People need fair insurance coverage in a medical emergency

Two patients come to my emergency department with identical symptoms. One turns out to have a potentially life-threatening problem and will need immediate surgery. The other has a minor medical condition and will be able to go home 

As the patient, you don’t know if you’ll be the one with the life-threatening problem. And it’s not your job to know. It’s my job as an emergency physician. Both patients were prudent to seek emergency care.

However, Anthem Blue Cross Blue Shield is trying to make it your job to diagnose yourself by warning you not to go to the emergency room unless you know that it’s a medical emergency. The company has developed secret lists of diagnoses that they say are “avoidable” ER visits. Some conditions on the list include “influenza,” — which kills tens of thousands of people each year and “blood in the urine,” both of which can be a symptom of a medical emergency.

This policy is active in six states now and violates the federal “prudent layperson” standard that requires insurance coverage to be based on a patient’s symptoms, not the final diagnosis. Anyone who seeks emergency care suffering from symptoms that appear to be an emergency, such severe abdominal or head pain, should not be denied coverage if the final diagnosis does not turn out to be an emergency.

The same law also prevents insurance companies from requiring patients to get prior authorization before seeking emergency care.

A 2013 study in the Journal of the American Medical Association found a nearly 90-percent overlap in symptoms between emergencies and non-emergencies. As an emergency physician with more than 25 years of experience, often I can’t tell the difference until a thorough medical exam, radiological studies, and lab work are completed. How can an insurance company possibly expect a patient to know from home?

People need fair insurance coverage in a medical emergency. Recently, the American College of Emergency Physicians released videos depicting ordinary people dealing with potential medical emergencies, but hesitating to seek help out of fear they will get stuck with a huge bill.

In late 2017, Sen. Claire McCaskill, (D-Mo.), representing a state where Anthem implemented this policy, sent a letter to Anthem’s CEO requesting answers and internal documents from the company. “Patients are not physicians,” Sen. McCaskill said in her letter. “I’m concerned that Anthem is requiring its patients to act as medical professionals when they are experiencing urgent medical events.”

More recently, Senators Benjamin Cardin (D-Md.) and McCaskill, sent a joint letter to the Secretaries of the U.S. Department of Health and Human Services and the U.S. Department of Labor expressing their concerns and asking for clarification.

Anthem is not alone. It so far has implemented this policy in Georgia, Indiana, Kentucky, Missouri, New Hampshire and Ohio. But other health insurance companies, such as United Healthcare and Centene have also come under fire for developing similar policies and denying emergency care for customers. Add to that, last week, Blue Cross Blue Shield of Texas announced that, starting in June, it would make their policyholders pay for an entire bill at an out-of-network emergency department if their conditions were considered “not serious or life-threatening.” This is a dangerous trend that is growing.

Anyone who seeks emergency care suffering from the symptoms that appear to be an emergency, such as chest pain, should not be denied coverage if the final diagnosis does not turn out to be an emergency. But that’s exactly what is happening to many insured Americans.

Health plans have a long history of not paying for emergency care. For years, they have denied claims based on final diagnosis instead of symptoms. Emergency physicians successfully fought back against these outrageous policies. Now, as the future of health care is debated again, insurance companies are trying to reintroduce the practice. They are violating it and putting patients at risk.

Health plans must provide fair coverage for emergency services or patients will suffer. Insurance companies should not be allowed to scare patients away from seeking emergency care in order to increase their profits.

Dr. Paul Kivela MD, MBA is president of the American College of Emergency Physicians and a practicing emergency physician in Napa, California.