Anthem Emergency

EMTALA swings the ER gates open on entry. “Give me your tired, your poor, your huddled masses… but preferably your insured.” On exit, watch your back.

I’ve typed plenty on EMTALA already. It’s the law that says you can’t be turned away when you sidle up or roll into an ER. Recently, however, a new wrinkle has entered the mix. Anthem in particular has in some regions started to decline payments for ER visits deemed non-emergent. The problem is that “emergent” is in the brain of the beholder.

This article dives into the details of EMTALA: You have a right to be seen in the ER, but beware of the side effects.

Most ER docs think this is bad policy, especially if really sick people choose to stay home for fear of massive bills. Unfortunately, it’s hard to separate altruistic vs. business motives when ER docs cry foul here. Because if patients stay home, ER revenues subside.

Personally, I straddle the line as usual. I don’t want to see sick people afraid of coming to ERs. But every shift I meet large numbers of patients who really don’t need to be there. I recently read that more than half of outpatient care happens in ERs. Each shift I meet patients with cysts, nagging coughs and chronic aches that could easily be addressed in urgent cares or clinics, or even at home with a little reading. And sprinkled amongst them are healthy patients or parents desiring work or school notes. They each get vital signs, medical screening exams and the full billing cascade.

But if not Anthem, then who should decide emergent vs. non-emergent? Insurers only have the cryptic charts, codes and diagnoses, so they’re likely to make a lot of mistakes. If anyone should be the arbiter, I suppose it should be we, ER docs. Unfortunately, this responsibility I just don’t want. Often I grumblingly meet patients with ear pain at 2am; only to feel like a jerk after learning they didn’t make it to clinic because they’d spent the day picking lettuce, followed by their second job, followed by bedtime for the kids. “Emergent” is subjective.

An ER visit, a $12,000 bill — and a health insurer that wouldn’t pay

To me, we have an ugly system from top to bottom. Pre-R is my reaction. Anthem’s approach is just another player’s reaction to a diseased system. However, I suspect the bad press and ill will they’re generating will cost them more than they’re saving. Hard to know. For insurers in general, it really is a predicament. Few industries are hated more nowadays with premiums climbing and coverage deteriorating, with hospital charges climbing in parallel… and a guy who has likely never needed to buy health insurance at the helm.

Someone will reply: “Universal healthcare!” Fine. But until then…

  • Read. Exercise. Eat right.
  • Take charge of your own care.
  • Find the number of a doctor, NP, PA or another trusted soul who will answer the phone when called.
  • Consult Dr. Google. (Yes, I’ll admit that doc knows a lot more than me.)
  • Check out our Anxiometer.
  • If you have an iPhone, download Care Circles by Pre-R.
  • And go to an ER if it’s emergent.


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