Brittany Cloyd was doubled over in pain when she arrived at Frankfort Regional Medical Center’s emergency room on July 21, 2017.
“They got me a wheelchair and wheeled me back to a room immediately,” said Cloyd, 27, who lives in Kentucky.
Cloyd came in after a night of worsening fever and a increasing pain on the right side of her stomach. She called her mother, a former nurse, who thought it sounded like appendicitis and told Cloyd to go to the hospital immediately.
The doctors in the emergency room did multiple tests including a CT scan and ultrasound. They determined that Cloyd had ovarian cysts, not appendicitis. They gave her pain medications that helped her feel better, and an order to follow up with a gynecologist.
A few weeks later, Cloyd received something else: a $12,596 hospital bill her insurance denied — leaving her on the hook for all of it.
In recent years, Anthem has begun denying coverage for emergency room visits that it deems “inappropriate” because they aren’t, in the insurance plan’s view, true emergencies.
The problem: These denials are made after patients visit the ER, sometimes based on the diagnosis after seeing a doctor, not on the symptoms that sent them, like in Cloyd’s case.
What’s being said here is: A patient needs to self-diagnose their symptoms – correctly! – before going to the ER. Have trouble breathing? You have to decide if you’re having a heart attack, an allergic reaction, bronchitis, asthma, emphysema, COPD, lung cancer, etc.. If you don’t diagnose your condition correctly, then you get billed.
A month earlier, in May 2017, Anthem had sent a letter to its thousands of Missouri members warning of the change.
“Save the ER for emergencies — or you’ll be responsible for the cost,” the letter, first reported by St. Louis Public radio, stated in big blue letters. “Starting June 1, 2017, you’ll be responsible for ER costs when it’s NOT an emergency.”
Most people go to the ER because they think they are having an emergency and don’t know for certain, because… they aren’t flippin’ doctors.
It is hard to know how many visits are “avoidable” or “non-emergent.” Studies have estimated that anywhere between 4.8 and 90 percent of emergency room visits are “avoidable,” depending on the criteria and methods used.
Emergency physicians tend to cite the lower numbers, arguing that unnecessary trips to their department are few and far between. Insurers, however, often gravitate to the higher numbers that indicate they’re massively overpaying for routine care that could be delivered elsewhere.
The topic can be especially difficult to study because it often requires understanding initial symptoms — chest pain, for example, could be a heart attack or indigestion. Many studies, however, only rely on the final diagnosis.
“If you look at insurance claims data, you have diagnoses but you don’t have what the patient came in with,” Hsia said. “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.”
Of course, insurers cite higher numbers. It’s how they justify not paying claims – which has always been their business model. Doctors (you know, the people trained in the medical field) cite lower numbers – probably because they actually examine the patient.
The only way this policy makes sense is if there’s only one symptom attached to one condition – chest pain always equals a heart attack, stomach pain only equals food poisoning. But that’s not how it works. Symptoms overlap, and a patient cannot be expected to know what their undiagnosed symptoms reveal.
Congress is starting to pay attention:
On December 20, Sen. Claire McCaskill (D-MO) sent Anthem a letter stating, “I am concerned Anthem is requiring its patients to act as medical professionals when they are experiencing urgent medical events.”
McCaskill has requested that Anthem provide “all complaints received by Anthem from any entity relating to coverage of emergency room care in Missouri, Kentucky, or Georgia” and “all internal communications … relating to the company’s decision to clarify its policies regarding emergency room care utilization.”
I can’t wait to read those complaints and internal communications.
Meanwhile, this happened:
One week after Vox interviewed Cloyd about her emergency bill and inquired to Anthem about its emergency billing practices, Cloyd received a letter stating that the denial would be reversed — she had won her second appeal.
“We deeply regret if we caused Ms. Cloyd any concern,” Anthem said in a statement to Vox. “Anthem has made, and will continue to make, enhancements to our ER program to ensure more effective implementation of this program on behalf of consumers.”
What they deeply regret is Ms. Cloyd’s situation going public. If Vox hadn’t interviewed her, my bet is that she’d still have that bill. I’m happy for Ms. Cloyd, but know there are many more like her whose ER bills won’t go away. We are heading back to the days of medical bankruptcies.
This is the future of health care. Patient, heal thyself. Or at least, diagnose yourself before going to the emergency room. Better yet, wait until you’re appendix bursts before going to the ER, then you’ll know for sure.