Is Your Emergency Worth It? Let’s Ask Your Insurer…

BIOtech Now
Andrew Segerman

Imagine that it is 2AM and the pain is so severe that you cannot move. At this point, driving is not an option, so you call an ambulance assuming they know the fastest route to the emergency room. Thankfully, you have insurance to help cover the costs – or so you thought.

Enter Brittany Cloyd, a Kentucky resident who was spotlighted in a recent media report last month after her insurance provider, Anthem, denied her $12,596 hospital bill. Ultimately, the worst pain Cloyd might ever have to endure was diagnosed as ovarian cysts, which required multiple tests including a CT scan and ultrasound. So why would Anthem deny her claim? The answer might surprise you…

“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. … 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.”

Cloyd’s insurance provider determined that her visit to the hospital was not a “true emergency” – meaning the crippling pain she felt was technically not severe enough – and the bill would cost her nearly $13,000 out of pocket. In a letter from Anthem that Cloyd received, the insurer stated:

“We cannot approve benefits for your recent visit to the emergency room (ER) for pelvic pain … Emergency room services can be approved … when a health problem is recent and severe enough that it needs immediate care.”

Also noted in the letter were examples of medical conditions that would, in fact, warrant an ER visit which include “stroke, heart attack, and severe bleeding.” And since Anthem appears to be calling the shots on how grueling your condition really is, it is important to read the fine print, because it could cost you dearly – as Brittany learned the hard way.

But denying patients access to the medical services they need is nothing new. While insurance companies are busy citing drug prices as the cause for higher premiums, we should be working together to reduce the need for costly hospital stays and doctor visits. Instead, here’s what they have been up to over the years:

Evidence shows that some insurers discriminate against patients with particularly costly pre-existing conditions, which prevents them from accessing needed medicines for potentially deadly and debilitating diseases. And as we learned in 2015, New York Attorney General Eric Schneiderman sued a health plan, alleging that it refused to pay for hepatitis C drugs except for patients with an advanced stage of the disease.

What’s more, in that same year a study from Harvard University’s Center for Health Law and Policy Innovation (CHLPI) on insurance coverage for HIV/AIDS patients found evidence of discrimination, but this time on numerous ACA exchange plans. This caused HIV/AIDS patients “covered” in these plans to pay an average of $3,000 more out-of-pocket for needed medications compared to other plans. This, however, should not come as a surprise since some insurers require patients to cover hefty out-of-pocket costs for drugs that cure or treat complex diseases – often as much as a third or even more of a drug’s list price. That compares to an average out-of-pocket share for hospital care of about 3 percent.

In California, Blue Cross Blue Shield lost their tax exempt status after the state found the insurer was storing billions of profits untouched in reserves—money that could’ve been used to cover prescription drugs or prevent premium increases.

Finally, lawsuits against UnitedHealth allege that their prescription benefit design sometimes requires patients to pay co-pays that exceed than the actual cost of the drug.

After Brittany pleaded with her insurance company, Anthem eventually agreed to cover the cost of her medical care and to review its ER program. While this is the outcome we all hope for, it is unfortunate when insurance companies make it so difficult for patients to get the help that they need.

Check out the full story here.

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