ER Visit Denials

Imagine you just flew home from a dream trip to Europe and after getting a good night’s sleep in your own bed, you wake up with chest pain and trouble breathing.  Now you’re a young woman so heart attacks really aren’t on the top of your list of worries, but you’re really uncomfortable and a little scared.  A quick call to your doctor’s office and, once informed of your recent airplane flight and the fact that you take birth control pills, you are told to head to the ER.

The ER staff and doctor are very kind and you get an exam, some labs and a scan of your chest which show your pain is from a rib that’s out of place and NOT from a blood clot.  That’s a relief!  Sleeping in funny positions on trains and planes isn’t good for you!

Anti-inflammatories, heat and rest are just the trick to settle the pain and you’re feeling better in just a few days.  However, a different kind of pain starts about 6 weeks later when you get the bill for your ER visit.  Your insurance company has denied the claim, stating that they won’t pay for you going to the ER for a “non-emergent” visit.

Turns out insurance companies like Anthem are trying to control costs by denying claims for ER visits for what they consider non-emergency reasons.  A report published in JAMA recently analyzed what percentage of visits would not be covered and how that relates to the symptoms patients are experiencing.

The researchers found that about 15% of ER visits would be denied with the retrospective review policy.  The problem is that these denied claims had the same symptoms (chest pain, abdominal pain, etc.) as claims that were not denied.  The insurance companies expect patients to distinguish between different types of chest pain and abdominal pain without the benefit of medical training.

This is a mistake.  The researchers in this study noted that patients are going to be hurt by this policy.  If patients with chest pain are afraid their ER visit isn’t going to be covered if it turns out to NOT be a blood clot or heart attack, they will be less likely to get checked out in a timely fashion for problems that could be very serious.

I have a hard enough time getting patients (especially women) to go to ER for chest pain or stroke symptoms.  If insurance companies start denying claims for chest pain that turns out to be bad reflux, or stroke-like symptoms that turn out to be from migraine, people are going to be more likely to ignore their symptoms until it’s too late.

People should NOT go to ER for problems that aren’t emergencies.  Someone who goes to the ER for a sore throat (unless they are directed to go there by their primary care doctor) should have the option of an urgent-care level of care.  Too many non-emergency visits to the ER slows down care for those who have a true emergency.

It’s often hard for us with medical training to be sure someone isn’t having a serious problem.  I send folks to the ER all the time to be evaluated when I can’t reassure them in the office that nothing life-threatening is wrong.  Asking patients without medical training to make those decisions is going to lead to people being hurt.

QUESTION: Have you been to the ER for something that seemed serious but turned out not to be?  What do you think of this new policy?


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