PHARMACIST STEVE

On Aug., 1, 2017, Brittany Cloyd of Frankfort, Kentucky, said she experienced pain “worse than childbirth.” Her mother — who had been to nursing school — drove her to the nearest emergency room. Brittany thought her appendix had burst, but tests at the ER found she had ovarian cysts. She was given pain medication and told to follow up with her primary doctor.

Cloyd had an Anthem Blue Cross PPO health insurance plan and thought she would get charged just a co-pay for her ER visit. Instead, 15 days later she received a letter from health insurer Anthem. “Your condition does not meet the definition of emergency,” read the letter. She was responsible for the total ER bill — $12,596.

What Brittany endured is becoming more common in the health insurance industry, according to a Doctor Patient Rights Project (DPRP) study. It highlighted Anthem, which through its affiliated networks is the nation’s largest private health insurer. The DPRP contends that Anthem has instituted an organized policy of denial designed to make its subscribers — particularly those who are poor and reside in rural areas — too afraid to go to an ER for fear of receiving a bill like Cloyd’s, or more, for the visit.

“The purpose of this program is to spread fear,” said Dr. Ryan Stanton, a critical care and emergency medical specialist in Lexington, Kentucky.

Anthem spokesperson Joyzelle Davis, who said she hadn’t seen the study yet, issued an all-purpose response. “Anthem’s Emergency Department Review aims to encourage consumers to receive care in the most appropriate setting,” Davis said. “Anthem’s review [of claims] aims to reduce the trend in recent years of inappropriate use of emergency departments for non-emergency use.”

Anthem did not provide specific guidelines for what would be an appropriate visit to an emergency room. But in a letter addressed to companies insured by Anthem and obtained by the DPRP, the insurer made it clear that it didn’t want individuals insured by its policies to seek “care right away” at an ER when they could just as easily be treated at a doctor’s office or retail health clinic.

According to Anthem, more than a quarter of its subscribers’ emergency room visits could be treated elsewhere. “If we could reduce unneeded ER visits, we can cut health care costs by $4.4 billion a year,” the letter said. Consequently, Anthem noted, that would cut its member companies’ costs by more than a billion dollars.

“Controversial and dangerous”

Kentucky isn’t the only state where Anthem is rolling out this policy. It’s spreading across the South and Midwest, also. In Georgia, the American College of Emergency Physicians and the Medical Association of Georgia have filed suit in federal court to get Anthem to “rescind its controversial and dangerous … policy that retroactively denies coverage for emergency patients.”

Sen. Claire McCaskill, D-Missouri, sent a letter to both the U.S. Department of Health and Human Services and the Department of Labor asking them to look into whether certain health insurers had violated the “Prudent Layperson Standard” by denying claims. McCaskill is leaving office in January, and her staff did not respond to questions about whether her letter had been answered.

But her question goes to the heart of the matter. Congress enacted the Prudent Layperson Standard for Medicare and Medicaid managed care plans in 1997 and included group and individual health insurance plans in 2010. It defines an “emergency condition” as one in which the average person’s knowledge of health and medicine would dictate that you could go to the ER for treatment of acute symptoms of sufficient severity.

Do you have the ability to diagnose your own pain or injury, and if so, what do you do about it? If you go to the ER, will your insurer deny your claim, leaving you in economic peril? “Patients should never be in the position of correctly diagnosing their … emergency” before seeking help, McCaskill said in her letter.

137 million ER visits annually

But that puts millions of Americans in a vise. In an average year, nearly one in five people report going to the ER, according to the DPRP, for a total of 137 million visits. Doctors, patients and insurers note that statistics from 2012 indicating the average cost of an ER visit, at $1,233, is outdated. One reason for the surge in price since then, according to a University of Maryland study: the increased number of substance abuse cases — particularly among young and middle-aged adults — that now pass through an ER.

Anthem said even a small savings could benefit the health care system, in which Americans spent nearly $3 trillion dollars in 2015. The percentage of patients who leave the ER with no treatment whatsoever is 5 percent according to Anthem, while the Centers for Disease Control and Prevention (CDC) said it’s at least 3.3 percent. Some of these may be psychiatric patients.

But CDC data also appears to show that going to the ER might be the right choice for a serious condition such as chest or stomach pain and high fever. It said 43 percent of all ER cases lead to hospital admissions.

Critics said Anthem will likely keep pushing its policy of denying ER treatment unless it’s stopped. “Anthem is the big boy on the block, but other health insurers are picking up on it,” said Dr. Stanton. “They’re like a child getting into daddy’s wallet. They take a few dollars at a time and, if they don’t get caught, keep going.”

How to file an appeal

Those who feel they’ve been wronged can always appeal. “Patients should first appeal to the insurer,” said Executive Director Stacey Worthy of the Aimed Alliance, a health care coalition dedicated to innovation in medicine. If you get a written denial explaining the reason, then submit documentation and justification for the necessity of the ER treatment.

If you get a second denial, request an external review by an independent party, possibly a state insurance regulator, or someone it appoints. Worthy said it’s labor-intensive for the patient “because the insurer wants you to give up during the process.”

But it often doesn’t get that far, patient advocates said. The Affordable Care Act makes it clear that ER patients have the law on their side, if they can prove a true emergency. “Insurers can’t require you to get prior approval,” the ACA states. And a 2016 study found that 52 percent of retroactive denials were ultimately overturned after independent review.

Brittany Cloyd lost her first appeal, but she refused to take no for an answer. So she sent Anthem a second appeal with documentation and a rebuke.

“I’m not sure how one knows if they’re bleeding internally,” she wrote. “But I hope that it’s apparent … perpetuating scare tactics could certainly convince patients not to go the emergency room. I foresee an onslaught of wrongful death suits in Anthem’s future.”

Cloyd said Anthem then paid her entire $12,596 ER bill.