Health insurer is planning to punish patients for 'unnecessary' ER visits

[Cattledog]

http://www.latimes.com/business/hiltzik/la-fi-hiltzik-insurance-er-20170602-story.html

Anthem is the nation’s second-largest health insurer, with thousands of medical professionals on its payroll. Yet its Blue Cross and Blue Shield of Georgia subsidiary has just informed its members that if they show up at the emergency room with a problem that later is deemed to have not been an emergency, their claim won’t be paid.

It’s a new wrinkle in the age-old problem of how to keep patients from showing up at the ER for just anything. But medical experts say the Georgia insurer is playing with fire. By requiring patients to self-diagnose at the risk of being stuck with a big bill, it may discourage even those with genuine emergencies from seeking necessary care. And it’s asking them to take on a task that often confounds even experienced doctors and nurses.

“Patients don’t come with a sticker on their forehead saying what the diagnosis is,” said Renee Hsia of the Institute for Health Policy Studies at UC San Francisco, who has studied the difficulty of making snap diagnoses at the ER. “We as physicians can’t always distinguish necessary from unnecessary visits.”

Blue Cross Blue Shield of Georgia, the only insurer offering individual insurance plans in 96 of the state’s 159 counties, sent letters to its enrollees in late May stating that it would refuse to cover non-emergency ER visits starting July 1. It defined inappropriate visits as any but those that “a prudent layperson, possessing an average knowledge of medicine and health,” would believe needed immediate treatment. It hoped to encourage patients with non-emergency conditions to seek help instead at an urgent care clinic or a doctor’s office.

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[LisaM]

1. Many years ago I went to the ER with what I later learned was a panic attack.

I was in my 20s, I had no idea what was wrong, I was having trouble breathing, and I was dizzy. Obviously everything checked out, they taught me the trick of breathing in and out of a paper bag, and they referred me to a stress counselor.

Unfortunately, because I was having breathing issues, they put me in front on other people who probably had bigger problems. Luckily they figured things out and moved me on my way, but I can easily understand someone going to the ER in this situation.

[samnsara]

2. many already do this.. when hubby had pneumonia we had to....

...call the insurance company first to see if he could get to ER ( it was sunday).. They said NO!!! I had to drive him 30 miles away to a clinic that was open and then that clinic sent him to ER. So hubby had 102 temp and we had to drive 30 miles back to ER where we wanted to go anyway.

[Else You Are Mad]

3. Back in 2008...

I was at a hardcore show and was punched in the head and had a laceration on my forehead that exposed my forehead. Since I was out of network, I had to call the insurance company while in the emergency room to argue with them that I could not wait until I was back in state to go to an in network hospital. In the end, they only paid for half of what I owed to the hospital but it was still affordable out of pocket with a payment plan because the hospital was willing to work with me.

If I waited to go home and get an appointment with my primary care doctor I would have had to have plastic surgery to fix it and it would have cost tens of thousands that would not have been covered at all by insurance.

[Ilsa]

4. This is what happens when MBAs, whose only real understanding

of health is what their personal trainers taught them, take over running the backbone of healthcare access in our country.

[haele]

5. Well, since they don't pay for mortuary services, it's a profitable decision.

Tell people they can't just take Momma to the emergency room on the off chance that it's just a bad case of Lunch at Chipotle that's causing her to feel a bit down with some nasty heartburn, and when she keels over at work the next day with a widow-maker heart attack, that's one less high risk patient to deal with.
Tell a type 2 diabetic that the nasty cut on his leg doesn't require an ER visit, he should just put a bandaid on it and wait to see what happens; well - he was going to lose that leg eventually, anyway...put it off until he needs surgery, and then tell him that his surgeon and anesthesiologist are out of network, so he'll have to pay them out of pocket. Unless he dies first of something else that might have been treated quicker due to the ER visit instead of waiting months until he couldn't function anymore.

It's all about the costs. Because after all, everyone clearly remembers their HS health classes with the attendant Red Cross first aid week, right? And if you went to college, you probably had a few medical or public health courses, or listened to Dr. Oz, or could use the internet to look up your symptoms for free at Web MD, am I right?

Haele

[renate]

6. I hope it's not too long before stories like the ones in this thread are considered barbaric

... by Americans, that is.

The rest of the world probably can't believe we put up with a system like this.

[Ms. Toad]

7. It's a variation on an old theme.

Nearly every insurance policy I've had charges a hefty copay for the ER - which is waived if you are admitted to the hospital.

(Followed by a sneaky move that you can be sent to the floor of the hospital for "observation" as long as it doesn't exceed 24 hours, and then you get charged for both the ER copay and hospital coinsurance)

There is a significant problem of ER visits by people who use the ER as their doctor's office. Mighty expensive care for routine stuff that could wait until the next day when the doctor's office opens up - made worse for quite a while because the ER was the only place people without money could go for care because they couldn't turn you away.

The extreme restrictions on pain killers also inappropriately drive people to the ER. My spouse regularly gets kidney stones - and when she does her doctor doesn't have any open appointments for a month. Since she can't get pain killers without bein gseen by a physician, their solution is to tell her to go to the ER.

But going to the ER for nonemergent care (including for someone who regularly gets kidney stones) is not a good use of medial resources.

Yes, there are lots of situations in which it is unclear whether it is an emergency - but a low grade fever and moderate respiratory distress in an otherwise healthy individual, or emergent kidney stone pain that requires no more than a prescription for a narcotic pain relievers are not appropriate reasons for going to the ER.

There needs to be a happy medium, when emergency care for people who reasonably need such care, is available at a reasonable cost.