Blog | Monday, April 23, 2018

Insurance company denial of emergency care - part 2

Last week, I opined about a decision by Anthem to deny paying for Emergency Room (ER) care that it deemed to be non-emergent. My point was that insurance companies should not be obligated to pay for routine, non-emergent care, recognizing that we need a fair and reasonable method to define a medical emergency. In my view, payment should not be denied to a patient who reasonably believes he needs ER care, even if the symptoms are (hopefully) found to be innocent after a medical evaluation.

For example, if a patient develops chest pain at 10 p.m., and is worried about an acute cardiac issue, he should call 911. If the ER determines that chest pain is simple heartburn, it would not be reasonable for Anthem to deny payment for this “non-emergent” condition. We're all a little smarter after the fact once we know the outcome.

Some medical complaints, however, are never medical emergencies. If you want ER care for a runny nose, a cough or a sore knee, and you proceed to the ER, explain why you think your insurance company should pay for this.

Emergency Rooms must accept every patient who seeks care there by law. A patient cannot be turned away regardless of how trivial the medical issue is.

One approach would be for every ER to have two tiers of service, Tier 1 for true emergencies and Tier 2 for all the rest. Some ERs have such a system, but I think this should become the standard of care. The Tier 2 facility could be equipped to provide efficient, low cost care for appropriate medical issues. ER personnel are already highly skilled in triaging patients and could direct incoming patients toward the correct tier.

Here are the benefits.
• Patients with minor complaints would be seen without waiting for hours while ER personnel attended to truly ill individuals.
• Tier 2 facilities would be designed to provide lower cost care.
• Tier 1 could operate more smoothly since patients with routine medical issues would be siphoned off.
• There would likely be an overall cost savings to the health care system.

Ohio legislators are already threatening legislation to attack Anthem's ER denial of care policy. As a gastroenterologist, this craven political grandstanding nauseates me. Politicians, who spend a career spending other people's money irresponsibly, aim to lecture a private company who wants to exercise reasonable cost restraints. Give me a break.

Would Anthem and her sister companies cover Tier 2 care? Could they assert that since the patient was determined in the ER to have a non-emergent condition that the care should be on the patient's dime? I'm not answering this question, I'm merely posing it. I do think that the present system when a patient expects or is entitled to any ER care being covered needs to be reformed.

When insurance companies pay millions of dollars for unnecessary care, guess who's really paying for it?

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.