Critics say new insurance policy denying 'non-essential' ER visits expects patients to diagnose themselves

Cloyd with her daughter
(Vox photo by Luke Sharrett)

Anthem, one of the country's largest health-insurance companies, is increasingly denying coverage for emergency-room visits it concludes were not true emergencies. The policy, which has been implemented in Indiana, Kentucky, Georgia and Missouri, exempts patients younger than 15, weekend visits, and patients who live 15 miles or father from an urgent care center. Other patients can be left on the hook with huge ER bills, though, Sarah Kliff reports for Vox.

That was the case with Brittany Cloyd of Frankfort, Ky., after she went to the ER for severe abdominal pain that she thought could be appendicitis. She was diagnosed with ovarian cysts, and was prescribed pain medication and told to make a follow-up appointment with her gynecologist. Anthem refused to pay the $12,596 bill because it deemed pelvic pain not severe enough for immediate care. In the refusal letter, Anthem listed "stroke, heart attack, and severe bleeding" as examples of acceptable medical conditions for an ER visit. Anthem denied Cloyd's bill twice, but approved it after Kliff asked the company for an interview.

"Anthem’s new policy mirrors similar recent developments in state Medicaid programs, which increasingly ask enrollees to pay a higher price for emergency room trips that the state determines to be non-urgent," Kliff reports. "Indiana implemented this type of policy in 2015, and the Trump administration recently approved a request from Kentucky to do the same. Beginning in July, Kentucky will charge Medicaid enrollees $20 for their first 'inappropriate' emergency room visit, $50 for their second, and $75 for their third." 

Anthem argues that it's trying to cut health-care costs and keep people from using the ER inappropriately. But critics say the policy effectively forces patients to practice medicine and diagnose themselves. "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," said Renee Hsia, a practicing physician and professor of health policy studies at the University of California San Francisco.