Can Your Insurer Retroactively Deny Coverage for “Avoidable” ER Visits?

Visiting the emergency room is expensive, and a whole lot of Americans hit the ER every year – with some critics claiming that many of these visits are unnecessary.

In fact, one insurer thinks it’s come up with an excellent way to addressing this issue: Anthem refuses to pay for visits it deems “avoidable.” And that can leave some patients holding very large bills.

The way people utilize emergency departments can be complex. For people who are underinsured or uninsured, the ER may be seen as the best way to quickly access treatment. For those with good insurance coverage, poor communication about access to urgent care — which provides appointments quickly within regular work hours — can be an issue. At other times, long waits for available appointments may push people to the ER, as well as the lack of a triage line to help people decide if something is an emergency.

But sometimes, a genuine emergency arises — or the symptoms are such that they could indicate a crisis, but you won’t know until you get evaluated. For example, someone experiencing severe chest pain might be having a life-threatening myocardial infarction — or severe anxiety or heartburn.

In 2013, researchers examined non-urgent ER visits to determine the scope of the problem, and what they found may come as a surprise to some people. Many of the visits resulted in diagnostic imaging — and even led to admissions to the hospital, demonstrating that something was seriously wrong. Just last year, researchers found that less than 5 percent of ER visits were actually wholly avoidable. In other words, flippant dismissal as “unnecessary” might not actually be warranted.

Anthem claims to want to save money, of course, but the insurer also insists that this policy will also keep unnecessary cases out of the emergency room. However, until people began pushing back, the company didn’t even consider the circumstances that led people to the emergency room — like symptoms that could be an indicator of something gravely wrong. And this was actually a violation of federal law.

People worried about affording the cost of care may decide not to go to the ER, which Anthem views as a good thing — but physicians aren’t convinced. Patients staying home could put themselves at serious risk of complications, or even death. After all, some things can’t wait until an appointment opens up at the doctor’s office.

According to NPR, several states are working on bills that ban this type of differential coverage, compelling insurance providers to cover ER visits.

There’s another issue looming for people receiving health care in the emergency room, though: What happens when the hospital is in network, but your doctor isn’t?

Emergency rooms often host traveling doctors and specialists who may not be part of an insurance company’s plan. And that means patients will have to pay out of pocket for their services — or pay a higher share of care, depending on the specifics of their insurance plans. Yet, it’s not like a patient in medical crisis can request a verification that a physician’s in network, or request a transfer to another facility to see a different provider.

Health care costs in the United States are undoubtedly rising, but the cause for these cost increases doesn’t lie in how many patients use the emergency room every year. Issues like skyrocketing prescription drug costs, noncompetitive pricing and a health care system built heavily on administration rather than point of care — including all the profits for insurance companies — are the real culprits.