Beware this insurer’s sneak attack on emergency care coverage

Most people buy insurance to protect financially against potentially catastrophic events and emergencies. But if you have health insurance through Anthem, a health insurance company that covers an astounding 1 in 8 Americans, watch out: You may be on your own in an emergency.

Anthem has introduced a restriction on emergency care coverage, effectively denying most if not all coverage if they decide after your ED visit that you didn’t have an emergency condition. Say you went to an emergency department for severe abdominal pain and nausea that sounded like your cousin’s appendicitis, only to find out the cause was a nasty stomach virus.

After the dust has settled, Anthem reviews the bill and decides that your visit was inappropriate and could have been treated in your doctor’s office or at an urgent care center. The company then covers only a fraction of the cost, if any, and you are responsible for most of the bill. What’s more, this expenditure would not count towards your deductible or out-of-pocket limit.

Last year, Anthem and its subsidiaries notified its members in Georgia, Kentucky, and Missouri of this new policy. It is part of a national cost-cutting strategy for the Indianapolis-based insurance giant, which posted a $2.46 billion profit in 2016. The American Hospital Association, American Medical Association and American College of Emergency Physicians have publicly denounced this policy, and Sen. Claire McCaskill of Missouri is investigating it.

Undeterred, the company announced its denial policy in three more states earlier this year. In Massachusetts, Unicare, an Anthem subsidiary that provides health benefits for Massachusetts public workers policies, buried a “non-emergency” clause on page 47 of its member’s handbook without any announcement at all.

This restriction defeats the core purpose of having insurance — to cover unexpected emergencies.

Vox told the story of a young Kentucky woman who went to an emergency department for severe abdominal pain. Anthem declined to cover her $12,000 bill, saying the visit was not an emergency because the final diagnosis was an ovarian cyst.

Judging the appropriateness of a trip to the emergency department after the fact is unfair. Why? Because it is difficult for individuals who are acutely ill to determine if they have a condition that qualifies as an emergency. Is that pain in the center of your chest a heart attack, or is it just heartburn? Is that sharp headache just another migraine, or is it a burst brain aneurysm?

Even the most experienced emergency triage nurses frequently get it wrong. A 2013 report in the Journal of the American Medical Association showed that, at the start of emergency visits, they identified as non-urgent only 13 percent of patients who ultimately had diagnoses that didn’t qualify as emergencies. The reason? Those patients had the same spectrum of symptoms that brought nearly 90 percent of patients to the emergency department.

This tactic of reviewing emergency department visits after the fact isn’t new. In the 1990s, managed care companies commonly denied coverage for emergency care. And insurers tried to discourage patients from going to the emergency department by requiring pre-authorization for such visits. Patients sometimes deferred lifesaving care for fear that their insurance would not cover it.

In response, states and the federal government passed laws requiring insurers to cover emergency care based on the prudent layperson standard. This standard defines emergency medical conditions as “acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in [serious deterioration of health].”

Maryland passed the first prudent layperson standard in 1992. Other states followed, and it became federal law in 1997 as part of the Balanced Budget Act. In 2010, the Affordable Care Act renewed this standard for emergency care coverage as one of the 10 essential health benefits.

Simply put, Anthem’s retrospective denial of emergency care coverage is unethical and illegal. It threatens patients’ safety and their access to emergency care. Individuals covered by health insurance with this restriction won’t have the financial protection they expect when seeking care for a medical emergency. Instead, patients may find that their insurance did not cover the visit cost when they receive a bill out of the blue.

Patients will be forced to be their own doctors, weighing a trip to the emergency department for what could be lifesaving care against possible financial repercussions if they guess wrong.

Despite the outrage by lawmakers and physician organizations, Anthem has continued to expand this dangerous policy nationally, threatening to reverse the progress we’ve made in patient safety and access. More striking is that Anthem is sneaking these restrictions to emergency care coverage without announcement, such as through Unicare in Massachusetts.

Denying retrospectively determined “inappropriate” emergency department visits is as unsafe today as it was 25 years ago. Patients across the nation need to examine the details about emergency care coverage in their health insurance plans, especially if they are covered by Anthem, Unicare, Blue Cross Blue Shield, or one of the other subsidiaries. This fine print needs to be exposed so physicians and patients can fight back, as they have in Ohio, where the state legislature will introduce a penalty for restrictions such as Anthem’s policy. After all, in an emergency, your life — or savings — will depend on it.

Shih-Chuan (Andrew) Chou, M.D., is an attending emergency physician and health policy research fellow, and Jeremiah D. Schuur, M.D., is the vice chair of clinical affairs for the Department of Emergency Medicine, both at Brigham and Women’s Hospital in Boston. The opinions expressed here are the authors’ and do not reflect the views and opinions of Brigham and Women’s Hospital.