Most health insurance policies cover ER care, with a caveat: the care must be for a medical emergency, or at least for the purpose of making sure the patient’s symptoms don’t require emergency care. If you go to the emergency department to receive diagnostic tests or treatments for a condition that is clearly not a medical emergency; your insurance company may decline to cover the cost of those services. Denial of coverage for emergency care is becoming a serious problem. The fine print in your insurance policy may indicate that the policy will not cover ER services for a non-emergency condition, and leave you with the responsibility for paying the entire bill. Seems like a pretty straight-forward issue; but in fact it is a very complicated one, with lots of nuances and grey areas and potential unintended consequences. What may seem like a very minor medical problem can turn very serious in a matter of minutes, or be the first subtle hint of a life-threatening condition. Likewise, what may seem to be a very ominous collection of symptoms can turn out to be caused by conditions that are entirely benign. If it were easy to make these distinctions, it would not take years of medical study and experience to get good at it. Even the most experienced triage nurses in the ED have some difficulty identifying those patients who will need to be admitted into the hospital from those who can be safely discharged home from the ED.
So how is someone who does not have this kind of training and experience going to know when their health insurer is going to decide, after the fact, that a visit to the ED will not be covered? This dilemma was the genesis of the prudent layperson standard, which states that insurers subject to this standard are required to pay for emergency services and care of an emergency medical condition, which is defined as: a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possess an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
This standard of course raises as many question as it answers, such as: what is a prudent layperson, and what is serious dysfunction of any bodily organ or part? Is someone who freaks out at the sight of blood by definition imprudent? Is a child that loses his hearing from an ear infection suffering from serious dysfunction of his inner ear? What if, untreated, the hearing loss becomes permanent? What if someone with the sudden onset of a headache decides not to go to the ED, fearing that he will get stuck with an uncovered bill for thousands of dollars for an ED visit and a CT scan if his insurance company decides, after the fact, that his headache was something that should have been treated in a doctor’s office? Perhaps this man will be lucky, and it was just a simple tension headache, or perhaps he will have ignored a warning sign of an impending aneurysmal hemorrhage, and suffer irreparable disability or even death.
If you are lucky enough to have insurance with a plan that provides a nurse advice line to help you decide whether or not you need to go to an ED or can wait to see your doctor the next day, the chances are very good that regardless of how minor your symptoms might sound to the nurse, he or she will end the call with a caveat something like this: “of course, if you really think you are having a medical emergency, you can always go to the ED”. Does this mean the insurance plan is agreeing to cover your ED visit? Nope. It just means that if they told you that you probably can wait to see the doctor in the morning, they are covering their ass in case this was bad advice. In other words, if you needed to go to the ED and didn’t, perhaps it was YOU that wasn’t being prudent.
When Anthem BCBS sends its enrollees a letter advising them that Anthem will not cover the cost of ER care for non-emergencies, and uses a list of so-called ‘non-emergency diagnoses’ to guide the coverage decision: they are skirting the intent of the prudent layperson standard by ignoring the considerations that lead someone to seek immediate medical attention in an ED. Anthem is also sending a message to their enrollees. The message is: Anthem doesn’t trust you to be prudent, and Anthem will decide after the fact if you were sufficiently protective of their profitability when you decided to go to the ED. Apparently, it is not enough to require a copay of $100 to $250 for a visit to the ED, plus a 15-20% coinsurance payment, to deter you from misusing the ED: they need to threaten to stick you with the entire bill to encourage your prudence. If Anthem was willing to comply with the prudent layperson standard when deciding not to cover ED care, they would have a physician, or at least a nurse, review the ED physician’s record, triage notes, and nursing notes, and not just consider the final diagnosis on the claim. It is much cheaper to just deny the claim, and wait to see if the patient and/or the physician or hospital challenges the decision on appeal.
Ok, I get it. Some people do use the ED inappropriately. But when they do, the insurance company spends a very small portion of their overall budget for health care services on these visits. Small, as in minuscule. This policy isn’t just about recouping these costs, or passing them on to enrollees: it is about testing ways to change patient behavior, and it is about an insurance plan reinserting itself between the patient and the physician in medical decision-making when requiring prior authorization for emergency care services is precluded by law. If health plans really wanted to reduce unnecessary ED visits, there are many different ways this could be accomplished safely and in conformance with the prudent layperson standard.
If you put enough hurdles in the way of a decision to go to the ED for care, with high deductibles, larger copays, higher coinsurance payments, and the threat of denial of coverage; inevitably you will deter patients from getting prompt treatment for time-critical conditions like stroke, heart attack, sepsis, and the like. Somehow Anthem and other plans have done the calculations and decided that keeping patients out of the ED when they need not be there is more profitable than paying for the additional services and managing the consequences that could have been avoided if prompt ED care was provided. Somehow, suffering and disability was not factored into the equation.