Anthem’s New Health Insurance Policy: Diagnose Yourself Before Going To The Emergency Room

Via Vox:

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.





37 comments on “Anthem’s New Health Insurance Policy: Diagnose Yourself Before Going To The Emergency Room

  1. The Republicans and Insurance Companies have wanted to restrict ER visits for a very long time, if for no other reason that the cost is dramatically higher than a doctor. In addition the ER takes in a lot of poor people as current laws generally state they can’t turn anyone away. Like many other things the Republicans want they fear their intentions becoming common knowledge, perhaps because what they want is usually an attack on the middle class and their ancient foe the poor.

    • Agreed, bamboozer! Insurance companies have always increased their customers’ premiums to cover ER costs of the poor and uninsured people. This new policy actually targets people with health insurance. Their demand that people self-diagnose is complete lunacy. It’s also reckless and irresponsible.

      A side note: I have never understood why people against the ACA mandate felt it was okay to stick people and with insurance and hospitals with the bill.

  2. “This new policy actually targets people with health insurance.” This is Anthems policy, NOT all insurance companies policies, correct, Pandora?? Just trying to clarify.

    • The title of the post is “Anthem’s New Health Insurance Policy: Diagnose Yourself Before Going To The Emergency Room” so there’s that. However, my guess is that where a company the size of Anthem goes, others will follow.

  3. Nobody listened, but the big problem with the ACA is that all it does is give people health insurance — leaving them to deal with an insurance company. Frying pan, fire.

    Back when one of my employers used Aetna, they initially refused every single bill sent to them, for at least 60 days. Then they’d pay, but only after being contacted about it. Every. Single. Time. And I had no real recourse, because that’s the shitty insurer the bozos who ran Gannett went with.

    I want national health insurance just so we can eliminate all the paperwork.

    • The ACA isn’t perfect, but it is a stepping stone. The main thing it accomplished, imo, was changing how people viewed health care – as a right. It also clearly defined what health insurance must cover with its essential benefits. As Republicans are finding, it’s nearly impossible to undo the ACA because people like the benefits and taking these benefits away is deeply unpopular.

      My friend, who died of breast cancer 6 years ago, battled with insurance companies “Every. Single. Time.” to cover her treatments, as well. People who don’t understand this is the insurance company’s business model are probably people who haven’t faced a serious illness.

      • What I found so infuriating was that this was for things like routine annual exams. They were only doing it to gain the extra 60 days’ interest on the money.

        Luckily for my family, I was no longer with that company when my wife and youngest child each faced life-threatening vascular problems.

        • Their game is to wait you out and hope you’ll give up and just pay the bill.

          I’d love to see the numbers on the bills that should have been paid by the insurance company. I’d bet this is a line on their asset/revenue sheets – called something like, “money we saved by denying valid claims”

          • They paid them all eventually. But if you run this scam on millions of bills, you’re talking about millions of dollars gaining interest for Aetna while the doctor’s office is forced to go without payment for 60 days.

    • “I want national health insurance just so we can eliminate all the paperwork.” Ha-Ha, now that is funny, the government to have less paperwork?

    • The reason behind your bill being refused, could have been the problem of your Dr’s office, not submitting it under the wrong code or modifier.

      • Give me a break. My doctor is tied into the Christiana Care network. I’m pretty sure they know the coding.

        Do you have actual experience in this area?

        • Had the same issue with CC. Billing wise, you are considered a new patient each time, within their system. Was very frustrating, until the Dr., got involved.

  4. Jesus fuck, but you’re stupid. Any single-payer system has less paperwork, because there’s no need to try to shift costs to someone else. You stupid fuck.

    • Alby, Really. You kiss your kids with that dirt mouth! You should not be that way and as Pandora says, “you should be warned for personal attacks, I have never said words like that towards you. You should at least keep it civil!!!

      A great deal of the paperwork is dictated to the Dr’s by the CMS. They have been working on plans to reduce that amount and try to focus more on the patient, but that has not come to fruition as of yet. They’ve been talking about it for years. Patients over paperwork is currently a big push.

      • First of all, fuck being civil. I’m being forced to correct your misinformation on a daily basis. You are a pain in my ass. Stop posting your moronic opinion here and I won’t curse at you anymore. See how easy that is?

        Second, all that paperwork is, as I said, due to the priority of shifting costs to someone else. If the same company or government had to pay regardless, most of the paperwork would disappear; the only amount needed would be to keep America’s tens of thousands of crooked doctors on the level.

        • Sorry for you, that someone is forcing you. Getting paid for that? Maybe you should see a Dr for your PITA.
          Make sure you tell the Dr., that you see the next time, that he is crooked, especially when you go to your Proctologist! You know for your pain in the ass!

          The government wants a paper trail, just look at Medicare and Medicaid.

          • You are the one forcing me.

            Do you really not know the differences between the programs? One is run by the federal government and is therefore relatively inexpensive. The other is run by the states and therefore is not.

            Basic logic escapes you, so I’ll point out that just because many doctors are crooks does not mean all of them are. Just as the fact that you’re stupid doesn’t mean all Republicans are stupid.

            You really should learn to visit web sites to do something other than spout your dim opinions. For example, you might learn that

            In 2012 Donald Berwick, a former head of the Centres for Medicare and Medicaid Services (CMS), and Andrew Hackbarth of the RAND Corporation, estimated that fraud (and the extra rules and inspections required to fight it) added as much as $98 billion, or roughly 10%, to annual Medicare and Medicaid spending—and up to $272 billion across the entire health system.

            Here’s the article that’s from:


            If you read it, then compare it with the swill you link to, you’ll notice that it has not only those facts but the context for them, making it easy to detect the bias in the writing.

            My point, buddy, is that you don’t have the intellectual chops to hang here, yet you won’t go away and keep doing offensive shit like posting links to Republican sites while you’re at it.

            Spewing low-level ignorant opinions is no way to spend your life, fella. Go learn something, then come back.

            • Ew…didn’t realize blockquote doesn’t work in comments. It says:

              “In 2012 Donald Berwick, a former head of the Centres for Medicare and Medicaid Services (CMS), and Andrew Hackbarth of the RAND Corporation, estimated that fraud (and the extra rules and inspections required to fight it) added as much as $98 billion, or roughly 10%, to annual Medicare and Medicaid spending—and up to $272 billion across the entire health system.”

              That’s where my reference to “crooked doctors” comes from.

              • Just a legnd in your own mind, oh that’s right you wrote for Gannet, the local liberal rag! Yes, there is fraud everywhere, get that Buddy!
                You don’t think there won’t be fraud under a “Single payer” system? You’re the fool, then!

                “You are the one forcing me.” then go over to DL.

                • Dear sweet Jesus, save me. If you could read, you would note that I said we would still need paperwork to keep track of fraud. What is wrong with you?

                  A legend in my own mind? That’s why I post under an alias rather than use a widely known name?

                  I just can’t wrap my head around how dull, incurious and brainwashed you are.

                  • “widely known name” Maybe, it should be “Worldly”…………..OMG!

                    • Back on topic, Anono.

                    • Pandora, how about the personal attack on me, the same should go for Alby!! If someone said that to you, they would be banned. IMHO and with all due respect.

  5. Stan Merriman

    It is just not insurance companies….hospitals and their E.R.s are a huge part of the problem….particularly so called not for profits like Christiana who are unaccountable for their tax exemption. My spouse a few weeks ago fainted from the flue and then fell, hitting her head on a stand holding our dehumidifier. I administered CPR immediately because she was not responding, also called 911 for an ambulance. She was taken to Wilmington’s Christiana ER where she was kept in a treatment room for 12 hours; after initial examination and Drs. given her history of an Aneurysm years ago, we were both assured she would be admitted to a room as soon as one came available. We were both cognizant of hospitals screwing around with ER charges prior to admission and thus, kept asking about admission and told them, if not, she wanted to be discharged from the ER. She was put in a room after 12 hours, examined there again with Drs. looking at her Xray and Cat Scan with further discussion about information we gave them in the E.R. that an MRI was not possible given a metal clip in her head. She was discharged that afternoon. Two weeks later we are told via a letter her admission was rescinded by a “Utilization Review Committee”. Many hospitals have real time UR committees that act on the spot when there is any issue about the efficacy of an admission, giving the patient a voice in the billing/medical implications of such a decision. Not Christiana, they met days later and rendered their reversal. So, my spouse was lied to the entire time in the ER. We are hoping her Medicare and her supplement will cover most of the cost, but don’t know. Christiana is about covering their financial ass and getting their money from us which wouldn’t have happened had they discharged her from the ER as we requested. This is medical dysfunction right here in Wilmington with virtually no other provider choices.

  6. Single payer with universal coverage is the only way to stop this evil game, the whole for profit operation of American healthcare is an open invitation to profiteers seeking to “work the system” and line their pockets. In the grand tradition of all things corporate it’s a heartless game that impoverishes the sick and seeks to profit from the misery of others. Hey! Reminds me of another evil aspect of conservatism: For Profit prisons.

    • We should also note that the single payer does not have to be “the government.” The entire Medicare program in this country has a total of 700 government employees and another 2,000 or so contracted out from — so much for socialism — insurance companies.

      What morons don’t understand is that competition is not always good for the consumer. In the case of health insurace, the “competition” boils down to trying to force someone else to pay. Republicans/morons don’t understand that because their propaganda sources won’t tell them. If you ever click on any of the links “Anono” provides, you’ll see his “news” sources are so dumb and shallow they make Fox sound like particle physicists at MIT.

  7. Carper took $10K from Anthem in 2016, $3K in 2012.

    Just sayin’

  8. Peanuts. Not even enough to get him a decal on his fire suit.

    • Well, those peanuts in Tom’s pocket are paid with your premiums.

      Just sayin’

  9. I was involved with a youth soccer team that traveled to Scotland a couple of years ago. One of our players suffered a fractured bone in his lower leg. He was taken to the hospital where his father filled out a half page form. He received good care including
    pain medication and a wheelchair for use throughout our stay. We never saw a bill or any other paper work.

    • Thanks for sharing that story, Ckars! We have several friends and family members who have experienced the same thing. One gave birth while living in London – no bill, and then they sent a nurse and support people to help her once she and the baby were released. Now, that’s what family values looks like!

  10. Anono, I don’t really care if people swear or call each other idiots, etc. as long as they are staying within the comments’ rules and are staying on topic.

    • “We aren’t especially interested in commenters whose main contribution is belligerence, flame war bait, insults,”
      I think what Alby said, would be classified as an insult. Nuff said! IMHO

  11. waterpirate

    My sister recently returned from a junket to Korea. She fell ill there and was sent to a local hospital for emergency treatment. She received bloodwork, medication, mri, and a plethora of other testing. The staff warned her that due to her not being Korean she would be responsible for the bill, in cash, and it would be expensive. 14 hours later she was released and went to the window to pay….. The total was $785.00! She paid with a cc.

  12. Healthcare and healthcare insurance in America is a racket, a racket that’s allowed to fester and grow by the politicians of both parties. Several posts here show clearly that it doesn’t have to be that way. What keeps it in place is the corruption of both parties including both our beloved DINOS Carper and Coons. No one in countries that have single payer universal coverage lose their house, their savings and quite possibly their life. It’s a failure of democracy that it continues to go on and a failure of the electorate to demand change.

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