A Major Insurer's ER Denial Policy Is Completely Arbitrary, Study Finds

Image for article titled A Major Insurer's ER Denial Policy Is Completely Arbitrary, Study Finds
Photo: Jack Taylor (Getty Images)

Emergency room visits can be a costly ordeal, with the average bill running close to $2,000 by some estimates. In response, some insurers have implemented or are considering policies that would let them later deny coverage to people whose ER visits were judged to be “non-essential,” in hopes of discouraging unnecessary trips. But new research published Friday suggests that the criteria used to deny coverage is completely useless at predicting when someone is or isn’t sick enough to need the ER.


In 2017, the insurance company Anthem debuted its ER denial policy in three states: Georgia, Missouri, and Kentucky. A year later, it expanded the policy to three other states. If a customer who visited the ER was ultimately diagnosed with one of many “non-emergent” conditions or symptoms the policy has singled out—such as nausea, pinkeye, or even cuts and scrapes—the insurer would consider denying coverage. Other criteria, such as if the person needed intravenous fluids or other emergency care, was 14 years old or younger, or visited on the weekend, would exclude someone from being denied.

The researchers behind the current study analyzed a national database of over 100,000 ER visits made from 2011 to 2015, and retroactively applied Anthem’s guidelines (updated as of 2018) for denial.

By their count, they found that one in every six insured ER patients could have been forced to foot the bill if Anthem’s policy were to be embraced by all U.S. insurers. But these patients weren’t really that different from everyone else: More than 85 percent of people who visited the ER in general in their sample had some of the same symptoms as people who could have been denied coverage. Of these people, 65 percent went on to receive emergency care. And even within the potential denial group, the researchers found that about 40 percent also received emergency care.

An infographic of the team’s findings.
An infographic of the team’s findings.
Illustration: Chou S-C, et al. (JAMA Network Open)

The team’s findings were published in JAMA Network Open.

“Our results demonstrate the inaccuracy of such a policy in identifying unnecessary ED visits,” the authors wrote. “Furthermore, patients cannot reliably avoid coverage denial as most presenting symptoms could potentially lead to a nonemergent diagnosis.”


The unreliability of the policy, the authors warn, is likely to force patients to make a horrible choice between “weighing the risk of delayed treatment for severe disease vs an uncovered medical bill.”

The study looked at what would happen if Anthem’s policy became widely adopted, but the company already insures nearly 40 million Americans. And there have been no shortage of heart-rending accounts from Anthem customers who claim the policy has left them with thousands of dollars of medical debt after being treated for serious, even life-threatening conditions.


The American College of Emergency Physicians has accused Anthem of violating federal law with its policy, due to a provision of the Affordable Care Act that mandated insurers cover ER visits that meet a “prudent layperson” standard (in other words, they can’t deny coverage for someone who went to the ER with symptoms an average person could consider serious). Earlier versions of this law became commonplace following attempts in the past by insurers to deny ER coverage.

According to a congressional investigation by the office of Sen Claire McCaskill (D-Missouri), released this July, Anthem has considered 10 percent to 20 percent of ER visits for denial, while ultimately denying coverage for 4 percent to 7 percent of visits. These denials have become less common in the first half of 2018. But the authors of the new study say there’s no telling the damage this sort of policy could cause if it became widespread.


“If retrospective denial policies are widely adopted, they would place undue financial stress on patients with acute illness and could increase barriers to timely emergency care, particularly to those least able to pay,” they wrote.

An Anthem spokesperson shared a statement with Gizmodo that said the insurer’s policy “aims to reduce the trend in recent years of inappropriate use of EDs for non-emergencies.” The statement added:

If a consumer chooses to receive care for non-emergency conditions at the ED when a more appropriate setting is available, Anthem will request more information (including additional medical records) from the hospital and a statement from the consumer as to why they went to the ED. An Anthem medical director will review the additional information using the prudent layperson standard, and the claim might be denied as not a covered service. In the event a consumer’s claim is denied, they have the right to appeal.

Anthem has made, and will continue to make, enhancements to ED Review to help consumers receive the right care at the right place and time.


[JAMA Network Open]


Tebow Kneeled First

Unfortunately this is not surprising. Your insurance is going to do everything it can to not pay your claim. That is how they make money. They do not want you to know the rules. They do not want you to know what they will and will not pay for. And they will try not to pay whenever they think they can get away with it. A claim is an argument that you have to win, and if you get denied at first you have to keep fighting it if you want to keep your money.

Welcome to America.