital.
What's wrong with this picture?
9
Every time I read an article like this, I feel so fortunate to have a prepaid health insurer that operates its own hospitals in an integrated system of medical care. It adheres to the prudent layperson standard and my insurance card includes the statement, “If you think you have a medical or psychiatric emergency, call 911 or go to the nearest hospital.“ A few years ago, I took a bad fall. I suffered some serious cuts and was in pain, fearing I may have broken some bones. I went to the emergency room, where I was immediately registered. Within a few minutes, a doctor came to get me. Under his care, I was triaged. He determined it was not an emergency, and escorted me to an adjoining urgent care unit where my wounds were dressed, I was sent for x-rays and it was determined that I had some serious strains but no broken bones. I paid a small co-pay and went home. I was grateful that my caregivers, insurance company and hospital were all one system in which, at a point I feared I needed emergency treatment, I received the medical care I needed, the system’s triage at the emergency room provided it without utilizing emergency care needed by patients in more serious situations, and I had no need to worry about an insurance claim being rejected.
8
It's not just the insurance companies. Many companies are self insured and the insurance company is only providing administrative services. In that scenario, don't think the company yout work for isn't the pressuring for lower claims.
4
The examples cited in this article of individuals being denied coverage by Anthem are clearly egregious. An inability to breathe, chest pain, new severe radiculopathy are definite reasons to go to the ED.
But Anthem does have a point. There are many patients who show up the ED who full willingly know they don’t have an emergency. Sometimes it may be because these patients don’t have a PCP or because the wait for an appointment may be inconvenient. Some patients, as one commenter pointed out, may receive an after hours recording from their physician and thus may seek emergency services because a nurse or physician is not able to triage their symptoms over the phone.
As a society struggling with rising medical care costs, we need to strive ensure that our patients use emergency services responsibly. That onus is both on the provider (having the ability to have an on-call nurse or physician triage urgent issues - potentially avoid an ED visit altogether) end and on the patient (get a PCP, and use them).
1
Conservatives tell us we should be concerned about Big Government that wants to stand between us and our doctors. In other industrialized countries, Big Government stands between their citizens and their insurance companies. Private insurance companies are highly regulated, like utility companies. For some reason, Americans consistently vote against this.
8
So advice by the medical profession to go to the emergency room if you feel a tightness in your chest is by insurance company standards is wrong. When you call your doctor with any other issue and you get a recording, if it’s an emergency call 911 is wrong.
Clearly this is tragic policy to not pay the bill of someone that might need emergency care but decides not to based on finances is wrong
To make this policy is dangerous but I don’t remember receving this new policy change, this is very wrong because many will hear only after their friends or neighbors receive unpaid bills they can’t afford, now it is likely they will underestimate their symptoms with catastrophic consequences.
Once again Americans are the victims of unrelated profiteering.
7
What happens to people who have mental health or substance abuse issues when they visit the ER? Are they treated as other patients? Are they referred to mental health facilities? Are addicts treated differently since mental health and addiction services are paid less? Insurance companies and ER doctors should be on the forefront of insuring that all patients be treated equally. If it means that urgent care centers are integrated into the ER, then insurers, physicians and hospital administrators should establish these facilities.
3
Another example of capitalism run amuck.
I note that in the article patients are referred to as "customers" and "consumers."
In the US people are commodities with a multitude of functions or uses and this article speaks to our function as healthcare commodities. The goal is profitability to healthcare providers and insurers and these 2 behemoths have spent years and untold sums of money to achieve the most profitable way of dealing with this commodity (us).
In all debates and discussions on healthcare there are 2 underlying principles which are rarely, i ever mentioned: Rule #1, insurers must make a gazillion dollars; Rule #2 healthcare providers - the business people who run the hospitals, clinics (including physicians), drug companies and equipment and device suppliers - must make a gazillion dollars.
Otherwise, why have healthcare at all?
11
The physicians are not making a “gazillion” dollars as you contend. In fact, the ones who provide the best evidence based, minimalistic care often have a hard time paying their educational debts and making up for slave labor salaries until they are 30 years old.
4
I was referring to the executives of the clinics that employ the physicians you are referring to. My primary care physician is one whom I admire and suspect is underpaid.
I might add, I feel sorry for physicians, lawyers and other professionals who owe huge debts for their education, especially those who went to school for the primary purpose of making a lot of money. They have a pretty good job and should, by and large, enjoy it.
True. Some mds do make a lot of money. Most do not. Physician salaries make up 10% of total health care spending. So if you made them work for nothing, your bill would go down an average of 10%. You won't fix health care by simply ratcheting down all doctors salaries. Otoh the ceo of HCA made 21 million in 2016. A little more than most mds.
1
1. Emergency rooms do often have an urgent care if they feel a visit doesn’t warrant a ER visit. This decision is made by a Triage nurse. But not all ER’s have this.
2. Broken System: if this guy died from the back pain (let’s say it was a busted artery). I believe you can’t hold the insurance company liable due to a gag clause. So they have convinced the court system they are not in the medical decision making business!
3. Regulation: for profit insurance companies will do ANYTHING nuanced that they can to alter how medical decisions are made. For years , They have been denying claims for doctors visits, refusing to pay for medications and making patients have high deductibles if they go to the ER ( mine was $250) . They are clever though: on a seemingly good note, They have been REWARDiNG patients for good behavior. For example, patients paying less on premiums for not smoking, and getting a discount for doing an annual physical. So the way they make money is in part a factor of choices that doctors and patients make. Doctors will not bill certain codes nor will they prescribe certain medications as a response . Patients will think twice before going to the ER due to high deductibles.
This example cited in the Article really takes it the next level however...
3
I think the states should pass legislation that provides for the payment of liquefied damages for wrongly denied claims. This puts some skin in the denial for the insurance company: if they guess wrong they automatically pay the claimant or his estate, if it comes to that, a hefty penalty.
6
Ah, and let's mention the situation where "their" urgent care is different from a non system urgent care. I have a very professional urgent care a few minutes away but until after I used it, it was not clear it was outside the system. "Their" urgent care uses a lab in South Carolina, has a billing system in Texas and has huge waits with no one in the waiting room. The staff take incredibly long breaks which is one contributor to the waits. Basically, it is badly run by an subcontracted outfit in Texas. Not urgent and not care.
13
I have a novel idea. How about we pay primary care doctors (yes doctors - not ‘providers’) more than just peanuts so they can have a reasonably sized patient panel and help some these folks decide whether or not an ER visit is necessary? If primary care doctors had the ability to see fewer patient and not spend all of their time on paperwork, etc., it would save the system plenty of money: fewer ER visits, fewer referrals to specialists, more palliative care at the end of life rather than expensive, painful ICU stays, etc. Speaking as a specialist, the answer has always seemed to obvious to me. PAY PRIMARY CARE DOCTORS MORE. Sorry for shouting - just hoping someone who has the ability to make changes will listen...
13
Agreed. They are Already starting to do this Meaningful Use) but we need more financial incentive!! They are actually giving us bonuses now if we can show them:
1. We are open on Saturday and Evenings
2. We can answer patients phone calls or emails within like 2 hrs.
I guess they translate the above two measures as reduced ER visits . But it’s not a substantial amount of money!
3
Can't blame the insurance company this time. 99% of the time I side with the consumer. But, straining your back is the time to make an appointment to go to a doctor. Yes, I know, there is a wait involved, and you have to schedule an actual appointment which is a pain, also, in the neck. Doesn't make the emergency room visit, which is reserved for critical and acute care, the right choice.
5
Glad your crystal ball is working so well. I'm a physican, a boarded internal medicine specialist with many years of experience. If that patient would have called me, I would have sent him immediately to the Emergency department. Yes, back strain is on the list of possibilities, but so is dissecting abdominal aortic aneurysm, right sided myocardial infarction, gall stone pancreatitis and other possibilities that require emergency care if the patient is to survive or avoid substantial morbidity. You only know it's not life threatening until after the fact, when the appropriate evaluation and testing have been done. The next time you have chest pain, assume it's from something that makes emergency care unnecessary, like esophageal spasm. If you don't die or end up with life altering congestive heart failure, then you'll know you're correct. Are you willing to take that chance? If not, then don't be so cavalier about taking it for others.
23
Didn't you learn the mantra 'think horses, not zebras' as a medical student? When you strain your back, the most likely issue is a strained back. In fact the original poster is correct, it doesn't make sense to go to emergency room in this situation. There are always exceptions, but if everyone went to the ER to cover every possible exception, our society would be spending so much on health care that we can't spend it on other priorities like improved education, technology development, new roads, ...
If one never had a strained back (or any other condition), how does one know if it is serious or not? You think the first time a person experiences something they know exactly what it is. That is an unrealistic expectation, but the same argument the insurance company is making.
Then you think if one has an excruciatingly painful and sudden experience, one should wait until the doctor's office is open, then make an appointment for sometime in the undetermined future. That is just silly.
9
Our health insurance industry was created to service health care provided by employers at a time they were seeking to provide non-cash employee compensation. That need has been gone for many years. The only reason for the industry's profitable continuance is greed and political power. It serves no useful purpose and should be eliminated. The government has long demonstrated its competence in processing the financial functions of the healthcare industry in Medicare. It is time to cut the free loaders out of the picture. Now, as to that hospital and physician industry ...
9
The article fails to point out that Anthem is a for-profit insurance company traded on the NYSE. Their interest is purely financial, and patients and clinicians are seen as mere annoyances in their quest for money. Should anyone be surprised that Anthem is putting lives at risk to make a buck? The only way to make our health care system really work is to take the profit hungry insurance companies out of it.
25
Whether an insurer is a for-profit or not-for-profit entity, it is a for-profit organization. The only difference is whether the profits go to shareholders or upper management and other 'owners'.
15
So now we all must be expert diagnosticians if our insurance company is to pay the benefits we pay for. Another excellent example of why we need single payer.
25
Another reason for-profit medical care is not good for our society at large.
7
The for profit insurance companies that control US health care exist to maximize investor returns, not to provide the insured with the best possible health care. It is the way things are done in the US, where greed and profit are held in higher regard than the needs of its citizens. Unless the system is changed to end the ability of people with money to buy legislators things will never change in this country and health care is just the tip of this problem.
29
The Emergency Medical Treatment and Active Labor Act (EMTALA) is a federal law enacted in 1986 that requires anyone who presents to the E.R. to be medically screened, treated, and stabilized before discharge. It's also known as the Patient Anti-Dumping Statute to ensure that anyone who is uninsured cannot be turned away.
It appears that Anthem is now requiring patients to diagnose their own pain or ailment as a true emergency before going to the E.R. This is nothing but a blatant approach to get around the existing law that was intended to protect the public at large.
26
Who has the best government covered insurance paid for by tax dollars majorly?? our elected representatives and their families.
Bet they don't get hassled by this. And we ,the public, think this is OK ?
23
Federal government employees have a choice among about 20 plans. I chose BC
1
Nothing will change so long as too many Americans remain such strange, brainwashed people. The USA has got to be the ONLY country in the world with huge numbers of non-rich people who are willing to passionately defend the interests of private sector, for-profit health insurance companies.
If a young person you love dearly announced her or his intention to attend a for-profit university like DeVry or Walden, the average American would likely be horrified and urge the person s/he cares about to reconsider. Because most people know that for-profit universities are blood-sucking, trash enterprises. Why doesn't such near unanimity of opinion exist regarding for-profit health insurance companies like Anthem and Aetna? DeVry, Walden, Anthem, Aetna--I see no difference.
33
Because individuals don't make the contracts. Employers do. This unholy relationship must be severed. It no longer serves anyone interests except insurance companies and their shareholders, if it ever did.
6
One of the scariest things is that surprise bill. If you're ill or injured, whether you need the ER or urgent care, you can hardly be expected to ask every doctor, nurse or technician whether they accept your insurance. You may be prepared for a normal co-pay, but what happens when you get hit with a surprise bill? Many people live from paycheck to paycheck, and this can hurt as much as their physical ailment.
28
You contest it with your insurance company, been there done that, won the battle but it's an ongoing war.The only way it's going to change is to vote in those who will change it.
19
I have a nursing background, but now wonder what Anthem would consider acceptable (not my insurer). I have only been to the ER once for an illness - nausea & vomiting with which I had become dehydrated. I got 2 liters of IV fluids and some magnesium. Now I wonder what I would do if I had Anthem and the situation arose again. Would that be sufficiently ill for this insurer? Immediate care centers do not, as far as I know, do IVs. Would I have to worry if I was dehydrated enough for them to deem the visit 'necessary'? This is crazy and can be life threatening.
32
In fact my clinicians how do even advised me just to go to ER; it was the better way to get treated for something related to a foreign object in the eyeball, although it had happened a month earlier. (which led to a cataract and then unsuccessful cataract operation, and further complications; I am still got blurry vision in the affected esyeball
2
I'm told over and over to call 911 if this is an emergency. If the dispatched personnel think I should be taken to the ER, I don't want to hesitate or disregard the advice because I'm afraid my insurance company won't pay for the ER visit.
For profit health insurance companies appear to only answer to their stockholders, not to their customers.
29
You've made your case! If Anthem or another insurer, and I use that term extremely loosely, denies your claim, get the recording of your call to 911. Case closed.
Or, how about we just get national medical coverage which removes the profit motive from taking care of illness?
5
You’re funny: now who is it that’s supposed to be the “dispatched”? How about newly married!
Dispatched personnel=people sent by the 911 operator to respond to a call.
Funny? Don't think so.
This is why we need universal healthcare. ERs charge too much for their services and insurers trying to control costs end up being the bad guy. True medical triage instead of defensive medicine would be so much better. So, yes, we also need tort reform. Too many people sue and win when they were not truly harmed but they contribute to increased medical costs.
21
My mother had a normal German health insurance, as do I, and when she was sent to the clinic's E.R., she was diagnosed with ischemia. Years before, I had gone through the same thing with a severely case of iridocyclitis. The total of our expenses was roughly $35. But we were seriously ill.
Our problem here is with people who go to the ER for illnesses that could just as well be treated by their G.P.; .e.g. kid stubs his toe, indigestion, a cold that has become a little worse. Now that would warrant making these people pay for the visit (our ER visits are paid for by the health insurance). The plan now is to institute patient portals, where doctors examine the incoming patients, then either refer them to their GPs for care or, in really urgent cases, to possibly be admitted to hospital.
As has been stated by other commenters, making people pay will only serve to make them hesitate to seek medical care even if they have symptoms pointing to potentially life-threatening illnesses.
7
Uni Healthcare will not change the pirates of rice in China or the cost of ER admission; Those costs are driven by in efficiency, greed, and general malfeasance (laziness)
3
Tort reform has largely eliminated most medical malpractice claims. This is used by hospitals, so-called emergency clinics and doctors as the phony bogey man to excuse the outrageous charges for the ER and its misuse as a primary care giver.
3
The problem is not the insurance companies.
The problem is the healthcare industry and the republican party.
Fixing healthcare should focus on healthcare and on paying for healthcare.
Some things to consider:
Expand Medicare to include the population just as every other civilized country does today.
End the conflicts of interest that characterize the doctors' cartel.
Open more medical schools.
Close the wage gap for nurses.
Open more community health centers.
Make health education mandatory in public schools.
Pay for it all by charging the full tax for government support of oil (this means the military costs of protecting our interests in the Middle East) and by reducing the military hardware budget by 40%. Go back to the draft and the wages associated with it (my E1 pay was ~$70 / monthly in 1968; my EOS pay as an E5 was ~$500; my GI Bill + a full time job put me through college debt free).
The solutions I've outline may be precisely wrong, but they are directionally right.
It can be done.
It won't be done so long as republicans hold political office and Americans embrace the propaganda put forth by those politicians.
37
Congress controls the number of doctors, not medical schools. Residency is a required step in make a fully-licensed doctor. The number of residency slots is determined by Congress. A half dozen new med schools have opened in the last five years. Without residency spots, those students are MDs with no future.
19
Thank you for your service. You made some good points except for the last one. As someone who has served three combat tours in Iraq and has been retired since 2012. Your last point is ludicrous. No current service member couldn't live off a slave's salary ranging from 70 to 500.00 a month due to something called inflation we had in the last 50 years since you served. Even though their are young men and women willing to serve our nation but they wont serve for peanuts. We could save money on the acquisition side of equipment and multi billion dollar weapon systems. But the greatest investment our nation's military is in our personnel. I rather serve with an all volunteer force than draftees who feel they are being held against their will. If we are going to back a bygone era of the draft it must be applied evenly across our society i.e. no dubious medical deferments like bone spurs and etc.
8
Exactly. I was visiting Israel when I came down with a extremely bad cold. I went to Hadassah University Hospital - Ein Kerem Urgent care. I was charged 1000NIS or $375 for lab work, chest x-ray and workup by a Dr. I was also given meds on site.
In the United States this would have cost way over $375 even with Insurance.
4
I am a retired American living in Germany and have access to their health care system. The last thing people here would think about is "Can I afford this". I also like everyone have dental coverage. Co-payments for doctors, even specialists or meds are very low or nil.
The health care problem in the USA will never be fixed because of money and bombs are more important than people.
49
The system we have is great, isn't it? In the USA I had to shell out $40 just to see a GP. That one was a good man; the second, follow-up exam he did in a hallway, then as I was recovered, did not charge me a cent because I had not been in his office as such.
Americans, so it seems, have to pay for even the smallest bit of medical care. The richest nation in the world? Perhaps, but the least caring as to its population. ALL people deserve quality medical care, not just those who can pay cash for it.
24
The small handful of times I've been to the ER I've had time beforehand to call my insurer's nurse line, which works as a sort of triage over the phone. In each of these instances I clearly needed to go to the ER but I called the nurse because I consider it a form of insurance against my insurer second-guessing my decision to go to the ER.
How's that for "patient-centered" care? Step 1: Take precautions to defend yourself from your own insurer.
My experiences with urgent care have been a mixed bag. In one instance, urgent care couldn't treat my problem and sent me to the ER. I had thought I was being smart by going to urgent care to avoid the big ER co-pay and ended up having to pay both. My out-of-pocket cost would have been lower if I had gone straight to the ER.
36
Be careful. Not all urgent care centers have MD's on site. They have them available but not always physically present.
4
from recently retired insider attorney on claims denials:
Over 40+ years of working inside our coding+claims systems that comprise mostly "fee-for-service" insurance plans, I've learned two important numbers: 86% of first-level claims denied (by a computer algorithm-driven response) never get appealed. Of those that are appealed where the insured (1) reads the plan document(s) and (2) include relevant parts + specific facts of "medical necessity" for the service(s) denied . . .in the first appeal that has humans reading what we submit, 97% are paid.
Until our hodge-podge of medical "providers" is somehow untwisted AND trained medical professionals refuse to be tethered to electronic medical records instead of patients most of their hours and income, denied claims appeals to human reviewers is our best avenue.
May be a good idea to consider doing what I did - rarely: Offer the appeals supervisor in a live phone call a chance to pay the claim OR be featured in my next national and local story BY NAME and plan as being "a huge problem in plan claims denials for enrollees." Stay away advice costs plans money.
19
I think you hit one of the nails on the head. The insurance company accountants play the odds on the percentage of people who won’t appeal their unfair policies and they come out ahead, so they have financial incentive to continue them. It is only when publicity gives them a bad image and threatens away payers that they will make the financial decision to drop unfair policies such as this.
7
This conversation should include the following, particularly for right wingers here who bemoan that taxpayers are stuck paying for ER visits, and that health care isn’t a right:
Article 31 of the Iraqi Constitution, drafted by the Republicans in 2005, signed by George W. Bush, and ratified by the Iraqi people, includes universal health care for life for every Iraqi citizen:
“First: Every citizen has the right to health care. The State shall maintain public health and provide the means of prevention and treatment by building different types of hospitals and health institutions.
Second: Individuals and entities have the right to build hospitals, clinics,or private health care centers under the supervision of the State, and this shall be regulated by law.“
Interesting set of priorities by the right wing.
56
The GOP: Make Iraq Great Again. America, not so much.
5
A few years ago I experienced sudden tingling on one side of my face while I was feeding my 6 month old son. I realized immediately that I could be having a stroke. I was especially worried because I have a venous malformation that increases my risk of stroke. I told my husband and we packed the whole family into the car and went to the ER. I was seen pretty quickly and got a full workup including a CT-SCAN. They concluded that it wasn't a stroke and recommended a visit with a neurologist.
Soon afterward I received the bill and was informed that my insurance company had denied the claim (~$3000) because it wasn't an "emergent situation." I appealed.
The representative was sympathetic. One thing I learned from her was that often the staff at the hospital do not code the visit correctly, leading to a denial. I called the hospital and they eventually worked it out.
If this happens to you-- appeal, multiple times if necessary. Given the circumstances, I was willing to pay $3000 to rule out a stroke, but the experience has caused me to think twice about subsequent visits for members of my family. If my kids are sick on a Thursday, I will do anything to get them to their pediatrician before Friday afternoon, because in my area, the ER is a better option than urgent care on the weekends.
21
You and the hospital staff spent time and effort to address a situation that does not happen in any other civilized country. It is a waste. I continue to vote against situations like this.
5
I was just thinking about the coding issues. Surely there are "trigger words" that more readily ensure coverage. I get that there's a fine line between strategic coding and fraud, and I'm not sure where that line is.
3
Federal law, EMTALA, legally entitles patients to evaluation in an emergency deptartment. Funny that insurance companies have no requirements to cover that evaluation.
20
The salient issue here appears to be an initial determination of the level of care needed. Clearly we cannot expect patients to make that determination with any degree of certainty. Wouldn’t it, therefore, make sense to change the way initial care is offered at hospitals by bifurcating the E.R. into urgent and acute sections with a specially trained medical professional in a triage role determining which is appropriate for any given patient? Let’s put the responsibility for such an important decision in the hands of those best qualified to make it and not force patients to gamble with their lives.
25
The bifurcation can be largely handled by automated diagnostic interviews, if only the law would allow it.
1
ERs are expensive but most of the cost of an ER is fixed (If there are 2 doctors on duty and ten percent fewer patients visit you still need two doctors( same if you have 1 or 2 CT machines and techs to run them). You still need the same variety of medicines and they still expire and have to be replaced; there will just be more thrown out if fewer patients visit.). This means that if there are fewer visits the cost of each visit will have to go up to cover the cost of the ER being there when it is needed. So insurance companies will end up paying the same total amount for less medical service and have to pay the additional cost of Urgent Care visits.
7
No, it is more likely that the insurance company will hold the line on payments forcing the ER into the red and often resulting in the ER shutting down, This would delight the insurance company
3
So you can serve an infinite number of patients with two doctors? Your logic is on vacation, far far away.
2
When the ACA was being legislated, Republicans said it would make the government come between you and your doctor. But with our private insurance system - which the ACA didn't eliminate - corporations can come between you and your doctor.
We need to get the profit motive out of health care.
75
Not long ago, I woke up one day with a terrible headache, and seeing double. I went to an urgent care center, which gave me a diagnosis and sent me to the ER. Yes, it took forever to get treated at the ER, but much of the delay was for fairly extensive lab tests and X-rays. In the end, the urgent care center's diagnosis turned out to be wrong. On the one hand, my condition was not life-threatening and therefore, I suppose, not ER-worthy. On the other hand, I don't think I could have gotten the careful diagnostic work I needed outside of a hospital.
So, in my opinion, at the very least, a patient who does start at an urgent care center and is referred by them to the ER should not be denied coverage no matter what the ultimate diagnosis. There's a vast middle ground between the rush-to-surgery crisis situation and the patient who goes to the ER because he can't be bothered to find a doctor.
18
It is entirely reasonable for an insurance company to seek to reduce fraudulent or unnecessary claims.
It is entirely unreasonable for a patient experiencing what may be a serious event to be asked to diagnose themselves.
It is entirely unreasonable that hospitals have a financial interest (for profit or litigation avoidance) to admit patients to the E.R. Regardless of how appropriate.
Is it unreasonable to consider requiring all medical establishments to have well staffed triage areas where patients are evaluated and then directed to the appropriate level of care?
18
I have Blue Cross Blue Shield. The way they discourage ER use is with a $1,000 emergency room co-pay. (That's a price hike: in 2017 it was $400.)
41
I have Blue Cross Blue Shield of California (not available out of the state of California). My ER co-pay is $125.
It sounds like you are insured with Anthem Blue Cross Blue Shield, the company referenced in this article. Anthem is an "an independent licensee of the Blue Cross Blue Shield Association based in Thousand Oaks, California." You might be better off switching insurance companies if you can.
4
How is a non-medical person supposed to determine, if they cannot breathe, whether it is a pulmonary or a cardiac problem, or a panic attack?! And if it turns out to be a panic attack, that person may still need medical intervention and medication. If the patient did not go to medical school or nursing school HOW would they even BEGIN to guess what was wrong with them? These insurance companies are simply operating under the trump/gop doctrine: Do as much harm as possible, extracting as much money as possible from your "customers," (VICTIMS) and give back to them as little as possible. In other words, insurance companies should not be involved in making health care decisions, as their modus operandi is to extract the most profit from their victims, by denying as much care as possible. You wanna talk about "Lock them up?????" We've got so many crooks and thieves in this country that who to be locked up, and a sizable number of them are in government and industry.
57
Glad this policy wasn't in place when I was taken by ambulance to the emergency room during a panic attack.
8
A reason not to go to an ER.
1
I suspect the point was, Bill, that Danny felt symptoms that were fearful and went to ER which resulted in the diagnosis of panic attack (which wouldn't be paid for by Anthem), not Oh boy, I'm having a panic attack lets got to the ER for the fun of it.
And the point of the article that you be qualified to diagnose what is really wrong without medical experience or diagnostic equipment and if you guess wrong punish you for it.
Sure, but only in hindsight. There have been women who presented with symptoms of a panic attack (e.g. problems breathing, fast heart rate, dizziness, etc.) and who actually had a blood clot in their lungs. Every once in a while, I hear about a malpractice case where a young woman with no other health problems dies because she was mislabelled as having a panic attack. It's also possible to have both -- e.g. being anxious because you are actually sick.
One of the most common bankruptcy risks in the US is medical. Do you feel lucky?
33
Transfer of money from poor to the rich.
1
3 years ago as a customer of an Anthem Blue Cross company, my identity and those of 80 million other people were stolen because Anthem failed to take necessary precautions to protect our personal information stored on its computer system.
Anthem has never paid for that "avoidable" negligence on its part, which has caused "serious risk" to its customers' financial health.
Anthem now wants to have its cake and eat it, too, by denying ER coverage on trumped up charges of the care not being immediately needed. Why are these profit-making health insurance companies even allowed to exist anymore?
88
Anthem has their people in the US House of Representatives and Senate. Do you?
4
Anthem should have 24/7 doctors on call to decide whether you should go to the emergency room. If they make the wrong decision, the doctor and Anthem should be personally culpable with big bucks attached.
41
So, if one suddenly has unexplained excruciating pain, one should make a phone call to an insurance company. It is not the first think I would think of.
5
A couple of years ago I had some stroke-like symptoms and went to an urgent care. They promptly passed me on to the ER. Fortunately false alarm but two bills.
If provider's goal was to reduce cost and maximize health, ERs would serve all and apply triage to provide simple cheap services as well as the costly heavy duty stuff.
But instead profit is the goal.
26
If you have a choice buy insurance through a not for profit health insurance company like Kaiser Permanente. If the only thing the insurance company cares about is a good return for shareholders they are not providing real health care. They are the middlemen. We should have a better choice though and that would mean every one can buy into Medicare.
28
You only have that choice a) if you have such an entity in your state and b) you have funds to pay for it.
2
My 10 year old took an 11+ ft fall onto concrete. When I saw him laying there unconscious, all the mental preparation for this moment I did over the years went out the window. Broken neck, spine or worse? EMS took him in the ambulance. I suggested going to the closest hospital but they told me it would be a waste of time because they would only send him to the local Medical University children's trauma center. X-rays, ultra-sounds and a bunch of other stuff revealed many bruises and a broken wrist. The insurance company denied the claim because the injuries did not warrant an ER visit. I contacted the ER attending physician and informed the insurance company that she would be willing to testify as to my child's condition. They finally paid.
83
I love urgent care, which is closer to me and faster than emergency options. In fact, I can't even remember my doctor's name. I have seen my APRN for a decade and feel I get superior medical care.
Emergency rooms are for true medical emergencies and in most cases doctors are not even required to treat routine ailments. While people will err on the side of caution, which is understandable, making more cost-effective medical care decisions are everyone's responsibility.
4
The article wasn't about using ER's for routine care. It was about insurance denying payment to people who genuinely feared they were seriously ill, and not being doctors, could not tell whether their symptoms were a major emergency.
A lot of symptoms can be signs of both mild and serious illness. Conditions that can kill you, cripple you or blind you very rapidly may start with subtle signs -- for example, heart attacks, aneurysms, head injuries, strokes, embolisms, acute glaucoma, asthma, detached retinas, and "flesh-eating" bacterial infections. Patients shouldn't be penalized because they could not magically diagnose themselves in advance to rule out something serious.
3
Sure, John —just so long as your medical problem occurs before 8 pm on a weekday or 5 pm on weekends and you can drive 20 miles to the closest urgent care.
5
By that logic, if a person shows symptoms of having a stroke, goes to an emergency room accordingly, and finds out she isn’t, she’s acting irresponsibly.
Good grief. What is it with the ugly strain of sneering and scorn of anyone who makes a wrong decision currently coarsing through the US?
4
Recently, I took my extraordinary healthy husband to the ER with a real medical emergency, the result of outpatient surgery anesthesia earlier in the day. The ER was packed with young parents with young children, children sick with uncomplicated respiratory issues. Children who clearly didn’t need to be treated at an ER. Medicaid is paying for a majority of these visits at 100%. These children could have been seen in a practitioners office or at one of the numerous urgent care offices in town. These parents want the very best care for their children which they equate with the most expensive. They want their child to see the doctor, not the nurse practitioner at the urgent care clinic. They want their child to have every test possible. So, do we have a problem with overuse or inappropriate use of ER’s? Absolutely. The question is how to fix the problem and have people get the care they need in the least expensive manner possible.
18
"These parents" might not have been able to get a timely appointment with their primary care provider.
23
How do you know "medicaid pays the majority of these at 100%?" Did you ask them what their insurance was? Also, how do you know they all have "uncomplicated respiratory issues?" Are you a physician who examined these children? Two of my children have asthma, and our pediatrician always told us to go to the emergency room for episodes. We did go to urgent care once, and they sent us to the hospital, where my oldest was admitted. Speculation is dangerous territory.
39
You’re making an awful lot of assumptions about the people you saw in the ER. Did you actually speak with them?
15
A. It would be interesting to find out the credentials of who is doing the non approvals, and the data used.
B. If these claims are appealed, what is the percentage of reversal, this approvals then on the appeal?
C. Really? These E.R. visits are denied, but we taxpayers are expected to pay for Melania Trump’s weeklong inpatient stay for an outpatient procedure? Deplorable!
36
Anthem is not the problem. They are a corporation with the purpose of making profits. They do not provide health care. They exist to provide profits, including 18 million for the CEO who dreams up ways to make more profits.
The problem is free enterprise in the insurance market. Free enterprise dictates that billions of dollars gets siphoned out of the system. Anthem competes with other corporate entities that are likewise engaged in drawing profits, billions of dollars worth, from the industry. While Medicaid and Medicare and the VA suffer from merely corruption, it is baked into the system of insurance as a for profit company.
It is the same with private school and private prison and private investment of retirement savings. What ever YOU spend, rip your money in half and burn it. Trump and his cronies are pushing for more privatizing. Read profiteering and you'll know the score.
49
I worked for Blue Cross/Blue Shield of central NY in the 1970s. They were a NOT FOR PROFIT enterprise. There was no such thing as a co-pay or co-insurance. They weren’t even allowed to make money on the employee vending machines. Go back in time to when this changed and you will find the place where our health care started going down the tubes.
48
As a company that has spent $6.1M in 2015, $6.0M in 2016, and $5.4M in 2017 on lobbying, Anthem very much is part of the problem. You can be certain that their lobbying is focused on easing and reducing insurance company regulations.
One major reason that the US has a private insurance model is that wealthy powerful companies like Anthem spend large quantities of money in Congress to fight against any movement towards single-payer or low-cost medical care for all.
It is simply not adequate to dismiss the role of Anthem and its lobbyists by stating that "Free enterprise dictates that billions of dollars gets siphoned out of the system." Unfettered, rapacious free enterprise would eliminate child labor laws, workplace safety laws, food safety laws, etc. It would return us to the Gilded Age with high child mortality, disease rates, and short brutish life expectancies.
Until Americans as a collective recognize that healthcare is a basic human right, they will be subject to the vagaries of the market and profit-making entities like Anthem.
25
This go to urgent care is a joke. First every time I do that I am not properly diagnosed and wind up having to follow up with another physician to get the situation addressed Thank goodness nothing serious. Second the current state of health care delivery in this country has made it nearly impossible for the individual practice to survive. You get swallowed up by a conglomerate who then dictates the terms We now have concierge medicine available to those who can afford it. You want to have single payer then have it for everyone. Only by including the wealthy and influential in a single payer system will it be effective
35
I work hard for my medical benefits; I do not think that anyone illegal or on Medicaid should have the same care as me
5
Medical care should be a right, not a privilege. If you are human, you should be able to get healthcare. The wealthy have enough advantages in this country; healthcare shouldn't be one of them.
7
All the people I know on Medicaid work for a living. A lot of jobs don't offer benefits any more. Other people I know used to feel the same way you do -- before they got laid off in their mid-fifties during the recession. You yourself are not immune from life's misfortunes, just oblivious to them.
Does congress or Donald go to Urgent Care? I don't think so.
It is the lowly plebs being fleeced. It is we, that fund the trillion dollar profit industry, that gamble with our lives and those of our loved ones.
We have Anthem. We are urged to first see our primary first or use an Urgent Care. Our primary is difficult to see with less than a 2+wk appointment. Good Dr. We like him. Have had him for decades. Yes, thank you Pres. O, we did keep our Dr. Our Urgent Care is only open during business hours. They are swamped and do the best they can. Nice place and people.
I came home early Sat. morning to find my spouse pale and gasping for breath. Not dying by my layman prognosis. Urgent Care had an 2hr. wait. Which we did. Upon entering they listened and diagnosed bronchitis. We mentioned her sisters bout with embolism. They rechecked and immediately called for an ambulance. Pulmonary emboli in all 4 quadrants of her lungs. ER told her she was lucky to be alive.
We plebs are not medical doctors. We should not be making life and death decisions on issues we know nothing about. We are gambling with our lives, cause we might cost a for profit Co. money.
Med. 4 All.
That life you save, could be your own or one you love.
147
I have insurance through Anthem, and I can say they are a TERRIBLE company. They deny payment for everything. I could tell many stories. But life now works like this: 1. Get sick 2. Go to doctor. 3. Fight with Anthem over their refusal to pay doctor. Or often, I just don’t go to doctor to avoid step 3. Which is I think what Anthem wants.
43
Most insurance companies have realized that they can pay a clerk 5.00 an hour to turn down 50% of all claims. Many patients will not fight it and just pay themselves. Some will die and the claim never will be paid. A few will put themselves through the rigor of fighting till the claim is paid or they lose the case. Whatever the outcome, profits are maximized and there is no one to stop this practice since the Insurance commissioners on most states are heavily lobbied.
Sure there are people who use the ER as a primary care doctor, but there are more that need serious problems ruled out, and that costs money to do.
12
Me as well. I *had* gone to the Urgent Care three times, only to be told "there's nothing wrong" and "it's a matter of perception" (fancy way of saying, it's all in your head) ... I give up. What's the point of going to the Doctor, with "care" like this? What happens, happens.
2
Anthem the most vile and despicable insurance company in the healthcare industry. Sue them if they don't pay.
36
United Health Care gives them a run for their money.
13
Nationalized health care. Put these parasites out of business.
46
The problem here is simple: Shareholder dividends and executive compensation are more important than the well-being of living, breathing people. Jill Becher, the Anthem spokeswoman, would never admit to devaluing a person's life, but she is, and she's defending the prioritization.
This isn't confined to Anthem, either. How many articles have we all read over the years about how Walmart, Amazon, Tesla, etc. treat their employees? About how big pharma restricts access to life-saving medicine, and how agro-chem companies use toxic chemicals in food? It was only 10 years ago that millions of Americans lost everything while the financial masterminds behind the crisis lost nothing at all. The problem is that we as a society have allowed money to outweigh literally every other consideration, to the point where we as a society seem to be fine with harming tens of millions of people as long as the Dow stays high. The ultimate proof of this is in the White House.
I'm part of this too, I'm sorry to say. I'm typing this on an Apple computer, I drive a Ford, and I'm as removed from the source of my food as any other urbanite. I think this is what makes me angriest, is that I'm part of a society that sees absolutely no genuine value in individual's lives, but the problem is so overwhelming that I can't hope to do anything about it.
27
Reviewing the final diagnosis instead of the initial symptoms is a classic case of hindsight bias. I can’t believe a court would agree that hindsight bias is the right way to determine if a prudent layperson would believe emergency medical care was necessary at the time of the accident.
69
You are correct. Of course, your case with a private insurance company would have a long road to a courtroom: your insurance policy probably requires that you use mediation. And good luck with that!
4
Emergency Departments often see patients who are afraid they're having heart attacks and turn out to be having anxiety attacks. And those patients include physicians.
The reason is that humans can't reliably distinguish between anxiety and some other conditions.
And, when they show up for triage, the nurse or doctor can't necessarily tell either.
So, after the workup is done and the diagnosis is anxiety, the insurer is going to say they should have been able to figure it out - without the workup?
47
There is another crisis patients are facing that is not being addressed. As an ER doctor on almost every shift I send people home we want to admit "Observation Status". That is less than 2 nights in the hospital. These are often patients needing to stay over night for rehydration or evaluation of a possible heart attack. Many are refusing because insurance companies refuse to pay for observation status. We do the best we can but patients refuse to stay because they cannot afford the bill. This is a dangerous situation that is happening daily. It is a huge gap in our health care system that puts many patients at undue risk. I hope this begins to be addressed.
104
I know that "observation" is not covered. Why can't you change the IDC and CPT codes to something that is covered by insurance
14
Because insurers will look at symptoms and treatment too, not just the diagnosis code. I used to work In utilization review in an ER. If clinical doesn't meet inpatient (vs observation) criteria set by the insurer, insurer may deny. But, like others have said, your best bet is to appeal. Reviewers are often poorly trained, rushed & miss details in the clinical. An appeal will look deeper.
While I sympathize with your motives, why should a doctor have to make something up in order that her patient receives the proper care?
Why is it I have the feeling that if the management of Anthem or their family members went to the ER for the symptoms described in the article they would not be questioned at all?
As I have said in the past I am all for a single-payer health system as long as I can be assured that I and my family will be treated the same as my Senator and his or her family.
57
You won’t be—there will be a two tier system
1
So let’s say you’re feeling weird and really wrong. You go to ER thinking you’re dying.
Assuming it’s nothing but indigestion, at least we now know. Big bill.
Assuming it’s real, life saved. Also big bill.
Assume you don’t go because of the bills and then the next day you collapse. Now you’re rushed to the hospital and you insurance pays way more for the aftercare and attendant treatments for your truly emergent condition.
How can you ask people to know ahead of time what’s a real emergency and what’s just panic or paranoia? Most people don’t even know their basic anatomy—let alone when they’re in the midst of thinking “I’m dying!”
34
You forgot to mention Anthems CEO Joseph Swedish made over 18 million dollars last year. With salary’s like that they will have to either raise rates or cut services.
52
this is the conservative playbook.
take Neil Gorsach. when a truck driver leaves his disabled truck because he fears for his life, he rules he should have stayed with the companies property yo protect it
is there any doubt if he froze to death and the family wanted to get compensation he would then rule he should have left to get shelter.
48
Yet another example of our pathetic "privatized" health system as our country more and more looks like "Hunger Games".
29
The President is going to go ballistic when he hears how many people are disrespecting the Anthem.
52
Am I the only person in America who is sick to death of our "health care" system? Big Bucks for Certain People System is more like it; enough!
If life is a Constitutional right then so is health. Health care is an American right and a Constitutional right.
Demand universal health care. Anything else is flat out barbarous.
42
It is, unfortunately, not a right.
Should probably be, but it isn't.
4
Sorry, but healthcare is NOT a right
3
NYC Dweller, why not? "Rights" are a purely human construct. We define them;we can and do redefine them. That's why laws can be added, amended and repealed. The Bill of Rights was intended by the Founders as a starting point, not an endpoint. Some were against adding a Bill of Rights at all, lest it be thought that those were the only protected rights. You see -- they predicted your mindset.
Hey, these insurance companies are out to make money, not cater to every ache and pain you have. Medicine is a free enterprise system here, not some "socialized" bleeding heart right like in some countries. So Buck Up. Yeah, we may turn down a few people who die, but just think of the profits to be made ! MAGA all the way !
12
Welcome to the new normal
4
Anthem failed to delete my personal data long after my employer switched to another insurer, and predictably allowed hackers to steal it thru typical corporate complacency and malfeasance. Even among their misbegotten peers they are a disgrace. Imagine going to work for an organization whose profitability depends on spreading anxiety and stress. I don’t know how their employees sleep at night.
27
Anthem is displaying greed writ large. No one wants to go to the ER. You go if you have something horrible or at least think you do. You have a big copay as well. But, then to have the insurance carrier refuse to pay, makes something already bad, magnitudes worse. This tactic of discouraging use of the ER by simply not paying, is criminal. The people that dreamed it up and who implement it, should be prosecuted. Anthem happily takes premiums and then refuses to pay. It is fraud and it should be considered criminal fraud.
26
My perspective, after 35 yrs "in the system", as a provider....Single Payer....put all the third party payers/scammers out of business, and save 40% of what is spent on "healthcare"/yr.
35
Many people pull the trigger and go to the ER for silly reasons. It is important to go when you have big cuts, possible stroke/MI/ broken bones. But junkies go for more opioids. This is more and more common. Diabetics go for insulin. These are a waste of resources. I have sat in an ER with serious facial trauma for hours because other dummies were wasting ER resources.
11
You are so correct. ER nurses have told me about their "regulars" who show up every week looking for painkillers for phantom ailments
7
George, you should have just gone over to those dummies and explained that you were psychic and knew nothing serious was wrong with them. That's what I do! Just let those annoying diabetics suffer the consequences of their foolish addiction to expensive insulin.
Of course, I never challenge the people with real heart attacks and strokes -- I can always tell them by the flashing neon signs on their foreheads. You know, the whole problem with emergency rooms is all those patients. They keep locking the triage staff into the bathrooms, so they can't prioritize me.
1
When NY Times headlines mirror "The Onion," you know we are in trouble:
https://www.theonion.com/health-insurance-ceo-reveals-key-to-company-s-s...
When your health system is based on profit, the health corporations seek profit above all else. The scandal is not that this is illegal, but instead that it isn't. Who does Congress work for, anyway?
19
C'mon, people, stop your whining and bow down before your corporate gods. Don't you know they are our masters? Congress does!
16
Two years ago, I had an attack of severe chest pain that failed to subside. I followed the guidelines and went, reluctantly, to the emergency room, where per protocol and my age the pain was treated as a possible heart attack.
Fortunately, the cardiac test results were negative; the issue was gastrointestinal. But I was fortunate; the doctors to whom I spoke all agreed that, given the nature of the symptoms, I had done the right thing.
As my experience indicates, even doctors can't always make a differential diagnosis without testing; professional diagnosis is a necessary medical service. It is troubling to think that if this happened today, Anthem might not cover my bills, and worse to think that someone might die of a heart attack because that risk caused them to hesitate in what could be a life-threatening situation.
35
What a completely rotten group of people. What will it take for Americans to put the country back into balance? How many Republicans must be defeated? How many GOP policies need to be repudiated? Donald Trump and his ilk are criminals.
21
Universal healthcare. Don't penalize people fr not understanding the severity of their illness. Penalize ERs for price gouging.
This is getting to be too much. Folks, lets all just agree to die and maximize share holder value once and for all.
19
ER's are price gouging because people with insurance are paying for people who don't have any insurance but go to the ER for colds, headaches, etc.
4
Dweller, you make an excellent case for Medicare for all.
Well done.
The examples in this piece are mostly egregious denials of coverage, and denial without review of symptoms is outrageous, but the fact is that many people show little restraint in zipping over to the ER. There are surely many more examples of silly visits that were denied than legitimate ones. A weird rash. A chest pain that would probably go away with a Pepcid. Light-headedness that’s just dehydration that Gatorade would help to ease. Moreover, most doctors would agree that ER medical care is often inferior to care of the same problems in other healthcare settings. It frequently leads to over-testing and excessive care. Doctors and nurses overworked in a sometimes chaotic environment with protocols not followed. And it adds to the premiums of everyone else. No one should be expected to ‘be their own doctor,’ and you should certainly jet to the ER if you think you’re dying, even if it’s out of sheer ignorance, but I don’t think it’s too much to ask for people to have some basic knowledge of personal health. Not only so that we have an idea of what can wait and what can’t, but for overall quality of life.
5
A rash can be a symptom of a meningitis or a severe drug reaction. Chest pain is experienced in a variety of conditions ranging in severity from minor heartburn to a myocardial infarction. Lightheadedness may be a symptom of dehydration however it could also be a manifestation of a lethal heart rhythm. Additionally, it is a disservice to all Emergency Department nurses, physicians and other professionals who provide care to all comers without regard for their insurance status. The care rendered is essential. If as stated "most doctors would agree that ER care is often inferior..." why would physicians send patients to the Emergency Department on a regular basis? It is, in fact, to have advanced diagnostic evaluation to determine who is in need and to administer necessary therapeutic care. The multiple simplistic assumptions mentioned here are indicative of a limited perspective, influenced by the false choice presented by the insurance business between proper medical care and cost. I am an Emergency Physician and experience this on a daily basis. Enjoy your day, and when a severe headache comes on suddenly don't just take an aspirin and call your insurer in the morning, head to the ER so you can be evaluated. Hopefully it is an unusually bad tension headache. But if is a bad day for you, as it is for some, you will treated for your brain bleed. Hopefully your insurer will pay.
1
Well, a lot of women have died needlessly because the indigestion tuened out to be an untreated heart attack and the Pepcid didn't save them. But it's a small price to pay for efficiency. My friend's swollen ankles turned out to be congestive heart failure. A lot of things can kill, cripple or blind you very quickly, without seeming very serious at the onset. I trained in ultrasound, and some people had routine tests and went home, while others had the same routine tests and were told by a doctor, "You need surgery immediately. I can't let you leave the hospital, even if you don't feel too sick right now. "
2
This doctor Don C. is spot on. ER care is the front door to medical care delivered in the US, and describing it as inferior is ill-informed. ER physicians are, for the most part, highly trained and skilled.
In Australia when we visit outpatients in the ER for whatever reason we pay nothing at the hospital nor do we get squeezed by unscrupulous health care funds. Yes it may take a while to be seen but I’m happy to pay my Medicare levy in my tax for this service.
21
How about a middle ground. Is there something wrong with making people think and be proactive -- taking ownership of ones health?
If they do -- Insurance should be there to pay.
For years my policy paid the ER co-pay ($100) if admitted to the hospital. Fair IMO .... The co-pay went up over the years to $250 ...still fair. It's now $500 -- And I pay if admitted or not (not fair). I'm also on the hook for the first five (5) days if admitted -- at $500 per day ... for years it was $250 and three (3) days.
It's been years since I needed an ER (dog bite) (gallbladder/ removal) ... but, I cut my leg at my house last year. My first thought was ... do I need an ER (yes) ... can I use an urgent care (?). I went to the local hospital's urgent care -- quick/efficient/great doctor .. and not full of sick people. Typically with hospitals bills I don't know what it actually cost for the visit and 10 stitches ... my co-pay was $125 and that included the follow-up to remove the stitches.
Some people do overuse the ER .. there has to be some skin in the game to make people think of alternatives .. but, not paying at all for a once in 5 year event should not be allowed.
7
Good. It’s about time someone started policing completely unnecessary ER visits. As a physician I cannot tell you the burden people without emergent illnesses place in ERs, hospitals and taxpayers in general. If you have a cold, get a PCP.
10
I don’t believe you are a physician. If you were, you would understand many people go to emergency room because they don’t know what else to do. And that is because our healthcare system in the USA is broken beyond belief. If we had a decent national healthcare system, people wouldn’t be forced to go to the emergency room for minor things; they would have more sensible options and would understand and use them.
28
People without health insurance will never get a PCP. They will just show up in the ER and walk out with care and the taxpayer footing the cost
3
XLER: A cold????? The patient couldn't breathe, and his pulse was 150 beats a minute. Maybe he should have just waited to see if he dropped dead.
18
Remind me again why we have private insurance companies standing between us and health care.
22
Atrocious behavior from yet another 'insurer' where the CEO took home nearly 10 million. After 'taxes'.
Until we decide to put the professional clinical physicians and their hard -working nurses back in charge of our health and kick out the extraneous and wantonly over paid insurer CEO's and their profit centered MBA errand men, the insurers will continue taking us all to the proverbial financial cleaners, if they don't kill us first.
What I find deplorable is how do we allow this kind of unethical conduct to continue, when every other developed nation refuses to allow insurers to wreak this kind of financial havoc on its' citizens. God help America.
16
The business model for private health insurance remains collect premiums, deny benefits. That never will change. The only cure is an everyone covered for everything, zero copay, federal single payer system financed by progressive taxes. Even then cheapskates in government green eyeshades will try to deny benefits, but at least a government that denies, or tries to deny, benefits can be voted out. Those with private health insurance do not have a similar recourse.
17
The claims handler at an insurer isn't a Doctor, yet they determine what treatment you are permitted to have, and what drugs can be prescribed. All this without seeing you in an exam room, or even requesting the medical records from your Physician(s).
So the precedent is already set that Insurers practice medicine, and make medical decisions. Now they are just extending this "right and privilege" to potentially life threatening emergencies.
Insurance companies (some) have put clauses about "prior authorization" for emergency treatment into employer health policies for years. One of my insurers claimed it was not an impediment to prompt treatment to call the insurance company for authorization first before heading to the ER. They even had 48 hour "wait periods" for some symptoms.
10
I recently had a major infection. Sadly it was on a weekend and by the time I called the "so-called" urgent care center supplied by my clinic they were closed. They suggested I go to the ER. I refused as I was afraid I would get sicker there waiting plus the incredible co-pay. I went to the clinic 1st thing in the morning. Why aren't there 24x7 clinics in this country is beyond me especially for the amount of money we pay to get this so-so care.
13
When I was a child (back in the 1960s), the pediatrician visited me at home when I had scarlet fever, chicken pox, and once with a very bad cold. He didn't have to any expensive testing to see what I had. He prescribed what was necessary, told my mother what to watch for and left. My mother knew she could call him if there were any complications or problems. Today it's almost impossible to get to see the doctor in a timely fashion. Today they don't make house calls. Today doctors are barely available during office visits because of the need to comply with every requirement the insurance companies put in place.
If the insurance companies are more concerned with their profits than our health they are in the wrong business. I would suggest that they get out and that our politicians work together to give us a medical system that works no matter how little we earn. It should include every part of our bodies as well as ongoing care, elder care, etc. The money we waste on deductibles, paying premiums and co-pays could be channelled instead into paying for a universal medical care system.
Oh, I forgot, our politicians are in the back pockets of every health associated business in this country. Forget about them attempting to fix things for us. We don't count.
33
It is only a matter of time before other insurers adopt Anthem's practice so switching policies is not the answer. The least Anthem can do is provide a hotline number people can call to find out if their malady falls under the ER-worthy umbrella. Of course, there is no question if one has been stabbed in the chest but back sprains (no matter how painful) may not warrant a trip to the ER.
The problem here is the ER is the only 24 hour medical care that exists in this country. There are "urgent care clinics" but in my experience they are to be avoided because they steal credit card numbers and use insurance cards fraudulently. What are we supposed to do if a situation doesn't warrant going to the ER but can't wait until morning or until Monday?
8
Insurers have for years conspired to relegate physicians and elevate instead walk-ins, PA's, HMO call in centers with insurance employed RN 'health managers' - anyone and everyone who has no long-term relationship with a patient, does not provide 24 hour coverage, is acceptable as a substitute to an experienced primary care physician. Is it any wonder patients flock to ER's instead of calling a physician familiar with their base-line health, or one of that MD's coverage group? Health Insurance executive compensation is at all - time highs, their stocks doing quite well. No one is going into primary care, the pay is low, the hours are long, and no one appreciated what a beautiful thing it was to have credentialed, highly skilled diagnosticians available, until they were gone.
10
Not everyone has had good care from a pcp. After 3 bad experiences I won’t try again. I have a PPO Insurance so that I don’t have to.
I have found PCPs to be “jack of all trades master of none.” Serious illnesses was missed as I was pushed out of the office with suggestions of stress or reflux—their favorite go-tos. Really bad outcomes were avoided only because I got myself to specialists who properly diagnosed and treated. My health is good now thanks to my specialists.
A dear friend died from stomach cancer despite every common symptom because the PCPs decided she had reflux, stress, irritable bowel syndrome and then fibromyalgia! We all know that fibromyalgia is the word doctors use when they think your pain in all in your head. Sure enough, they put her on psych drugs and added anxiety meds to her list.
Well, it was cancer and finally diagnosed correctly by an excellent ER doc. Too bad she went to the PCPs... Had she skipped the PCPs who just made their idiotic pronouncements, she could have seen a gastroenterologist who would have seen the cancer with an upper GI when it was still treatable.
2
While the thrust of the article is Anthem's policy with regard to use of the E.R., am I the only one to think the hospital bears some of the blame, when a diagnosis for a back strain, and an aspirin, is charged $1,722? There has to be some linkage between the actual cost of care, and the charges for care. What is happening here is that the hospital is using the E.R. to cover the costs of uninsured patients and other overheads. This is wrong.
16
No, you are no the only one! I completely agree -the costs charged by hospitals and providers are often opaque and almost always outrageous. And yes, because they are largely covering costs they can't recover elsewhere. Insurance premiums are high in part because of inefficiencies, in part because of profit but largely because the cost of care is wildly out of control - and that's on the providers and hospital systems. Everyone, rightly, complains about the high cost of health care and yet want all the care they think they need, where they want it, when they want it = massive costs.
1
The various actors who abuse the health care system include pharmaceutical companies, insurance companies, "frequent flyers", etc. Everyone will have to make sacrifices if we are going to avoid being devoured by our medical costs. There are other things that I want my taxes to pay for.
3
So the high deductible plan (mine is $6,500), and the ER copays - usually at least $250 - is not enough? Health insurance companies are asserting the right to retroactively deny coverage for what they believe to be avoidable?
Can we finally admit that Obamacare is fatally flawed?
Medicare for all.
9
If you voted for Trump, you're getting Trump Care.
18
No, many of us voted for Pres. O, and admitted it was a pass though plan even when new. It was simply a holding idea till Universal Care could be implemented.
Just cause we acknowledge that the ACA was a guaranteed profit machine for Pharma, Med. et al doesn't mean we voted for Trump.
M4A is the answer to O Care and T Care.
Obamacare is better than not being able to get ANY insurance because you're middle-aged and self-employed and an individual policies is higher than your rent, if you can even find anyone to cover you. It's also better than being denied cancer treatment under your employer policy because you once had a benign tumor somewhere, and it pre-existed the policy. Obamacare is a stepping stone. But let's blame it anyway, and not the Republicans who sabotaged it.
Insurance companies are businesses, and they are going to always act to protect the bottom line. That's what businesses do. They are built from the ground up to make money. Just expecting businesses to "put people before money" is like expecting a shark to become a vegetarian. It's the role of a government of the people to restrain that behavior through regulation.
The strange thing about America is that our "government of the people, for the people" usually acts to protect the bottom line of large businesses before the people it is supposed to serve.
Most bizarre of all, you can usually count on about half of the people to vote for a government that protects the bottom line of large businesses. But then they seem surprised and outraged when their interests and even lives play second fiddle to corporate bottom lines.
21
Insurers are bottom feeders at their core. They make the fiends that work in private equity look generous. Until we have single payer we will never have “affordable” health care.
25
Another triumph of the free market!
The chief worry of patients in an American ER isn't, "Am I going to die or be disabled"? but "Oh, Lord, I hope I'm deathly ill, because otherwise my insurance won't cover it...."
24
I think it's OK to deprioritize treatment for the Obese and others who make no effort to take steps that cost nothing and will significantly improve their health.
4
Self-affirmation through cruelty, eh?
10
But at least YOU are perfect, never do anything that has the slightest potential to adversely impact your health, and are a paragon of virtuous clean living.
17
My doctor is an hour away. The nearest ER is 20 minutes away. If I am experiencing something that seems very serious, what should I do? I am not qualified to diagnose myself.
Our healthcare system is ridiculous and embarassing. Articles like this just make me want to cry.
VOTE in Nov.
28
More absolute proof that we need universal healthcare...like Canada.
47
In our area, ERs are choked with a steady flow of illegal immigrants. Most of their ER visits would be classified as avoidable. Because they choose to exist in a “cash only” economy, their apparent poverty allows them to dodge payment for their visits and payment of taxes.
Our failing social safety net directly and indirectly subsidizes their food, housing, healthcare. The playing field for our poorest citizens is biased in favor of hiring illegals.
8
I don't think any illegal in a NY metro ER is competing for a job with any unemployed low-skilled New York resident.
You have no data to support your absurd claim
13
Do you work in that ER? Do you work in the hospital's claims department? How are you so familiar with the nature of those people's medical conditions, when medical diagnosis and treatment is supposed to be private? Did you do background checks on all those people? Or are you just looking at a bunch of Hispanic people and assuming they are illegal immigrants? Do you even have personal knowledge of any of this, or are you just passing on rumors?
7
Dude, whom is absurd here?!
Mayor Bloomberg, testifying before the Senate seems to think differently. "Although they broke the law by illegally crossing our borders ... our city's economy would be a shell of itself had they not, and it would collapse if they were deported," he said. "The same holds true for the nation."
https://www.judiciary.senate.gov/meetings/field-hearing__-comprehensive-...
According to an analysis in 2000 to 2006 data, there are 374,000 undocumented immigrant workers in New York City, which makes up 10 percent of the resident workforce.
More than half of all dishwashers in the city are undocumented immigrants, as are a third of all sewing machine operators, painters, cooks, construction laborers, and food preparation workers.
http://www.fiscalpolicy.org/publications2007/FPI_ImmReport_WorkingforaBe...
Dude, really?! Just being obtuse or playing with semantics?! C'mon.
1
I am not a doctor. I don’t play one on television. I didn’t even stay at a Holiday Inn Express.
How on earth am I supposed to know if my chest pains are indigestion or a heart attack (just like my brother, father, and grandfather all had at this age)?
It is dangerous silliness like this that will lead to single payer health care in the U.S.
44
What a careless piece. Why shouldn't patients be the lynchpin in the relationship between physician and payor? The payor was selected by patient. For far too long patients have been exculpatory from the conversation. If insurance is too complicated for a patient to understand coverage, the whole construct should be scrutinized. Anthem's conduct described here is egregious and should be addressed head on. Patients with Anthem should stop paying Anthem and seek other care. What and absurd policy to highlight with any other conclusion.
Why should any doctor or hospital take Anthem with this policy? Every hospital in the country should go out of network and patients should be told th truth - if you trust the horrible people making policy at Anthem with your health, you cannot expect them to help you or be there for you at your most critical time. Message to patients - Put your money elsewhere and let this insurance company die, not you.
2
If that's the only insurance offered to you, you take it. If it's all you can afford, you take it. That's how our wealth care system works. There are no real choices in it.
17
Not everyone has a choice. For some employees, Anthem is the only option offered by their employers. ACA options offered by the state certainly aren't any better. That said, states could put requirements into place that control how (and whether) insurers like Anthem can operate in their states. MA requires its residents to possess insurance or we pay a tax penalty. MA creates a captive market but fails to protect its citizens by ensuring that the insurers operating within it act in the consumer's best interest. The system is flawed at every level. It's a disgrace.
6
It’s a lot more than 5% of ER visits that are not necessary.
7
Credible, verifiable data?
2
Funny, isn't it? The supposed PRO-LIFE movement wants to make every woman's uterus into government property. But when it comes to protecting the health and wellbing or born people, including children, the supposed PRO-LIFE movement does NOTHING. In fact, MOST PRO-LIFE people are ANTI-LIFE.
29
This is outrageous and what is so wrong with the American health insurance industry. Anthem should be sued for their "avoidable ER program".
Through training, experience and continuing education, physicians use their differential diagnosis skills to determine the etiology of a patient's symptoms. This abominable insurance company is asking patients with no experience and training to do the same. If a patient's self-diagnosis is such that he/she feels it warrants an ER visit and it's an "avoidable visit", then Anthem won't pay the bill. If the patient's self-diagnosis leads him/her to ignore the symptoms and not visit the ER, it could lead to more serious problems or, at worse, a catastrophe. I have seen too many instances in my career where patients avoided going to the ER or seeing a physician because they thought their ailment was a minor issue that would go away. Some of these patients ended up in the ICU or dying because of their hesitation. Anthem's "avoidable ER program" is immoral and unethical because it is asking the patient to play doctor. I assure you that some of their "customers" will pay the price for this atrocious policy.
19
Anthem CEO got $18.5 million in annual compensation. That money has to come from somewhere!
120
Frank, this is precisely why insurance is such a nightmare for consumers. The CEO cares about his compensation and the stock price.
4
Insurance corporations bring NOTHING to health care but their profit margin.
Their conduct is an obscenity.
27
Multiple comments are outraged at the cost of the ED visit. Break down the costs for the complaint of a cough. Emergency physician, X-ray (tech radiologist transport), blood (phlebotomy, lab tech, pathologist), triage nurse, your nurse, nursing assistant, pharmacy (pharmacist, pharm tech), hospital administration (CEO, registration, billing department, IT department, cleaning staff), for-profit insurer (CEO, claims processor).
2
And even with excellent health insurance, I got separate bills from many of them--and add facility charge, ambulance blood-suckers (the ride, the medical supplies, the techs--all separate), surgeons, anethesiologists, and every stray dog that is suddenly "out of network".
What happened to banning "balance billing"?
Go into ER and all the way through you have NO IDEA who the people you deal with are part or your plan--they are all mixed together, and even personally may not know.
It is a hot mess, and I am not a frequent flyer.
8
Anthem is the worst! They are Cleopatra… Queen of Denial.
When I had cervical spinal fusion surgery a few months ago, for a problem that was 20 years old, they immediately wanted to sue whoever had "caused" my injury. They also wanted to deny half the care for the surgery. I'm sure if rescission were still allowed, they'd be doing that too. Good thing I'm on an employer-sponsored group plan and they can't kick me off.
I don't understand how Anthem's business model requires such an obnoxiously aggressive approach, while United Healthcare, another large insurer, is so much more reasonable to deal with.
14
My spouse, whose family has a history of heart issues, was told by Kaiser not to go to the ER anymore for what was being diagnosed as anxiety attacks. Each time he arrived the episode passed before they could give him an ekg.
After he showed up on their clinic door (rather than ER) in the middle of an attack per their orders, they sent him home to ‘calm down’ because he didn't have an appointment. I threatened to sue them if he ended up dying. Six days later, and a few tests they hadn’t earlier wanted to authorize, they found he had two collapsed veins requiring stents, which they scheduled on the following Tuesday. He didn't make, they ended up doing emergency surgery that Friday.
I would rather fight them over an ER bill.
P.s. I think it is past time that all doctors and medical staff wear lapel patches designating what health insurance groups they have contracts with. Think Nascar. Patients should not have to play twenty questions with every one that pops up at their bedside in an attempt to avoid being slapped with a bill for an uncovered consultation or service.
29
Insurance is traditionally for unexpected high costs and not for day to day or moderate expenses, or for the redistribution of wealth based on means. In that health insurance for a family may cost well over 10,000 a year, one might not expect it to cover expenses below thousands of dollars. Catastrophic health insurance used in rare cases like heart surgery or a car access is consistent with this purchase.
In most years I use neither my home owners or car insurance, and of course I have never used my life insurance.
Why have we become so dependent on regulated or corporate health care and the decisions made on our behalf and lost control of so much of our earnings.
When I was a child, we paid doctors directly and submitted receipts after the fact. There was power in being the one who paid the providers directly. You were the decision maker. You might not get reimbursed, but you decided what care you got and thus whether or not it was needed.
4
You must have a lot more money than I do, or you have never had a medical emergency. Medical care costs a fortune, and very few people can pay for it out of pocket.
11
The Insurers are tired of the 'gauging' by some my colleagues - yes, colleagues!
1
Is there not another side of the coin? Persons overusing ERs? Are there not persons who, once hospitalized, doctors decide to keep an extra day or two before discharging them to return to their lives of unfinished prescriptions, poor living habits, and drug or alcohol abuse?
We spend 17% of GDP on health care. Western European countries and Canada spend 10-11%. Five percent of the people consume 50% of US health care expenditures. There are many things that we need to do and many more that we need to try. In general, we need to ensure the health care consumers take responsibility for their own health and otherwise have some skin in the game. Let's give Anthem a reasonable opportunity to try to discourage excessive ER visits.
2
In the nineties I experienced the severe and sudden pain of a kidney stone. Having no idea what was suddenly going wrong, I called 911 and paramedics came by. An ambulance ride later, I was diagnosed, medicated and in the ER. To avoid the cost of checking me in, the doctor had me lay drugged in the ER area for seven or eight hours and sent me home. Still in a bit of a daze, I took a cab. While Kaiser Permanente did cover the treatment, they refused to pay for the ambulance ride. I remember thinking how ridiculous and dangerous this was. Anyone who has had a stone knows the resulting pain can be shockingly sudden and unbelievably extreme. You cant possibly know if something has ruptured or a heart attack has begun. Self diagnosis and attempting to drive yourself to the hospital in such brutal pain is both ludicrous and potentially deadly. Anthem is even farther out of line than Kaiser was in my case. When you have sudden and severe pain, you must always call 911 without hesitation. If an insurer refuses to pay for your treatment after the fact, the legal system must subsequently slam them down hard. Anthem doesn’t just deserve fines for what was described here, it’s executives deserve removal. Perhaps a little jail time for fraud and racketeering is in order as well. You don’t get to cause death and injury in order to make your quarterly numbers. That behavior makes you a direct danger to the public and you should be treated as such.
34
I'm 65 and unless I'm unconscious and someone else calls the EMTs, I'm not going to an ER for precisely the reasons described here. I had a weird problem, literally unable to keep my eyes open. This persisted for four days and then cleared up. My Dad (96) is in an ALF. Someone came along and offered free cancer screenings for people 80-100. What if they find cancer? They won't do anything and what can they do for people that age? Has scam written all over it. My favorite story is the guy who went in for a routine gall bladder operation. While under, a surgeon, outside his network, steps in and the patient is billed $70,000. No, they are not going to empty my bank account.
18
I totally agree, but would add sometimes (in Emergency) a secondary dx of lung cancer can be good, as enabled a long Alzheimers patient to finally get hospice at home--and no did not treat cancer and was not cause of death.
2
Anthem had its origins as a mutual insurance company, but has now FULLY adopted the "for-profit" imprint. It has been responsible for too many denials of care, capricious withdrawls from markets, and other aggressive "profit- building"actions as reported in this and other newspapers. Why is it allowed to carry the respected "Blue Shield" label, which implies trustworthy values? I have no idea. Anthem has consistently put profits first and patients last. Shame on this corporate board.
8
Had never in my life been to the ER until I began bleeding after a routine massage. As an obedient insurance policy owner, I called my insurance company, which told me to call my primary care physician. She said she couldn't help me, & that I ought to go to the ER. I called my insurance company again, & they suggested that I try an urgent care center, rather than the ER. So I patiently went off to the nearest urgent care center, dripping blood all the while. The physician's assistant took one look at me & told me that he couldn't help me, either, & that I had better go to the ER.
I called my insurance company again, & finally, after hours of runaround, was given "permission" to go to the ER. The attending ER physician wanted to send me straight to an oncologist, but the almighty insurance company refused to pay the hospital's oncologist. It insisted that I go home, call its oncologist (located in a small town an hour-and-a-half away from home), & then wait days for an appointment to see him. The insurance company caused us all immense trouble, anxiety, and fury.
Insurance companies should be banned from meddling in healthcare, period. Their customer service people are not trained medical personnel, nor can they make diagnoses over the phone, & yet they are still empowered to tell patients where they can go & which doctors they are allowed to see.
This whole system stinks. Universal healthcare is the answer, for a host of reasons, no room to list them all here!
80
Allison’s comment should be a highlight.
4
Hospitals should set up in-house urgent care clinics and let the triage nurse route incoming patients to the appropriate care.
15
Absolutely yes. It makes total economic and health care sense. So of course...nobody is doing this. Obamacare did NOTHING to set this up.
2
The medical industry has been complaining about clogged E.D.s and people using them for routine care for many years. Not surprising as there are A LOT of people who go to the E.D. and sit for hours and hours in the waiting room because triage suggests they aren't that sick. This behavior needs to change and billing the culprits is probably the only way to do it. Obamacare promised that E.D. visits would be reduced because people would have insurance. That didn't happen but it needs to.
6
I was in the business of health care for years. The first thing I would tell patients checking in is that insurance is not in the business of paying your medical claims. No. Not. Ever.
5
If Anthem expects people to think straight and make the most economic decisions when in great pain or fear for their life, then they don't have a clue about how people work.
They are in the wrong business.
16
Re the guy with a heart rate of 150. Good lord, anyone with a racing heart needs to be seen promptly. It might be just a panic attack or could be a serious heart condition. The insurers are all about money.
13
Chris, I have had panic attacks myself. They are awful beyond words -- you really feel like you are dying. But I know of at least two people who went to the ER with panic attacks (believing they were heart attacks) -- were told it was "nothing serious" -- given Xanax -- and sent home. They were fine healthwise, but the insurance refused to pay the ER at all. They were stuck with about $5000 in bills! and hounded by the hospital collection agency until they set up a payment plan. For one guy, this led directly to bankruptcy court a year later. As a result, I would never ever go to the ER with symptoms of a panic attack! I am terrified of entering an ER, because likely they won't help and you'll end up in serious debt or bankrupt.
2
Common sense should prevail here.
On the first few visits to the ER, it should be no questions asked and paid for by insurance unless it is outright fraud.
This should cover must people since most people never go to the ER multiple times in their life.
For the other people, who go more often, they should be told if their condition is not an emergency and told what to do, ie see a doctor, medicate themselves etc., but insurance should cover it.
After this, then start to charge the "patient", who usually ends up to be a hypo draining the system of trillions of dollars over time, just like the billionaire HMOs and Pharma execs.
4
Where do you get the idea "most people never go to the
ER multiple times in their life"?
Are you 12 or 30 years old?
Or spent your life never being active, outside and doing things--just swaddled in cushions?
Try to venture out of your house more and break a leg, up your count!
2
thank your for your reply Ivy...it has been my experience and that of all my family and friends that they have never gone to or rarely gone to the ER room.
In a nation where the most important thing has become money, life (liberty, and the pursuit of happiness as well) are lagging further and further behind, this comes as little surprise.
I managed my husband's ophthalmology practice for 12 years until he retired. I had seen the abuses of insurers, their unregulated third-party claims administrators, and erosion of the social safety net for the poor (Medicaid) even then--some 15 years ago. It appears to be accelerating now, even if the public is catching on.
Our politicians are often complicit: witness Romney's infamous "47% takers" comment, which implied that 150 million fellow Americans are somehow "life unworthy of life," to vanish at little or no cost: the poor, the elderly, people of color, LGBTQ people, and any other group deemed "unworthy." (Contrast this to Stalin's purges, etc.--50 million--and the very costly Final Solution for six million, including my family remaining in Europe in 1939; that require the the expenses of firing squads, roundups, and building and staffing remote murder facilities, not to mention transporting the victims there.)
Single-payer is the answer, and the proven answer. It cuts through the unnecessary overhead and fairly distributes the costs.
19
A friend's sister is a nurse. She went to work for a health insurance company. For every insurance claim she could find a reason to deny, she received a kick back from the health insurance company. She is making big money - far more money then when she was employed at the hospital as a nurse.
Insurance companies are "profit based" and the end consumer will never receive the care or coverage they truly deserve, as long as "profit based" health insurance companies exist.
The health care system is rigged. It's a legalized scam supported by paid for government employees who receive kick backs and campaign donations for voting in policies that support the health care industry's agenda. At what point will we say "enough"?
27
How can I as a consumer, with little medical training, determine if I should go to the ER for treatment when even my Internist, in consultation with another specialist, cannot make an appropriate decision?
Went to my GP on an "urgent" visit, appointment 2-hours after my first call to her. She suspected DVT and possible atrial fibrillation. She had a cardiologist examine me and they both decided I needed to IMMEDIATELY go to the ER at the hospital next door.
I spent the next 14-hours in the ER and had three extensive lower extremity exams, via ultrasound, a series of chest X-Rays, which let to a CAT scan. Additionally, I was on a 12-lead EKG the entire time and had blood drawn five times.
At 3 AM the next day I was discharged from the ER. NO DVT and NO agreement between five different physicians about my heart rhythms and possible AFIB. The end result was there was nothing wrong with me, or at least eight different physicians could not agree as to what was wrong.
I've had a similar experience with two prior AFIB (??) episodes and ER visits. Each time I've been held in the ER for more than 12-hours with tens of thousands of dollars exams, drugs, and treatments. Each time the various ER docs and my cardiologist argue about the symptoms, diagnosis, and treatment and each time I am sent home with no clear diagnosis.
I have repeatedly been told "Monitor your symptoms and if they worsen come back to the ER." What is a dumb consumer of high tech medicine to do?
17
What is so irritating is that no one calls out that private insurance has Always been the Death Panel that Palin et al warned about. Just before the ACA, my "premium quality" health insurance denied payment for a pulmonary embolism because of a pre-existing condition...lymphoma. Nice.
Insurance companies will not stop, ever, trying to avoid payments for health care. People have to understand, their essential business model, and they are Businesses, motivates them to slip out of paying for treatment any and every time they can. If they deny and you don't protest loudly enough, even if you are right, and they don't pay, that is a win for them. They will do that as much as they possibly can.
The answer to this nightmare is so obvious...
18
No one, including MD's and RN's, should engage in self diagnosis. Symptoms and new physical findings drive people to seek medical attention at ER's. For less urgent problems they will be referred to appropriate care givers in their communities. For more urgent issues tests, imaging, and prompt diagnosis and treatment is essential.
The decisions whether to pay or not pay for an ER encounter cannot be determined before that encounter.
Insurance companies need regulation and oversight to prevent harm to people who need timely care.
7
I make it a point to know where the nearest Urgent Care facilities are. I have had great highly skilled service at these places. Find where they are in your area. Walk in check it out. Note the days/hours they are open. If you ever need it you will be glad that you know where it is. I have gone there for stitches and received fast service.
3
Yeah, it's great -- until the day you go there with indigestion and it turns out to be a massive heart attack and you die because you just WASTED THE WHOLE AFTERNOON waiting at the Urgent Care Center. Or when the urgent care DOCTOR tells you your sinus infection is "a brain tumor!" and sends you to the ER...where they correctly diagnose "sinus infection" but bill you $4500 for a 10 minute consultation after a 7 hour wait until 2AM. And the insurance refuses to pay because "you don't need the ER to treat a sinus infection".
2
Blue Cross Blue Shield of Massachusetts found an even better way to scam their customers. On some plans, including my employer provided plan, will not cover any ER visit until the deductibles are met. For me that is $6500 or more than 10% of my income. Oh and there is a clause where avoidable ER visits will not be covered even if the deductible has been met. BC/BS's expectation is that you will go to an urgent care, waste an hour or two there and then get transported by ambulance (also not covered) to the ER if you are deemed "untreatable" at Urgent Care. My plan also does not cover lab tests and x-rays until the deductible is met. Too bad if your Rx or condition requires them.
You also need to be careful as many of the more advanced urgent care facilities are being classified as stand alone ERs and thus not covered. Your best bet, draw up a list of possible emergencies and build a plan on how to handle each one so you do not end up owing thousands of dollars unnecessarily. The long term plan needs to be weekly conversations with your state and federal representatives to change the US health care system so that we all can get the basic care need to exercise our rights of Life, Liberty, and to Pursue Happiness.
15
If you want a lower deductible, purchase an insurance policy that does not have one. Being a purchaser of individual insurance I did the algebra and quickly determined that several doctors visits and several non-generic Rx in a calendar year was all it took to make a Gold plan less expensive than a Bronze or Silver plan.
Your auto insurance has a deductible, so does your renter/homeowner insurance.
This is what happens when health care is treated as a privilege and not a right.
It's an obscenity that thousands of people die unnecessarily and prematurely in the richest country in the world because they can't afford insurance or because the insurance company can't make enough money on them.
20
I'm quite certain that Anthem considers 100% of visits to be unnecessary.
23
And this, and the shadow it casts through the social and conventional media, is likely one of the reasons why we are seeing more and more people in the urgent care setting with the symptoms of heart attacks, strokes, and other life threatening illnesses.
Just like it says on the sign out front, the urgent care cannot treat your heart attack, stroke, amputation, or other serious problem - we will call EMS and ship you right out to the ER, possibly in worse shape than when you came, due to the unavoidable passage of time.
If these insurers can get away with paying an urgent care price for your serious problem, even if it means that you will die because of it, they don't care, because all that they care about are their profits — Every patient they can induce to go to urgent care inappropriately may potentially save them thousands.
13
Many commenters have said, “there are urgent care centers everywhere.” No, there aren’t. We live seven miles from a rural small town where the hospital, though small, has a first-rate E.R. But the hospital doesn’t have an urgent care clinic, and the town is too small to support a free-standing UCC. I suspect that the regional healthcare system that runs the hospital has concluded that it, too, can’t cost-justify adding a UCC. So, if you use the E.R. because there is no UCC, you’ll be billed for—guess what?—an E.R. visit.
11
The Times when writing about medical and insurance issues should explain how people on other countries are treated in similar situations. That would be enlightening.
For example, no one is turned away from medical treatment in the UK. And no one is ever sent a bill for treatment. Ever. This sort of Faustian choice- go to the ER and risk incurring thousands of dollars in fees not covered by the insurance company, or else risk dying due to an undiagnosed critical illness or injury- just does not exist in other countries.
Let's see The Times shed its national myopia and tell us how absurd our system really is.
11
Here is a radical thought: why don't people stop going to ERs when they know they have something that is not an emergency? Cough, colds, rashes, scrapes, strained backs, twisted ankles, etc. do NOT need high-expertise emergency care. They need to be seen by a primary care doctor or an urgent care provider. People know this yet go to the ER anyway. I cannot tell you how many ER visits I have witnessed that were simply for the convenience of the patient. "I didn't want to wait to see my doctor" so they go to the ER. They want testing, MRIs and so on and demand them. And when asked about cost they say "it's fine, my insurance will pay." THIS is what the insurers want to stop paying for - and in this case they are right. Too many Americans want what they want, when they want it and they want it free. THAT is a major driver of increase health care expense - not the only one, but a big one. For all their greed and evils, the insurance companies have a point on this one. How to work it out fairly is more complicated, but coverage for emergencies should be assured, while people need to take responsibility for themselves and pay when something is just for their convenience.
10
I realize there are abuses, but how do you tell the difference? and if you actively discourage the hypochondriac deadbeats....what happens to the person who really DOES have chest pains or scary symptoms? but cannot access care?
2
Dx: need single payer
Rx: force this by voting 'correctly.' That will be the only way to bring long lasting relief.
9
Hillary said, very clearly "no public option ever".
Hillary said, very clearly "no single payer ever".
Hillary said "I am going to be Obama 3.0 and stick with Obamacare. No single payer -- no public option.
What is really said is you believe that "Democrats will cure all of this and its all Trump's fault -- after 16 months in office" -- as if everything was PERFECT before Trump!
3
Thank you NYT and reporters for this excellent story.
I have several acquaintances who go to the ER at the drop-of-a-hat -- which leaves me SMH... because they otherwise appear to be financially prudent.
...But, I'm at a loss as to how this behavior might be monitored and changed.
...Can't really blame Anthem for trying to rein in folks like this; but it's a tough call and people who make rare ER visits -- along with parents of small children -- should not have to worry about being stuck with a huge bill.
4
I work as an ER RN in a hospital that has an urgent care and an ER. The patients is triaged to UC or ER by a RN. The system works well for the most part, but the UC hours are 12-8 pm and too many people find it more convenient to come outside those hours for minor complaints. The UC fees are much less than ER but slightly more than the clinic. Some patients become angry when they want to be seen in UC but their symptoms are outside those parameters and require ER services and physicians. There are nurse lines for patients to call into but those have very conservative protocols to follow and they tell many tell too many patients to come to ER.
9
The failure of Urgent Care is that needs to be at the hospital -- with 24/7 staff -- and a kind of "triage" where nurses determine the difference between the guy with a badly sprained ankle -- and the woman who is having a massive heart attack. What we have today is a total failure and insanely expensive -- encourages just the wrong people to abuse the system while making it a bankrupting expense of honest people with real problems.
1
I guess who the US need approve a national law about health insurance. The government of Us can to compare the situation with others coutries. For example in Brazil exist a regulatory agency who is responsible and specialist for the health insurance. This is a form to improve the system, which get to benefict all the parties - the government, doctors, costumers and health insurance companies.
1
ER departments should be required, or encouraged, to have a co-joined UC (urgent care) department. UC can treat migraines, sprains, flu, and other things that are not in need of the array of things thrown at you in the ER. If the patient truly needs a higher level of care and treatment, simply shuttle them from UC over to the ER.
9
If I recall correctly, the second President Bush famously declared in effect that Americans could always get the care they needed in emergency rooms (thus defusing attempts to widen medical coverage for lower-income people). Is Anthem contradicting him?
7
Maybe ERs need to change the way they triage incoming patients, so if you say, "I think I'm having a heart attack" they don't immediately start treating you as if you're having a heart attack.
2
I wish the affordable care act did more to reign in the uncontrolled costs of healthcare, and in all cases, these healthcare costs are, ironically, the result of insurance companies with their arbitrary 'reasonable and customary' charges so they, the for-profit insurers, are guaranteed to make a profit. They can't even be accused of padding a bill when the charges that they make hospitals and healthcare facilities adhere to are padded to begin with!
And now, what, someone with a severe stomach ache needs to self diagnose, bypass going to an ER only to die of a burst appendix for fear if they go to the ER for something less they will need to pay the enormously padded ER bill a-la health insurers?
3
You're in what to you is serious pain (remember, when it's you, it's 100%). Or you see, even fleetingly, what you believe are signs of a stroke in a loved one. Of course you go the ER only to find it's effectively "nothing".
Nobody should be penalized for that, excluding perhaps medical professionals that should know better. The rest of us aren't doctors.
What ERs need is better fast triage to weed out the not so acute cases in a cost effective manner.
5
Simple solution: require that all hospitals with an er also staff a round-the-clock clinic. Triage at arrival.
6
It's time for a national health system, to get rid of all private medical insurance companies and health for profit. What other country has this kind of health care system? It's a sick system. It also wastes a lot of doctors' time on insurance issues when they should be spending more time treating patients.
9
The people we vote for don't run this country. Big business calls the shots, and until they say so, we will never have single-payer healthcare.
5
The AMA plays a large role in protecting the interests ($$$) of doctors.
The AMA represents a minority of physicians in this day and age.
1
Private insurance companies demonstrate their inability to protect the health and well-being of patients on a daily basis. Decisions like the one Anthem made here are the tip of the iceberg. They need to be removed from the health care equation and go back to insuring homes, cars, businesses, and the like. Single-payer has become a moral necessity.
6
All this uncertainty of cost and access degrades the quality of our lives, especially when we are sick and anxious.
Why do we allow ourselves to be manipulated by insurance and pharmaceutical companies as well as hospital corporations?
Why do we allow insurance companies in our health care at all?
7
Waiting for the lawsuit against Anthem when one of their insured decides not to go to the E.R. based on this policy and then dies or sustains debilitating injury as a result. Tick, tock.
6
Bottom line is that insurers try to not pay all the time. Remember when they don’t pay They make more money. If they delay a $1000 payment for 6 months, in essence with interest it saves them $10 - multiply that by a few million claims per year...
4
We physicians know that making a diagnosis can be very difficult at times. Simple-sounding symptoms can be early signs of serious disease. A mild cough could be the beginning of bronchitis or pneumonia. Shortness of breath can be the signal of heart disease. What patients may think is just an upset stomach can be onset of an ulcer.
Even when we have the patient right in front of us we can make mistakes. So imagine how great the possibilities for error are when a patient is asked to decide for himself or herself whether or not to go the emergency room.
Encouraging patients not to go to the emergency room can place Anthem at risk for a malpractice suit if the condition worsens or the patient expires.
In most instances, the decision whether to go the ER should be made after patients talk with their primary care doctor whenever possible.
Unfortunately, however, there is a serious of primary care doctors in our country. Many primary care doctors are overburdened and burned out complying with insurers’ regulations and rules. Office visits are hurried and often patients do not get the time they need to be listened to and examined. Many patients are only too familiar with this.
If Anthem wants to cut down on emergency room visits it should collaborate with medical schools on how fix the primary care shortage. It would help if primary care doctors were trained not only in greater numbers but quicker and in a way that better prepares them for society’s needs.
18
Kaiser Permanente School of Medicine is opening next year in Pasadena, CA to address the shortage of primary care physicians.
https://schoolofmedicine.kaiserpermanente.org/news/
I called my health insurer's nurse one weekend when I was feeling pretty bad with a cough and sore throat, and a few other symptoms. The nurse told me to drink lots of fluids. When I got to my physician on Monday, I was diagnosed with pneumonia and put on antibiotics and sent straight to bed for several days.
17
It doesn't work even if you do all the right things. Last November, after 24 hours of fever, intermittent abdominal pain, and vomiting, I finally went to local Urgent Care. Was evaluated and told to go to ER (a Friday night in NYC, I refused). UC doctor was adamant, eventually I capitulated. I had a CT scan and was diagnosed with acute diverticulitis, and admitted to the hospital for for IV metronidazole, ciprofloxacin, and fluids. I stayed in the hospital 4 days, and left to continue treatment at home as the vomiting ceased.
UHC rejected the entire claim - long story. They assured me I couldn't be charged for the hospital stay. But they still made me pay the $500 ER copay, even though I was a directed there by a physician and admitted to the hospital. Really?
24
20 years ago I was building a room for my soon to arrive son in our loft. I managed to rip open my elbow, you could see bone, very clear I needed the ER. When we got to the ER, the first thing I did was call my insurance company to clear everything, which is crazy. And I'm a state employee with very very good insurance.
11
Aching chest pain, shortness of breath - is it a heart attack - or anxiety and heartburn? I'm not a doctor - I don't know - and when I had those symptoms, everywhere I looked said go to ER immediately.
5% of visits, according to Anthem, are unneeded. Only 5%, and they're willing to put everyone through the wringer for a very rare problem, even when we use their own stats to evaluate this.
16
I've never said this before - but I like Missouri's approach. I've also had to deal with ER docs that bill me in addition to insurance and make a big fuss to get paid more than the insurance would pay. Mandatory mediation would be a good check and balance for this.
2
This is going to become a major problem. Many urgent care centers keep hours more like those of a bank, doctors offices close at 4 and aren't open on weekends, and if one calls the after hours number, patients are usually told to go to the ER.
Just what does Anthem recommend that one do?
22
India, we're supposed to become certified EMTs or we're supposed to figure that we'll drop dead at some point because we'll let something remain untreated for too long. Anthem doesn't care about patients. Nor does any other insurance company. They care about the money.
9
I took a bad fall on the ice rink, hitting my head hard and slashing open my forehead. The staff wanted to call an ambulance for an ER visit. I refused--too expensive and out of network because I was visiting from out of state. Luckily for me, the staff person was a nursing student and she butterflied my gash. I had a ticket home in two days, so I stayed in bed and saw my doctors once I got back home. Luckily, I healed. It is absurd, but count me as one where insurance co-pays and coverage limitations guide my access to health care. I am middle class, always carry insurance, but the excess pay outs and co-pays are so expensive that health care is not always accessible.
21
What Anthem is doing is at the heart of our country's health care problems. THEY are deciding for the patient what constitutes an emergency. THEY are deciding that THEY know better than the patient what's wrong and that the patient(s) better get with the program. Insurance companies are forcing us to gamble with our lives. (So, too are doctors when they aren't available enough on weekends and holidays which is one reason people go to the ER and not to a one of the walk in medical offices.) Deciding not to cover the costs after the visit doesn't change the outcome: it will mean that parents and patients will wait longer or not bother to go at all.
We are paying high premiums for narrow network, high deductible plans that have high co-pays, are inflexible, tend to lose claims, deny them even when justified, and tend to change things in the middle of the year when we can't change companies.
On a personal note: because of how idiotic and confusing our wealth care system has become I have ceased to go to the doctor for anything. It's easier to drop dead rather than suffer the thousand cuts inflicted by a profit hungry wealth care system that forces us to do a wallet biopsy before we can even consider making an appointment.
29
"They know better than a patient what's wrong..." People don't always know. I'd argue with that, as I've personally witnessed "patients" in ER for pregnancy tests, colds, or general fatigue. I've seen stoic people with frightening symptoms who should be in the ER but refuse/hesitate to go, not only for financial reasons but also the terrible conditions in NYC ERs, which can be at times overwhelmed with with drunks and drug addicts who either chose to go there or are brought by police. ER chaos and raving addicts can be frightening those who are in fact very ill.
Many (if not all) insurance plans have a 24 hour nurse to call when evaluating whether further care is necessary. I wonder how many patients use this service? I'm in full agreement with those who have suggested and intermediary assessment, such as a urgent care visit, not only to protect their health but also wallets.
What strains credulity is when urgent care recommends immediate ER visit, you brave the chaos, have a diagnoses, and yet the insurance companies disagree with a physician's clinical judgment and lab tests, and refuse reimbursement.
As far as your personal note, I could have written it myself.
5
The solution may be simpler than it appears. All hospitals should be required to have two “emergency facilities”. One is a traditional ER and the other follows the clinic model. When you come to the ER a health professional makes the determination of which of the two facilities you should go to.
It’s a win-win-win. Hospitals get more of the clinic business and have less risk of insurance denials. ER’s will be less crowded and able to provide better care to those who truly need it. The patient is directed to the right care solution and isn’t forced to wait endlessly in overcrowded ER’s. The insurers spend less on needless emergency visits.
Round the clock clinics are a real necessity and both the insurance industry and hospitals should be leading the charge to make that a reality.
20
Suppose you have a problem on a Friday night when all the primary care physicians won't be open until Monday morning and no walk-in emergency access exists? I stepped on a nail on a Friday night and called the emergency room to see what I should do. I was told that I had 48 hours to get a tetanus shot because if you get tetanus it's fatal, there is no cure. It would be more than 48 hours until a doctor's office was open and no walk-in clinics existed. Would insurance companies not pay because the only place I could get a shot in 48 hours was an emergency room? Are we supposed to take chances because we don't know if a puncture wound will be fatal or not?
25
Insurance companies don't care. Your health is not their chief concern. Think bottom line, profits, and what's convenient for them and you're on the right track. It's one more reason we need a universal health CARE system instead of the wealth care system we are saddled with currently.
24
"Other insurers are watching carefully. Anthem points to estimates that as many as 5 percent of visits are unnecessary."
That means up to 95% of ER visits are medically necessary.
Every insurance plan I've ever had encourages customers to call their nurse hotline before going to the ER. Every time I've called, they told me to go to the ER. One told me to call an ambulance and go to the ER.
My area has 4 Urgent Care clinics. Three are open 7am to 7pm. The fourth, operated by the hospital, is open 8am to 8pm. It's also the only one tat takes Medicare or Medicaid. If you show up after 4:30pm, they send you to the ER.
22
Why are consumers being asked to differentiate between conditions? It is hard sometimes to tell the difference between back pain and kidney stones, stomach upset and a heart attack. How about we try Medicare for all. That way when insurers become too expensive and unreasonable, there is an alternative.
20
so consumers are also damaged when other consumers in their plan overutilize er (and other) resources (leading to higher and higher premiums). the best solution is already being provided by some hospitals that provide both er and urgent care services with a triage directing patients to one or the other. another method is to increase er copays to encourage urgent care or primary physician utilization.
4
Time for universal medical/healthcare coverage in the U.S. Start by putting everyone on Medicare and eliminate the deductibles, pre-existing conditions, and restrictions.
20
Unfortunately, the companion article discussing the posting of drug prices in TV ads does not accept posts, so I'll leave one here.
It's about time we went back to not having pharmaceutical ads aimed at the consumer. This also leads people to diagnosing their own ailments and/or asking for medications that may not be optimal for them. And I'm sure the costs of those advertisements, estimated to be in the billions per year, only add to our overall health costs.
Let's get back to relying on our medical professionals to be current in the start of the art (including medications) and rely on their expertise.
16
Left undiscussed in this piece is that Anthem policies in many states are classified as "self-funded." As a result, state consumer protections aren't extended to those unlucky consumers who hold these policies. As an Anthem policy-holder in MA, unfortunately, our family has already faced denials for coverage with zero information about how to appeal or more generalized information on consumer "rights and responsibilities" to identify what is/isn't covered. In MA, we're required to have health insurance. The state should require that any insurer operating in the state fall under its consumer protections. The race to the bottom continues in the U.S. and it's quite clear that politicians - especially the GOP - are no longer even pretending they're not culling the herd. Death panels, indeed.
11
I know people who go to the ER to treat sunburn. Yes, insurance companies should say no to people who use it for non-emergencies.
9
That's so funny, I came here to make that exact comment! I'm a medical coder for a large hospital group, and see ridiculous uses of the ED all day, but sunburn stood out as exceptional.
2
I'd throw in pregnancy tests (though those who do this sort of thing are probably uninsured). I'd simply refuse to perform a pregnancy test in an emergency setting, without the presence of symptoms (i.e. possible ectopic pregnancy). We need frivolous patients OUT of ERs so that care can be given to those with true emergencies.
1
There seems to be this nutty belief that Americans go to the doctor too often, and that we'd save on health care with no loss of health if people went less often. I do know that as a member of a large health organization, which could certainly staff routine acute care 24/7 if it so chose, my only option for medical care at night or on weekends is to go to the emergency room, using way more resources than are medically necessary. People besides myself do sometimes do get ill enough to see a doctor or suffer a minor injury requiring medical treatment at night and on weekends. Why is an emergency room their only option?
24
Arbitrarily limiting care has become the private insurer's go to for driving profitability. It's their work around to no longer being able to exclude pre-existing conditions. Anthem and United Healthcare are in a race to the bottom for who is the worst. Denying emergency room reimbursement is just the latest addition to a long list of ways they insert themselves between you and your doctor which includes: Prescription drug step therapy where they start you on the cheapest medication and hope it works where it can take months of pain before you advance to a drug that works; Drug tiers, formularies and cost based exclusions made in the middle of plan years. Pre-certifications and third-party review of treatment plans second guessing your doctor for just about everything from physical therapy to radiation treatments for cancer; Rising co-pays; Higher Deductibles; Smaller and smaller networks of providers based on fees not quality of care.....
21
Let's get back to your Primary Care Physician, or other professional, to determine the right course of treatment, NOT the insurers or pharmaceutical companies.
9
Health insurance companies should be required to provide life insurance so they don't have an incentive to overly restrict medical care.
10
Our major healthcare problem is that we have allowed insurance companies to be the arbiters in this important sector. Their aim is to make profits and not to bring about the welfare of the public . The insurance companies are private players in what is rightfully a public sector and this intrusion of privatization and profiteering is the crux of our dilemma.
33
Dads,
And the NY Times has yet to do any serious reporting on the subject of rise of for-profit medical insurance, something that's only been legal in the USA for about 45 years.
These problems didn't come out of nowhere, as you know.
I consider myself a fairly liberal doctor but I think Anthem should continue to do what it is doing, though with a much better and less coarse system. If the ER is used for emergencies, it will shorten the waits for people who need them. It may also prevent people who are seeking narcotics from tying up the ER as well. I don't think it should be hard to find a fair system where there is lee-way for complaints around chest pain or altered mental status to be covered even if they are not emergencies, but ear infections are not.
6
V. Sharma,
No, you're not especially liberal. You've come up in a for-profit medical process delivery system.
It doesn't have t be this way.
"If the ER is used for emergencies, it will shorten the waits for people who need them."
Apparently you didn't read the article, Mr. Burton rightly guessed that he could have a serious emergency necessitating his trip the the ER.
One thing that will stop insurers from ever pulling this kind of thing is of course when someone dies from a treatable heart attack or stroke because an insurer would not pre-approve his/her trip to an ER so he/she didn't take it and died at home/work.
"but ear infections are not."
How nice of you to decided that Mr. Burton's severe back pain was about as serious as an ear infection, which of course can be a sign of widespread infection.
Thank you, really, for reminding readers how arrogant some MDs are.
9
When your head is splitting open with pain from a fulminating ear infection in the middle of a Saturday night, doctor, I hope your insurer refuses to pay for treatment, since this isn't really an emergency, according to you.
But if you get paid like most of the doctors I know, you will have no trouble paying the bill yourself. You and your arrogance and your high compensation are part of the problem.
5
Anthem (or as it once was - Blue Cross) has a long history of using any excuse to deny paying claims. This is not only my opinion but is based on having dealt with Blue Cross over the years both as the spouse of a subscriber and and as working in the field in medical offices. I always wondered if they spent more money in denying claims then they would have in simply paying them. Any one who has Anthem has my sympathy. Irene
22
The" prudent layperson " standard is likely as close to objectivity one might reach in such matters.
If a patient or consumer of services believes the claim has been unreasonably denied and the monetary cost is substantive there are "due process" appeal mechanisms in which the facts can be weighed and an ultimate determination made after the fact.
Patients ought not be placed in a position to reflect on whether or not their symptoms constitute a "true" medical emergency at the time they are experiencing the symptoms.
At the same time insurance companies must be held to a reasonable standard and subject to oversight and review on a not infrequent basis. Perhaps yearly. If one insurance companies rate of "emergency care denials" falls out of statistical bounds relative to the industry; monetary penalties would be in order.
7
There should not be insurance companies as gateways to healthcare. We pay for that litigation as part of healthcare, in addition to insurance company profits, as part of health care. Obviously that is money not going to healthcare. Health insurance is strictly a value subtracted proposition. It is absurd that we are still subject to this abuse.
14
I had chest pain and irregular fluttering heart sensations in February. Went to the urgent care, had EKG, they called an ambulance to take me to the hospital. I declined, made a cardiologist appointment instead. He did another EKG, sent me to the ER in preparation to do a transesophageal echo under sedation followed by a cardioversion to reset the heart rate as it was still in fibrillation with a high heart rate. Also found that the heart valve was damaged and severe blood regurgitation resulted.
In the ER, a doctor took some information. Then I was admitted to do the testing and procedure, kept overnight with heart monitor.
The hospital and cardiologist were in-network with BX in GA, part of the for-profit Anthem company. But then I got a bill from the ER doctor, who it turned out was out of network. For less than 10 minutes with him, I was charged almost $1500. The insurer would pay none of this, despite all I had done to show that this was not a frivolous visit. If Anthem is saying they have changed their policy so this kind of thing doesn't happen, they are lying. It happened to me.
Why do ER doctors in a hospital have a different insurance status than the hospital they are in? I don't understand this and doubt very many other people do either.
In fact, I don't even know why an ER doctor would be involved in this at all. The cardiologist had admitting privileges and was paid much less than the ER doctor for what he did!
40
This seems to be a new trick with insurers. The networks cover doctors but not the facilities they work in and vice versa.
20
Trebor, it's a new trick with facilities to make money. Every little thing is itemized. That mucous recovery system they charge you for when you're hospitalized is a box of tissues (at $30 a box perhaps).
Our health care system is not about patients at all. It's about how much money each provider, hospital, nursing home, lab, etc., can suck out of us. It's about how much the health insurance company can decline so we pay most of it. And if we can't afford it, that's just tough. We shouldn't get sick, have the accident, have the sick kid, or have the nerve to be born in the wrong economic class.
14
On the other hand, as an MD for almost 50 years, the number of times I encountered patients in the ER for complaints that had no business being there were many.
If you talk to ER docs over a drink you'll find the numbers of non emergency medical problems in ER's bulk large compared to the true medical emergency patients.
The ER in many locales has become an easy access, clogged, and often totally free, medical office used for routine problems.
13
"you'll find the numbers of non emergency medical problems"
ER docs are trained to know what is and is not a true emergency; lay persons who are patients not so much.
My primary care doc has an opening message on the phone when the office is called ... it says "if you think this is a medical emergency, call 911." So much for triage by the primary care doc. If ER docs have a beef take it up with primary care docs, not with patients.
16
I understand this is a common ER issue. There is an obvious way to solve it.
Who are these unnecessary ER patients, Doc?
I would rather stick needles in my eyeballs than go to the ER. And I am not amused hearing how doctors make fun of the public.
This sounds like a problem in the organization of care and suggests that too many doctors are having drinks together instead of covering patients. Perhaps doctors should create an on-guard system? My gp has one but municipalities can do this, too. In France every township has an on-call system, and in Paris they are dispatched to people's homes in emergencies. Can't you people figure this out??? [PS: Parent of medical student.]
9
I can see both sides to this. When I went through EMT training years ago I had to do time in an emergency room. I was shocked at how many people came into the ER with a simple cold or blister or scraped knee. On the other had there were the other (usually quiet shy people) who came in with some minor-seeming problem that ended up as a true emergency. Indigestion that was a heart attack. Dizziness that was a stroke. A painful hip that was really a fracture. The only answer I can see is a single payer system with a small co-pay fee for minor injuries and illnesses.
35
I agree with you being in an emergency room looks like being a regular doctor line because tons of people are there for no reason whatsoever. I don't understand why they go to the er instead of mailing an appointment or going to the urgent care facility.
4
Without a doubt single payer is the only reasonable answer to our country's ridiculously expensive health care system. If we had that (like every other developed country) people would go to a doctor and not to the E.R.
3
At a previous job at a health insurer, I noticed that the precert approval staff worked 9-5, Mon-Fri, with holidays off, so I wondered what would happen were a member to show up at the ER with chest pains (for instance) the night before Thanksgiving, be admitted on suspicion of a heart attack, then on Monday when the offices were opened, be tested and given a clean bill of health, which would then result in the admission being denied and the member be on the hook for several tens of thousands of dollars, when both he/she and the hospital had behaved correctly.
10
Good question. Without irony, maybe they use a call center in India outside of business hours?
1
The US medical industrial complex is on full display here in all its dysfunction designed to inflict maximum financial hardship. I know it's naive, but I am still waiting to see doctors banding together and publicly speaking out against our current system. By doctors not speaking out, they are violating their hippocratic oath, further eroding their credibility, and losing public trust. The merger of Target and CVS is a harbinger of things to come. Without trust in doctors, there is no incentive to maintain that relationship. Many will decide that an impersonal visit to Target or WebMD will be just as good of a credible option at a lower cost.
10
We would be sued and harassed for collusion if we tried what is suggested in the second sentence. Amazing, but apparently true.
2
"I am still waiting to see doctors banding together and publicly speaking out against our current system."
You'll have a long wait ... why would they do anything to reduce their incomes and increase their patient loads?
3
Oh, so physicians are to blame?
Let's also discuss the lack of a care continuum, which leaves people to choose between an appointment with a physician - subject to availability - and the ER. My urgent care facility is simply a regular family practice clinic that's open until 8 pm on weekdays and 5 pm on Saturday.
And what about the pharmaceutical companies, news media, and health education information that says, "...if you have [insert common symptom here], you might have a life threatening condition." Frankly, I have no idea if my body has a common cold or Ebola virus anymore.
And while we're at it, let's talk about people whose health care coverage is so sub-par that they won't get seen for a small issue due to large deductibles they can't afford.
Many decisions create unintended consequences, and it's about time we start having honest conversations about affordable access to health care for everyone - which is what they do in the rest of the world - instead of confusing it with simply having insurance coverage.
15
Today, almost every major hospital and medical provider is in close proximity to an urgent care facility -- often under the same roof or next door. If the triage nurse had the freedom to direct some patients to urgent care and others to the ER, both insurers and patients would be well served. This would place the decision out of the hands of insurers or self-diagnosing patients, so long as the triage nurse had no conflict of interest involving either the ER physicians or the insurer.
8
What shocks me most is that a hospital can get away with charging $1,722 for doing nothing. Just probably entering the door alone should be a $100 minimum cover charge, if hospitals really had their act together. Even car repair estimates once used to be free, but not anymore either.
9
The fear of being turned away from an ER caused my wife to avoid emergency care, when it turned out she had a blood infection and was hours away from highly dangerous toxic shock, something her primary care doctor told us after a delay. She survived, but barely.
53
My healthcare system is Caremount (formerly Mount Kisco Medical Group) in Westchester County.
This practice has been busy swallowing up smaller practices in the area resulting in too many patients and not enough doctors.
The wait times to see a physician can be ridiculously long. For an annual physical the wait time is about 8 months. That's time enough to develop a disease and die.
The last time I injured myself, a fall resulting in a rib injury, a call to the practice resulted in me being told the soonest a doctor could see me was over 5 weeks. I was told if I couldn't wait that long I should go to the ER. Having suffered through this type injury before I went to the ER to confirm it was not broken or in danger of causing further harm, I had no choice.
Again, recently some blood work came back with elevated numbers, 6 weeks to see specialist. Or, I was told, I could go to the ER.
This is the choice we are given, wait 1-2 months and hope you'll be OK or go to the ER...
25
I was once a patient at Mount Kisco before they started to become so big. When I had a serious problem the gynecologist wanted me to get a sonogram. I asked about the cost. The nurse told me not to worry because insurance would cover it. I had some other questions for the doctor. I called and the nurse told me that she trusted the doctor with her pregnancy and the doctor was an excellent doctor. (implication being I ought to be grateful and do what Doctor says).
I haven't been back since. I never got the sonogram and the symptoms resolved themselves. But I will never forget the nurse's refusal to allow me to speak to the doctor. And yes, there is always the advice to wait or go to the ER.
7
That is such a shame to hear. I was born into the MKMG system in the 60s and was a patient until I realized that it was nuts to commute from NYC (where I lived) to see my doctor. I continued to go to MKMG because I found the practitioners to be very skilled and practical - often providing reassurance when I was over diagnosed by a city doc.
My sister has had a cluster of odd symptoms since she was young - many of which were attributed to Lyme (before Lyme was a thing) - and her PCP worked diligently to seek a definitive diagnosis over the past 30+ years....a trip to the hospital with a suspected ectopic pregnancy about a decade ago found a benign mass...My sister's PCP has been her advocate - and the search ultimately revealed a host of genetic abnormalities. Maybe my sister is fortunate because her case is well known at the group....or maybe because she has no fear in navigating the system....Caremount (ugh I hate that name) knows it....and so does Aetna.
1
Gosh, can my kids sue the insurance company when my fear of unplayable bills has me waiting to check out a likely blood clot? And if so, what type of insurance does the insurer have to cover this likely result?
9
Thanks to my medical insurance company, I now pay more each year for less coverage. I actually cannot afford to go to the doctor beyond the limited so-called wellness visits for which there is no deductible (but for which I pay huge premiums). Thankfully, while older, I am in fair health and do everything I can think of the stay that way.
10
I had Aetna insurance three years ago. After a winter ice storm, I fell in my driveway. I went completely up in the air and the first thing that came in contract with the ground was my head, the right side of my face specifically. I was knocked out. My husband dragged me in the house. We called Aetna to ask what to do. There is always a possibility of a brain bleed. Aetna told us to go to 24 hour critical care, which we did. That doctor wanted me to go to the hospital for an MRI and scheduled one for the following day. I never made it. While in critical care, both my husband and I picked up a virulent flu, a strain we had not been vaccinated for. Within eight hours of leaving the facility, we were both sick as dogs. I didn't get out of bed for two weeks. In the end, I had a concussion and broke my cheekbone all the way back to my right ear. By the time I was well enough to have that treated, Aetna balked because I waited too long for treatment.
47
I heard (second hand, but reliable source) about a similar case (don't know which insurer) where somebody ratting the rapids got a compound fracture. This being pre-cell phone, there was no alternative other than somebody head downstream and send a helicopter in.
And, as in your case, the insurer "declined" to pay as there had been too long a delay between the injury and the admit for it to be an emergency.
So the patient had to pay not only the hospital bill, but also the helicopter bill.
9
IF we had a ratio of primary care physicians to specialists that was more appropriate...
IF we had quickly accessible primary care ...
IF we had urgent care facilities that were open 24/7/365...
IF health insurers had easily accessible nurses with whom a patent can have a quick verbal discussion of their past health problems, current symptoms and concerns prior to deciding between going to urgent care or an ER or waiting to see their primary care physician...
IF health insurers would collaborate with physicians, hospitals, pharmacies, nursing homes, home health agencies and others to develop a secure system that allowed rapid exchange in clinical information...
IF physicians would delegate some of their administrative responsibilities to nurses...
THEN denying coverage for avoidable ER visits might be appropriate.
25
Again, this is what happens when health care decisions based on what is profitable for shareholders rather than what is best for patients. It is very difficult to see how anyone with even a passing familiarity with the prescepts of corporate capitalism would think letting for-profit companies operate medical decisions is morally defensible.
40
Also, shows the virtues of universal single payer coverage.
The marginal costs of adding urgent care patients to the E.R. are quite small. It would simply require a greater acknowledgement of the legitimate triage function of the E.R.
The problem is with the financing system - using a fragmented set of intermediaries that are designed as business models rather than health service models which results in tremendous administrative waste and irrational pricing. That has made the U.S. health system the most expensive while falling short by leaving so many vulnerable to financial hardship.
A well designed single payer system - an improved version of Medicare that covered everyone - would solve the financing problem. Hospitals and their emergency departments would be financed through global budgets, just as we finance our police and fire departments. Health professionals could be paid by salary, or by negotiated fees in practice environments where that would be more appropriate. Other nations have proven that this would bring us greater value for our health care dollar.
We could end the nonsense of trying to shop for health care based on prices and instead select health care based on the most appropriate venue, using perceived quality when multiple options are available.
We really can have a health care system that provides us with the health care that we need, when we need it, and is affordable for all through equitable public financing.
12
Insurers know that the patient is powerless. The government does not have our backs, and insurers have cadres of lawyers who can bury patients in paperwork.
Patients are forced to bring a dull knife to a gun fight every time we go up against over billing by hospitals/doctors and every time we're denied a claim that should be paid.
The president has shown that he has no intention of reeling back the free hand insurers, pharmaceutical companies, distributors and healthcare providers have. Until action is taken by the administration and Congress, countless patients will suffer bank-breaking fiscal harm.
20
There is a constant groundswell in the insurance industry, though, of becoming member-centric; people are always being lionized in the company news for finding a way to stretch the rules and give somebody a break, the company will waive a lot of restrictions for people in a disaster area, etc. The folks in the delivery end are pretty much as interested in delivering good care as those doing the actual care.
But that cuts into profits, of course, and the investors with a financial interest and no view of members as individual people apply constant strong pressure to cut costs.
Iromically, some of those investors are mutual funds under pressure from their members to deliver high returns; and those members are
.. you and me. Or would you keep your 401k with a losing fund because it tolerated a losing insurer that spent more than it charged? What if the patient being denied was you? Such are the internal contradictions of capitalism.
Obamacare was in part a move to bolster this patient-centric movement by providing a marketplace where consumers could choose to pay for an insurer who put their care first, which in turn would eliminate the financial advantage of stiffing the member. The wisdom of the free market kind of thing that conservatives used to like, back when they came up with that kind of plan and Romneycare was implemented, before "conservatism" became all about eliminating all memory of the Kenyan Muslim socialist President who hated America.
2
gzuckier, it's an important point. But it's also worth noting that every other company gets to have their capitalism and eat it to. Every economy needs the rule of law to function. We could write those laws for the greater good, we could have excellent universal healthcare, and your 401k could still make a profit. But we don't. We write the laws based on bribes. (I mean, sure, "campaign contributions" and "lobbying" are the terms, but we all know perfectly well that it's no different than a suitcase of cash handed over the counter.) The laws are written to protect the existing players from competition, to bury the consumer in lawsuits and binding arbitration clauses, to fill every statute with a thousand loopholes, to guarantee profits and avoid taxes.... So yes, in that legal framework, the best investment for your 401k is going to be with the biggest sociopaths wielding the best-connected lobbyists. Yes, in this legal framework, an ethical player is going to get eaten alive and disappear. But it doesn't have to be that way.
We've gotten to the point where we pay for insurance, but can't use it. It's not just medical insurance, it's all insurance. Auto, home, health. Americans pay billions of dollars every year in insurance premiums, but we're all afraid to use it for fear it will be cancelled if we ever make a claim. What is the point of insurance? It provides no peace of mind, regardless of what the ads promise. Yes, it's expensive to cover claims, but that's what insurance is supposed to be for. To cover claims. Somehow it's evolved into this weird system where we keep paying for something. but don't use it because if we do we won't have it anymore. It's crazy.
169
Ms. Pea, you're correct. The idea of having insurance makes sense. Unfortunately, when/if you need it, what a mess. Outrageous is how one might describe it.
And yes, many will refrain from going to the ER because of fear and that decision may, indeed, result in terrible outcomes.
3
If the ER is the front door, why not have an Urgent Care right next to it? That way the UC doc could evaluate patient’s needs, rather than placing the patient in a role that they are not fit for. But then Anthem would probably question the EC doc’s decision...
12
An Urgent Care associated with a hospital charges Emergency Room rates in this area.
BCBS is my insurer, and when I called for advice on where to go with a broken bone they warned me against certain clinics because of their non-obvious connections with hospitals in the area.
7
As a retired physician I would like to see systemic change within the medical care delivery system.
What about a 24 hour urgent care/triage clinic located in each town right next to the fire department/EMT ambulance?
The clinic could be staffed by nurse-practitioners trained in triage. Family physicians and specialists would be on call at the hospital to advise the clinic staff by phone if needed. If the patient who shows up at 1 am with chest pain and shortness of breath is triaged to the hospital, roll out the ambulance and speed to the ER.
On the other hand the asthmatic can be given a nebulizer treatment and a steroid shot, observed for a reasonable period of time and sent home.
The clinic should have a good pharmaceutical closet so meds could be dispensed
The nurse practitioners will be trained to stabilize fractures etc. and voila: the ambulance rolls out again.
The drug overdose brought in by friends/relatives could be revived and observed and then sent on to a special addiction clinic.
Chronic disease can be treated at the Clinic. E.G. Parkinsonian symptoms would trigger a referral to a neurologist for definitive diagnosis and treatment: then the patient would return to the urgent care clinic for follow up.
And Universal Health Insurance would facilitate such a sensible system.
60
A few years ago, I had severe back pain and went to the ER. The doctor ordered a CT scan (I was skeptical about the need). It turned out that I had a ruptured abdominal aneurism. Without the immediate care available through the ER, I would not have survived. But my uneducated self-diagnosis was a back sprain. Because of that experience, I find anthem's policy to discourage ER visits questionable. I realize that my experience is an exception, But still...
205
You were one of the lucky ones. My mother had malaise over the weekend, then suddenly collapsed. It turns out that she too had a ruptured abdominal aneurysm. By the time they got her to the emergency room, it was too late; she didn't survive surgery. Had she received a timely professional diagnosis as you did, she might well be alive today.
14
"Without the immediate care available through the ER, I would not have survived."
But if you did not survive your medical insurance company would have saved on your treatment for your ruptured abdominal aneurism.
I wonder if they would have counted that as a cost saving measure?
22
Problem is a patient very often has to wait days to get an appointment to see their PCP, then sometimes weeks to see a specialist.
27
It is easy to blame the insurer, Anthem, for being too strict on ER visits. And that is partly true. However, the true culprit here is our healthcare system itself. Specifically, the spiraling costs of drugs, doctors, hospital visits, and yes, ER visits. Most ER's have a charge of at least $100 just for walking through the door. They call it a 'facility' charge and claim it is necessary to keep their doors open. And of course there are the $50 band aids and $100 charges for a dose of Advil. But worst of all is the lack of any serious codification of treatments. Hospitals & doctors play this game of 'upcoding.' It has become a billion dollar business just to teach administrative healthcare workers how to squeeze more money from medicare & insurance companies by basically lying about patient treatments and coding the treatment for a higher reimbursement rate. In the end we all pay the price for this dishonest practice in the form of higher insurance premiums and deductibles. This practice is now rampant in the healthcare industry and is a large part of the reason why our healthcare costs are skyrocketing while the actual level of care has not increased.
20
When my new born granddaughter, born in Spain, developed a rash, I assured my daughter it was a heat rash and not to worry. She and her husband did worry, however, and walked to the neighborhood health center. With no appointment, they waited 20 minutes and then saw a nurse and then a doctor. The baby had a heat rash. The new parents were relieved.
Can you imagine this scenario in the US? Because, you know, we are the greatest.
85
Zejee that sounds like (horrors) socialism! Oh no! Americans can't have that, they might get healthy or something at half the cost we pay now.
9
I have Aetna as my primary insurance and I saw this as part of my benefit summary, as well. It made me extremely anxious because I end up in the ER for migraines, and I wasn't sure they would consider that worth covering.
So far they have, but I don't know if that will always be the case.
7
If you have recurring migraines, have you seen your PCP or specialist about them? I don't know much about migraines, so this is not a criticism, simply a desire to understand: what is it about a migraine that warrants an ER visit rather than urgent care or following the advice of your regular treating physician?
2
Janis migraines can become unbearably painful, cause severe vomiting, dizziness,stroke like symptoms, and depending on the migraine type can actually cause a stroke if untreated for too long. The FDA just approved a the first migraine medication but it is not available yet. All previous medications were not designed for migraines and don't work very well and/or can have very serious side effects. Patients may need immediate IV meds with monitoring for a bad episode (I had to be hooked up to a cardiac monitor), IV hydration, a check for a stroke because it can be hard to tell if someone is having a stroke or migraine ect. Most people with migraine will avoid ERs if at all possible because the lights, smells, noise, ect can make the migraine worse but unfortunately sometimes there is no way around it. Even the medication the fDA approved recently will not prevent this. Reduce it yes but we have nothing that can entirely prevent migraines or tell a migraine patient at home if they are having a bad migraine or a stroke or something entirely.
1
IV medication. I've seen multiple headache specialists. I've seen pain specialists. I've seen neurologists. Nothing helps prevent them and the only thing that will break my weeks long migraines is an IV cocktail. I haven't yet found a way to get IV meds on an emergent basis outside the ER, so if you know a way I'm all ears.
Until then I'm hoping the new CGRP drugs will help me.
4
The idea of having a good arbitrage area right in the hospital is a good one. It should be staffed by an experienced doctor and not by students and residents who cannot make a correct diagnosis to save themselves.
The costs for service should be the same as in an urgent care facility. The extra personnel costs should pay for themselves.
Also, my experience with emergency departments is that there appears to be more personnel sitting at computers doing who knows what then there are taking care of patients.
5
The biggest problem is chest pain, which can be caused by a heart attack or by non-serious conditions, such as indigestion. The patient can't always tell what the cause is, and we know that immediate treatment is essential for heart attack survival. Therefore, coverage of ER visits for chest pain should not be denied or discouraged. On the other hand, it would be fair to the insurance company and the hospital to have a reduced rate for chest pain cases that turn out not to be for serious conditions.
4
Its a broken system when a short ER visit to get a diagnosis and be sent home somehow results in a $1,722 bill. If ERs weren’t driven by profit, they would just have nurse practitioners do an initial triage and charge a lot less.
13
The last time I was in an ER, my treatment was conducted exclusively by a nurse practitioner, and the bill was just as high. Hospitals do a great job of cost control, they just don't see any need to pass the savings on to consumers.
7
Open up doctors' offices that have weekend and evening hours specifically - they can charge a little more for the evening and weekend hours, and insurers could cover a little more - but it would save patients and insurers the enormous expense of sending basic medical issues to an emergency room simply because it's after hours (strep throat, ear infection, a cut that need a tetanus shot, sprained ankle etc.) This isn't the same as urgent care facilities - it has more in common with a blowdry bar that offers hair blowouts on Sundays and Mondays when traditional hairstyling places are closed.
7
There are urgent care centers allover the place, where they can treat and refer patients if they need hospital care and are open late into the evening and on weekends. Why would you recommend another layer of providers?
We have a bunch of Urgent Care centers in my area, none of which are open past 8PM or on Sundays. After 8PM or on Sundays the ER is the only option; it is at least a two week delay to get an appointment with a primary care physician.
ebmem - see Dave's reply below...many urgent care facility hours are only a little longer than standard Dr.'s offices.
I work in both ER and Urgent Care. The first thing we tell people with chest pain or shortness of breath is that we can give you some idea of what the problem is, but we don't have the sophisticated testing needed to rule in or out a heart attack or pulmonary embolism. Those things can lead to death.
I cannot tell you how many people come into the office or Urgent Care having a heart attack and refusing to go to ER for concerns of payment. On the weekend there are no adult offices open, and increasingly, the "contact your doctor lines" are really, contact the nurse lines.
On the other hand, people routinely come to the ER for ear infections because they cannot miss work tomorrow, or they have no local doctor. Medicaid in our state has been divided into 3 providers and many offices will not take the insurance, forcing those patients into the ER every time they get sick.
97
I'm a female with a heart problem. Once I learned about my symptoms, I was able to take medicine when an attack happens and avoid the ER, which I had every intention of doing on my own without having to be persuaded/penalized by my insurer. The other day I had a new symptom, which lasted only a few minutes. I reached out to my cardiologist, who scheduled an immediate appointment. A blood test uncovered that it wasn't a heart attack.
Understanding that females have uncharacteristic symptoms and heart disease is a major killer, I will go to the emergency room if I'm concerned regardless of the insurer's policy. I've fought them before and will again, but I am not going to put my life in the hands of insurance bureaucrats whose job it is to reduce the insurers' costs.
67
Good for you!
I worry about people with similar problems that might not have your resolve.
9
It doesn't seem that telemedicine has been considered as a potential solution to this problem. Sudden onset of severe low back pain after lifting is something that everyone has experienced. In a young person it is not an emergency requiring an ER visit. People with alarming but not serious conditions could be advised about treatment by a physician or mid-level practitioner, employed by the insurance company, via their computer at much less cost. Those where there is a doubt, or who have a serious problem could be sent to the ER with the knowledge that their visit would be covered. Since we can order food, bank and get financial advice by computer, isn't it time we started to get medical advice the same way.
6
A nurse line can also direct you to an urgent care facility, which typically has x-ray machines and other diagnostic tools and can always refer you to a hospital if you need a higher level of care. For other stuff that needs treatment but not a hospital, there are mini clinics in Walmart, Walgreens, CVS staffed by a nurse practitioner, who can diagnose a step throat and write a prescription, give you vaccinations, etc. They will promptly refer you if you need a higher level of care.
1
One way to combat the issue of ER visits that your insurer doesn’t want to pay (if you or a family member have the ability to do so): call the your doctor or whoever is on call, tell them your symptoms, and they will tell you to head to the ER. This record gives you more ammunition to demand that the insurer cover the ER.
31
Basically what you have going on here is a feedback loop. The same is seen in higher education. Patient demands are perhaps out of control because of the expense. Because costs are so high patients feel they can expect and demand a sometimes unnecessarily high level of care. Substitute students for patients and university for hospital and this principle can be applied to colleges and professors as well. Patient demands drive up costs and the cycle repeats.
One major difference in the two systems though is the clerical requirements. Patients might be more confident about the care they are receiving if they perceived more face time with the highest trained and paid medical professionals, i.e. doctors. It seems that the clerical requirements in medicine are seemingly designed to block doctors from listening to their patients and patients from hearing from their doctors. This leads directly to patient dissatisfaction, lack of confidence in health care providers, the feeling of being trampled on and impotence in getting needs met. The result - taking the 'nuclear option' i.e. an ER visit.
Rebuilding the doctor patient relationship; providing PCPs with additional time with each patient and restoring confidence in care received in non-ER settings could reduce the use of the ER. Unfortunately this program has costs too.
4
This is another reason to go to universal insurance/care, and it has nothing to do with individual experience.
Emergency rooms' costs are mostly fixed: Equipment, staff salaries, utility costs, all are the same whether someone uses them or not. This is why the cost of an individual visit is so high: The fixed costs are split up among only the folks who use it, and there are only a few dozen (or even a few hundred) of them per day.
With universal care -- with all those fixed costs paid by taxes (which is what insurance is, when you get down to it) paid by everyone instead of just policy holders -- this problem goes away. A visit to an emergency room would cost, at most, a token amount to weed out the frivolous visits.
But of course, with universal care/insurance, there is no opportunity for corporate giants to make multi-multi-million dollar salaries, no chance for them to charge thousands of dollars for medicines that cost pennies to produce, and since the corporate giants have congress bought and paid for, this will never happen.
23
And the corporate-media will continue to hide the truth from the US public: our health care system is the laughingstock of the developed world.
3
The circumstances under which an ER visit are automatically covered (barely mentioned in the article, and almost at the end) are key.
Honestly, as a person who's rather not have my out of pocket costs keep skyrocketing, I think this makes sense. The man with the back pain, the woman with the heart trouble, if they had the option to go an less expensive urgent care center, they should. Not saying they did (middle of the night, for example). But the general idea here is sensible, even if it takes some time to smooth out the details and for people to start thinking urgent care center first, and ER last.
3
So the patient who isn’t a medical professional has to decide on the level of their need to go to the ER? Have you been to an urgent care facility recently? The person who determines your need for care is the front desk receptionist. You can sit and wait for hours before seeing anyone with actual medical training. In cases of stroke a long wait before treatment can mean the difference between permanent physical damage or recovery.
54
If insurance companies don't want to pay for emergency room visits, then it should be THEIR responsibility to set up 24 hour urgent care facilities in every town/city where they offer insurance as a place where patients can immediately find out from a qualified medical professional if their symptoms require emergency care. Perhaps every town should have a 24 hour pharmacy, and every pharmacy should have a qualified medical professional on call.
121
Excellent idea.
Or maybe every town should set up their own medical network with urgent-care facilities and their own doctor residents, so people who reside in that area can access medical care and form a health-care co-op of sorts. Oh. And make sure to divest of cost-padding insurers and Big Pharma.
One can dream, no?
7
Really, they should set up an urgent care/triage center next to every ER.
6
I sympathize with all involved, the insurer and the patient. This is just a symptom of the insane healthcare costs in the US. ER charges are among the most outrageous costs in our healthcare system. I went to the ER for chest pain and after blood test, one chest X-ray, one EKG, and five minutes with the doctor I was discharged with a $5,000 bill for the ER and $1,000 for the doctor (both after insurance company “discounts”). Since I have a HDHP with $4,800 deductible it all fell on me. If I went to Urgent Care with chest pain I would be sent to the ER. The best way for the insurance company to reduce unnecessary ER visits would be to have a $250 deductible which should be enough to encourage most people to try Urgent Care first for most situations.
5
You do know that most Americans can't even cover 400 in unexpected expenses?
6
How about waiving ER fee ($500 in my case) when UC physician either directs you to ER or simply calls an ambulance to take you?
3
The primary goal of health insurance companies is to make money, to enrich investors and sustain the all-important bottom line. Every claim they pay means less profit. Every claim denied means increased profitability.
Insurance programs count on buyers not arguing their decisions and not moving their policies to another competing provider. They are willing to spend millions of dollars on advertising but dispute as many claims as their charts and statistics say they can get away with.
Healing is an art.
Medicine is a science.
Healthcare is a business.
106
I used to know someone who had been seeking better job and was hired by a company that promised to pay her during training for what was described as a high-level customer service position. After a few weeks of training in a boiler-room situation, she realized that the job, which had been presented as requiring a very high level of responsibility, was the first refusal for customers who had received a denial from their insurance company for treatment they had already received. There was a very rigid schedule for the employee to get the "customer" off the phone, a very strict quota for employees to meet in discouraging the customers from calling back. The stories were agonizing, the pressure was terrible, and despite having quit her other job and needing the money, she couldn't stick with it and quit before she was permanently hired.
5
this is not a new tactic nor restricted to one insurance company. I cut my thumb on New Years morning one year. I tried to go to the local urgent care but it was closed so the Emergency room it was. My original claim was denied because it was an "elective procedure or surgery." After appealing, the insurance company paid, but it I had to questioned it.
9
I have some sympathy with Anthem's concerns after my recent (and first) significant interaction with an ER.
After experiencing severe nausea and vomiting, I went to the ER, was given a CT scan, and diagnosed with an intestinal blockage. After four days I was discharged, but the blockage was still there I had to return to ER at another hospital in the same network. I brought my CT report, but the ER doctor insisted (over my vehement objections and suggestion of an MRI instead) that I have another CT scan. He argued with me, without addressing why he couldn't use the first CT scan, with such vehemence that I have little doubt that he had an incentive to order CT scans, or was at least being monitored on how many he ordered. Of course, after the CT scan, they said that I needed an MRI. Unbelievable.
I wonder how much of the pressure to have scans is to look for problems that can justify additional tests.
57
It was several days later. My guess is the Dr. wanted to see what if any changes occurred from your first imaging. If the blockage had changed in someway - the Dr. might be risking malpractice if he/she relied on an old scan. Maybe there weren't any changes - but if it had...you might have required an entirely different intervention. If you weren't concerned - why did you opt to go back to the ER?
5
The problem is there is no other option for people who are in that gray area of an emergency or not.
Here in the Netherlands there are 24 hour clinics where you call first for advice . Basically they make a recommendation as to whether or not immediate treatment is needed.
This is a much cheaper option than visiting an emergency room for those cases where one is not sure.
83
Most major insurance companies have 24/7 nurse triage via telephone for assistance with these matters. They just are not well publicized much of the time.
5
Here in America, if such a clinic didn't recommend immediate treatment and the patient turned out to have a medical emergency, the lawsuit would be for millions of dollars.
10
Use the nurse line from your insurance company if available. Make sure you get on the record the recommendation to go to an ER.
A recent experience I had suggested an urgent clinic unless I also had certain symptoms, then go to an ER. The clinic was adequate.
3
I work for United Healthcare, this is their policy on ER visits, as well. The article says other insurers are watching, but no they aren't. They all have these policies. They bank on you giving up.
217
GEHA, my insurance, woks though United. There is a 24/7 phone service, and CVS Minuteclinics are covered. If the problem is considered life threatening the preferred procedure is calling EMS. They can start treatment and have the ER prepared for you. ERs contain many sick people, are slow, and expensive., and driving there is the least effective way to get there.
2
"They bank on you giving up."
Truer words were never spoken- It's their "business model".
AND, They are all the same.
Being named the "best" insurance company is the rough equivalent to being designated the tallest midgit in the circus....
SINGLE PAYER NOW!!
27
If the insurance companies want us to determine our own diagnoses, we should be able to bill them for the services provided to ourselves.
Remember folks, if insurance companies actually had your health as their primary goal, they would better reimburse primary physicians, fund more urgent care offices, and decrease payments to specialists who fix problems the those two may have been able to prevent.
92
I hear you. But these costs are spread around to everyone.
This, along with ridiculously priced drugs, is why the monthly cost of health care -- whether you buy it yourself or employers provide it -- is approx $800+ / mo.
That's $10,000 / person / year after tax.
Approx $14,000 / person / year before tax.
Median household income is about $52,000.
2 adults in their 50s end up putting 50% of their pre-tax income to pay their health insurance premiums. And that's before the $3000 / person deductible.
10
I work in a licensed healthcare profession and am employed by a hospital system that provides my insurance. Like many businesses, they are self insured and use an insurance company to administer the policy.
Earlier this year I was out of town and became afflicted with one of last Winter’s bugs that was not the flu. As I was out of town and no local Urgent Care center was in the area, my options were a system owned ER or a system owned Primary Care Clinic. I, trying to be compliant with our instructions to minimize ER visits, went to the clinic and fully expected that it would be paid.
It was denied. The plan (I dare not call it insurance) which has in recent years morphed from real insurance to a very tightly controlled HMO expected that I only go to my chosen, Primary Care Physician or get a referral. For routine medical care when I was away from home. Supposedly this is to prevent doctor shopping, despite the fact that I neither sought nor received any kind of medicine that gets one high or is addictive. I got a steroid shot, a decongestant and an antibiotic.
The kicker is that had I gone to the Emergency Room literally on the other side of the parking lot, it would have been paid- minus my deductible. As the system is self insured and the treatment in house, the money would simply have gone from one pocket to another. They tell us to avoid using the ER, you do it and you get left holding the bag.
I doubt I am the only person who has seen nonsense like this.
171
I went to the new Urgent Care one Labor Day when I tripped over a box and got a huge egg sized, very painful lump on the top of my foot—I broke my fifth metatarsal. Healthnet refused to cover the cost of the boot and crutches—the letter said it was “not a medical necessity.”
21
No question, this new approach seems harsh but we simply do not have unlimited resources to pay for everyone's using the ER. Part of resolving it is for medical providers to do a much better job of triaging people coming into the ERs than they are. For example, a hospital could build in an "urgent care" clinic literally next door to the ER. When someone comes in the ER with a condition or injury that can truly be diagnosed quickly as a non-emergency, then they could tell the person, "You need to go to the clinic next door."
19
We may not have unlimited resources, but we have adequate resources. All we needs do is stop military adventurism and a regime change foreign policy world wide. In addition we could eliminate the need for charities like Wounded Warriors by funding the Veterans Administration.
7
Modern healthcare is expensive, check your itemized bill next time you need hospitalization. Doctors, bio-engineers etc spend hundreds of thousands of dollars on their education and licensing. Modern healthcare, like I said, is expensive, hence the need for insurance. And the cost is rising at multiples of the rate of inflation. And the Republican's response? Shop around for healthcare deals in the free market. No problem for people like Trump and our well compensated congressmen.
22
The use of ER departments as a doctor's office is a problem everywhere. If I make the wrong choice and go to my doctor's office but should have gone to an ER then I might pay a big price health wise. If I go to the ER when I didn't need that level of care I have wasted my and the system's time and resources. The problem is I don't know what level of care is needed until I have accessed the system. Charging me for making a wrong choice seems punitive particularly as there might be limited choices for entry into the health system. Perhaps the insurance companies would do better to find ways to triage patients better so that they start at the right place in the system. Legally however I don't think that you can diagnose someone's complaint without meeting with them in person.
63
When I had an HMO insurance, my doctor was seldom available. Often, it appeared to me that the receptionist was practicing medicine. When I had an irregular heartbeat I was offered an appt 2 weeks from Tuesday. Because there were no urgent care providers on the list of approved (ie, paid for) providers, I ended up in the ER room. My care was covered, but with a very large ($250) co-pay. For many, that co-pay could have been just the same as turning away from the Emergency Room.
49
Stories like his confirm the US has one of the worst and yet expensive healthcare can systems in the developed world. It’s a chaotic collection of providers and payment systems who all do not have the interest of the patient. The status quo cannot go in as most Americans receive substandard care and more will push for a national health service.
147
We must quit calling what we have a "system".
3
As long as Republicans are in control of congress and the
presidency nothing will change....I take that back....it will get worse.
2
Easy to blame insurance companies and they deserve some, but this is why the ACA is still very much a work in progress and we all need to keep pushing it forward.
33
It makes sense that insurance companies should use billing feedback to disincentivize ER visits for trivial matters. If they provide the correct price signal (one that customers can rationally use to calibrate their ER visits) this would have a major benefit: reserving ER resources (which are truly limited) for serious cases.
That said, I'm a parent and no parent in the middle of the night thinks "Oh, this problem with my kid can wait until the morning."
17
Most problems can wait until the morning unless, there are serious breathing issues, loss of consciousness or excruciating pain!
The last I heard, "price signal" is not a clinical sign or symptom that is used to diagnose any of the 14,000-70,000 ICD10 conditions(depending on how you count) that could conceivably present to an ER. The "correct" part of your statement assumes that the patient can accurately self-diagnose (including both disease/injury and severity) before showing up in the ER and then compare to a list of covered conditions.
So lets suppose you have migraines which are very painful and transient and often associated with symptoms that mimic "mini-strokes" (TIA's) or full-on ischemic events (strokes - limiting supply of blood to a portion of the brain, producing permanent and typically significant damage - or death). If the ERs themselves are challenged to differentiate these diagnoses (just one of MANY thorny differential diagnoses performed in the ER) - how are you supposed to do it? So maybe you would like to experience a stroke and die or maybe be paralyzed for life, maybe lose your power of speech - because you incorrectly interpreted the "price signal" from the insurance companies?
When insurance companies institute these kinds of policies, they are in effect practicing medicine without a licence - which I believe is illegal.
ER's are first responders in the healthcare system - not insurance companies. If insurance companies in the US position themselves BETWEEN first responders and patients - then guess what - the system will get even worse! Guaranteed.
8
So now we're supposed to assess our own medical conditions and situations and make an appropriate decision while experiencing an event? This is insane. If you're having something unusual occur, how much time is one required to decide which situations are life threatening or not. If we can determine all that on our own, what in the world do we need insurance for? After-the-fact review is easy.
165
It's easy. Just google your symptoms and diagnose yourself. Then rush to the ER because you've obviously got meningitis, Dengue, and a ruptured L4-L5 disc that's going to lead to permanent, agonizing pain unless you receive immediate surgical intervention.
Wait, is that not what Anthem wants? Hmmm... There is no solution to this problem. No country has been able to solve it. It's hopeless so we should just lie down and wait to get shot.
Sorry, I got distracted by the latest school mass shooting. What were we talking about again? Oh yes, how this country is completely broken and congress is doing nothing to help us. Right-o.
12
"Anthem recommends that patients with sprains and upper respiratory infections instead consider a visit to a primary care doctor or an urgent care center."
Sure, and one can get an appointment with primary care provider in about 3 weeks or so.
265
They may try an urgent care center! My PCP has appointment within a couple of days or same day for an existing patient with serious symptoms!
12
Only if you can find a PCP. In my area the insurer-provider directory of physicians who are taking new patients is completely wrong. I called a bunch of places and finally found a doctor, then waited almost 2 months for the first available appointment.
When I arrived there was no such doctor at the facility, and uniformly the employees had never heard of her, although some had been working there for up to 10 years. They had made an appointment with a Nurse Practitioner for me, and having waited two months I went ahead with the visit.
Afterwards I called both the facility and my provider (BCBS) and complained. That non-existent doctor is still in their provider directory as taking new patients.
I'd call it bait-n-switch.
46
I've worked on the development of rapid point-of-care Dx tests for decades, but don't see any for the types of "sprains" and "upper respiratory infections" that Anthem wants patients to self-evaluate and defer getting to MDs to figure out. We do have rapid flu testing, but it's not Over-the-Counter so cannot get to tests listed at fda.gov unless it is in the hands of someone "inside the system."
hmmmmm????
3
People overuse the ER for many reasons. I experienced what likely was - and turned out to be a DVT - over Thanksgiving, I've worked in healthcare so was determined to wait for a Monday appointment despite friends urging me to go. I made a calculated decision that worked out but I was aware it was a risk. Others make different assessments.
7
Your calculated decision could have cost you your life. A deep vein thrombosis (DVT) is a life-threatening emergency and should involve immediate treatment rather than a three to four day wait. You “won” but others with DVT symptoms who foolishly delay may not be so lucky. Those others are the very ones these profit driven actions to restrict emergency room care may kill.
7
When I was an healthcare industry analyst, I spent a week visiting Anthem (then WellPoint), meeting with 40 departments to see what, if anything, was different from the usual managed care company.
First, they gave me unchaperoned access - no PR spin doctors sitting in on meetings even with staff who didn't usually meet with outsiders.
Second, the patient was put first. When watching claims come in for review - I recall one for a wheelchair for a member with CP. The only request that Anthem denied - a specialized metallic paint job.
Leonard Schaeffer please come back and fix Wellpoint.....it will never be Anthem to me.
14
The vast majority of people in emergency rooms don't need emergency rooms, they just need a doctor or nurse to spend 10 minutes with them and reassure them that their symptoms are not an indication of something serious. But family doctors are not set up for this -- they aren't open evenings and weekends and have very limited sick appointments. Most of us can't even get our doctors office to even pick up the phone anymore. Insurers could help by telling their doctors to cover evenings and weekends and answer their phones.
91
I agree about people overusing the ER way too much. In my wife’s pediatric practice about 2/3 of the ER visits are wholly unnecessary. But people don’t want to wait for the morning when kids are screaming; I wish the hospitals would have an all night urgent care nearby, but it would not make enough money so that’s a nonstarter. Hospitals love ER profits.
But having just stayed up all night listening to her field calls from parents (for no charge) with questions raising questions ranging from critical and completely necessary to average to utterly absurd (the dosing chart for Tylenol is on our website and all over the Internet, people), I have to respectfully disagree about the phone part. Indeed, my wife is too available perhaps — she returns calls within 30 seconds of any page — but we’d have it no other way. Our community’s children and her patients are too precious to us.
21
When i was an ER volunteer, I encountered a lot of people who were there for minor issues because their PCP told them to go to the ER. This was in a major city with a huge doctor shortage and no urgent care centers (the mayor had publicly vowed to keep CVS from opening in-store clinics within city limits).
15
Some poor people may not own a lap top and may be able to use a computer only when the public library is open.
I recently spent four days in the hospital recovering from an infection I picked up as the result of a kidney stone operation I had initially expected to experience as an outpatient procedure.
The final bill, not including doctor's bills and lab procedures, amounted to more than $30,000, most of which was picked up by Medicare, which means I'll eventually be paying the freight through my taxes. I have no complaints. Medicine is just a business. One fine enough that it even gets paid for its own mistakes.
10
Any medical procedure or treatment has adverse effect that cannot be accounted for beforehand. This was most likely discussed with you prior to the procedure. Every ne is different biologically and can react differently when it comes to medicine.
Sometimes even kidney stone operations can lead to infections that require IV antibiotics.
These are not mistakes as you stated though.
4
My brother had a blood clot in a leg vein. The surgeon failed to close the incision correctly, and it became infected. This was their fault, and it is well known how many deaths have occurred after hospital acquired infections.
I have an amazing idea: How about we put "urgent care" centers in hospitals so that patients can be triaged and sent to the appropriate place. Individuals really have no way of knowing how serious their condition is. Maybe 5% of emergency room cases are unnecessary, but I'll bet 99% of those cases are people who believe it is necessary.
321
Excellent idea!
But note the insurance billing may not change: I went to an urgent care after an accident that required medical attention but not the ER. Despite the use of "urgent care" in the marketing put out by the hospital, they claimed they were not an urgent care facility. huh? I had to fight for months, supplying photos of the sight, links to web pages, etc to prove they were, in fact, defining themselves as urgent care and to get the insurance coverage. This, by the way, was with a $20,000 + premium for a typically healthy
family of 4.
25
This actually is the case at a hospital near me. They have one main hospital, with an ER, and another free-standing ER that's in the same building as an urgent care facility. On more than one occasion I've been in the ER and heard them admitting patients from urgent care.
13
This is an old idea that many ERs already use. Not sure though how common it is. Other systems have 24hrs call lines monitored by RNs to help triage and book immediate urgent care appointments but even then, the message is usually if the patient absolutely feels they need to go to the ER, they are not hindered from doing so.
6
If I can go to an urgent care center, it's much better, for something like a pain or burn, or even an animal bite. I will always do that if it is available, rather than use an emergency room. They will send me to a hospital if I need it, but I never have.
I don't know if they are available all over the country. We have three in my town.
14
My neighborhood has a bunch of urgent care places. BUT....they're not always open. AND....some of them lack basics, like X-Rays. AND....they tend to refer you to the hospital. AND....you have to figure out which one your insurance company will let you go to. AND....the deductible is hundreds of dollars.
In theory, urgent care centers are great. In actuality? Not so much.
10
When I was employed as an ER doctor, those paying me placed highest emphasis on chart completion, adherence to order sets, and comprehensive evaluations.
I was among the country's highest-paid data-entry techs: laboriously checking little boxes on a computer screen (instead of focusing on the patient).
This routinely generated the highest-level-of-service ER physician bills, and left the patient feeling ignored. As an employee, I was "corrected" when my charts didn't support higher level billing for professional services.
Meanwhile, every patient (or family member) wanted everything done, armed with Google printouts and patient support group blogs for evidence. Everybody with a backache wanted an MRI (immediately!) and everybody with a cough and fever wanted a Z-pack (immediately!).
Clinical judgement, expertise, logic and reason were tossed into the same trash heap where we've relegated all science, professionalism and authority.
So here we are: profit-driven companies employ minimally trained "providers" (so much cheaper than doctors.. and who needs 8 years of training anyway?). With minimal knowledge, they order unnecessary and redundant testing.. for a populace demanding everything, all the time.
And it's all overseen by accountants, managers, or, at the worst lawyers and advocacy groups hovering to pounce.
To paraphrase Jefferson.. "you get the health care system you deserve"
365
You are describing a system that has fallen under the control of medically unqualified persons and bureaucrats - not a happy situation and as expected and demonstrated by the epidemiologists - not a health situation.
But I would note that you have two themes woven together here. On the one hand - you have patients who are doing their best to get the best and most appropriate care, given the combination of an overabundance of information of variable relevance and quality, and a health care system that is at minimum a financial maze and for many a financial minefield. I have many years experience in healthcare - including ERs - and I sympathize with patients - the job of providers is to help inform and direct and shape that concern - as best they can.
However, with regard to healthcare bureaucracy and the for-profit foundations and superstructure of the system in the US - I think what is needed is some form of medically-assisted 'deconstruction' and transition to something that makes good clinical sense.
38
Rick, sad to see professionalism in medicine, like so many other fields, diminished or eliminated by bureaucrats and accountants. Doctors can join with teachers, engineers, and many skilled blue-collar workers who, like you describe, have been reduced to "techs", while many layers of managers and system analysts take charge. And since they choose the metrics, the results always show improvement.
How do we get professionalism and autonomy back?
48
Here’s a start off the top of my head.
1. Cap medical administrators in terms of numbers and their salaries as a condition of taking funding from CMS.
2. Don’t let hospitals “buy” medical practices such that physicians become mere functionaries and wage slaves instead of learned professionals. There are business models for doctors who don’t want to be bothered by the business sides such as large physician managed multi specialty groups.
3. Eliminate the independent practice model for mid level providers. They can be very useful and some are excellent. Others are little more than diploma mill graduates. Under some nominal physician supervision they can be fabulous.
4. Increase the number of primary care residencies and decrease specialist residencies.
5. Decrease specialist reimbursements and increase primary care reimbursements to incentivize more front line care.
6. Create Medicare-Medicaid parity.
7. Meaningful tort reform to help eliminate defensive medicine.
8. The physician’s decision about a patient’s health care plan is presumed correct cannot be denied by the insurer absent manifest error. Let doctors be doctors.
9. Eliminate middlemen as much as possible.
10. Cut back on the insane paperwork requirements which, however well intentioned, are killing physicians or driving them from the profession.
65
There is no discussion about whether Mr. Burton had access to Urgent Care or if such a center was to far away to be practical. If the latter, it is unconscionable that the insurer would deny coverage; however, if he had access to Urgent Care without more difficulty than the ER then he did not guess wrong - it is obvious his was in no way a life-threatening condition, he made a very expensive mistake.
9
A condition should not have to be life-threatening to be treated at the ER. Fearing a spinal injury is a perfectly good reason to go to the ER, paralysis is a fearful thing.
10
If insures want to avoid paying for "Avoidable" E.R. visits, they should mount a PR campaign to clearly educate patients and providers as to what is not covered in the E.R.. This is often confusing and is not clarified by the insurers until after the fact when they deny payment. It is in "the fine print" but is often not clear to the patient (or the provider).
76
While I feel no particular sympathy for the insurance company, reducing the use of emergency rooms for non-critical care is a laudable goal. Think we pay too much for medical care? I do, too. Overuse of the ER is a contributor. Isn't that one of the arguments for universal health coverage? Besides, I've never had private insurance that did not provide a helpline, staffed by nurses, who could help evaluate your symptoms and recommend the level of care needed, thereby shifting the responsibility to the insurance company. Doesn't Anthem have this?
33
Every time I've called my insurer's helpline, they have sent me to the ER. The one time they didn't, I turned our to have post-partum pre-eclampsia, which can be deadly.
18
I learned more about the private health care insurance or lack thereof - by reading this article.
So, thanks.
I am fast approaching 70 and is covered under Medicare.
How does Medicare pay for E.R. services??
5
"How does Medicare pay for E.R. services??"
Medicare basically covers 80% of ER services (if you have Part B); most Medicare Supplement Plans cover all or much of the remaining 20%. You can find the details at https://www.medicare.gov/coverage/emergency-dept-services.html.
3
Only in America, of course, are you you expected to self-medicate yourself to death....or visit the doctor and face medical bankruptcy.
All other rich countries have strong regulatory bodies that wisely and humanely negotiate or regulate hospital prices so that an emergency room medical bill totaling $1,722 to treat a patient in extreme back pain would never arise in the first place.
But our 17% of GDP Great American Medical Rip-Off demands a waterfall of profitable extortion.
It's a big, practical, profitable deadly joke on the American people.
Just copy Taiwan's conversion from a broken healthcare system to single-payer with universal coverage at 6.2% of GDP and put the American medical mafia extortion industry out of business already.
https://www.nytimes.com/2017/12/26/upshot/the-leap-to-single-payer-what-...
290
Good grief. I had 'extreme back pain' and went to an ER. Five hours later I went home with valium, oxy, and no diagnosis. A week later I got a bill for over $10,000.
Also a week later, I still had my back pain, so this time I went to the VA ER, and saw an Air Force flight surgeon on a quiet Sunday morning. Within five minutes, he had diagnosed a severe cramp, taught me a few stretching exercises, and I went home. Two days later the cramp was gone.
Moral of the story? I don't know.
33
Socrates, call our system what it really is: a wealth care system that tends to the injuries and concerns of the wealth care industry rather than those of the patients or their families. If you need medical care outside of your doctor's office hours and it's urgent but you don't want to be second guessed, wait until the morning or the next weekday. If you have to do a wallet biopsy to see if you afford a visit, you probably can't. If your doctor prescribes a medication that the insurance company doesn't want to pay for you can appeal it, pay for it, or accept their decision. If the medication is too expensive and the pharmaceutical company won't lower the price, c'est la vie.
The only real way to solve the problems presented by our wealth care system is to admit that every human being has a right to timely and appropriate medical care. It's not about preventing abuse of the system. Our current system abuses the patients far more than they abuse it. Doctors need a break too because there are only so many hours in the day and they can't spend them fighting over every denied claim.
GOP still stands for Grossly Overpaid Popinjays who know nothing about what the average American goes through for medical care, dental care, etc. It's time they learned. Let's subject them to the system they don't see: ours.
26
So, the hospital charges the insurance company for the E.R. visit, then the insurance company, charges the insured, through higher premiums, for the visit. Sounds like a, "for profit," business model to me! Of course, as the article points out, the hospital has overcharged by about 95%. Maybe, when it was only 50% they could still let it go, but now, the ER is a cash cow for most hospitals. A lot of people, with no insurance, and a desire to, "not die," use the ER for medical services. Medicare patients are certainly charged as well, so it's high time for, (gasp!), REGULATION. Or, Single Payer. So, no one is overcharged, for not wanting to die.
18
The insurers are not charities, to be sure, but they also ocaisionally cut corners by denying claims to see if an unsuspecting layperson will just pay an unjust bill to boost their profits. Those who have dealt with these companies know that and will fight, but they should not have to do that.
30
I’d like to see the total compensation paid to the top 10 executives of this firm.
7
In 1986 Congress passed, and President Reagan signed, the Emergency Medical Transfer and Active Labor Act. EMTALA makes it a crime punishable by fines and even jail time, for doctors and hospitals that refuse basic treatment to patients mostly triaged through the ER, regardless of their ability to pay. However, EMTALA includes no provision that forces insurers to pay for those ER services.
How convenient for the insurers.....
182
And EMTALA includes no accountability. Patients come to the ED many times for minor problems, ED's overuse imaging (almost everyone gets a CT scan) and hospitals are making big profits. Rare to go to the ED and get a charge less than $3,000 to $4,000 and that's if nothing is done. Add one or two CT scans and your up to $8,000 (CT scans cost $2,000 in the ED and $200 in the imaging center down the street). The whole system is broken
7
Thank you for this article. For many years patients have chosen Anthem because this company has inherited, by acquisitions, the trusted ‘Blue Cross’ names. They are, in fact, among the worst actors in the health insurance business. They have been sanctioned in many states for illegal denials of care, illegal cancellation of policies, and in general are among the most difficult for physicians to appeal to for unreasonable decisions and denials. Again, thank you for a public service.
234
Steve,
And we've all heard of heart attack victims not going to the ER because of either lack of insurance, or insurance akin to this.