Brittany Cloyd went into the emergency room in July 2017 with a worsening fever and stomach pain, she told Vox. The 27-year-old's family thought it might be appendicitis. Instead, she was diagnosed with ovarian cysts, a condition her insurer, Anthem, said wasn’t worth a trip to the ER—so it wouldn’t cover her $12,596 hospital bill.
Cloyd is one of the patients affected by Anthem’s controversial ER policy. In an attempt to steer patients toward less expensive sites of care and prevent overutilization, in several states, it’s warned its members they’ll be on the hook for an ER visit if Anthem determines it to be unnecessary.
Emergency physicians, who have been harshly critical of the policy, say very few ER visits are avoidable. Making matters more complicated, Anthem hasn’t outlined its reasons for denying claims in some states. The denial is also based on the patient’s final diagnosis, not symptoms that prompted them to seek care.
“If you look at insurance claims data, you have diagnoses but you don’t have what the patient came in with,” said Renee Hsia, MD, a professor of health policy studies at the University of California San Francisco and practicing emergency physician. “It’s not fair to expect the patient [to come] in knowing their diagnosis. If they did, they wouldn’t come in and wait for ours.”
As for Cloyd, she has appealed her denial twice, to no avail. Only after Vox interviewed her about the bill did Anthem cover her claim. In the future, however, she said she’ll be very hesitant to seek care at the ER—exactly the scenario emergency doctors say they fear.
“I have numerous health issues, and it’s upsetting and scary to think that I don’t have that option, but it’s just not worth the stress,” she said. “I told my husband, I’ll go to primary care, and they’ll have to force me into an ambulance to go to the emergency room.”
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