Physicians, lawmaker concerned about insurer's ER visit policy - News weather sports for Youngstown-Warren Ohio

Physicians, lawmaker concerned about insurer's ER visit policy

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A relatively new policy by one of the largest health insurance companies in the country has caught the attention of a local lawmaker and a group of emergency physicians. 

If you're covered by Anthem, your emergency room visit could be denied if you're receiving care for a non-emergency. 

The company said that it is a move to ensure access to high quality, affordable health care, but this group and a local lawmaker feel it could do more harm than good. 

A dramatization in a YouTube video from the American College of Emergency Physicians shows how people with stomach pain in an emergency room can have two very different diagnoses.

"Who here has simple diarrhea and which one of you has a leaking abdominal aortic aneurysm, a true life threatening emergency?" asks the doctors.

The doctors are illustrating this point to show that they are against a policy by Anthem Blue Cross Blue Shield in six states, including Ohio.

Your ER visit may not be covered if you seek care for a non-emergency, when a more appropriate setting is available. The determination will be made after your visit.

"I went to medical school, but that doesn't mean that I can tell by just looking at you whether you can go home or I need to do surgery to save your life," said one doctor in the video. 

Another physician added, "So why does your insurance company think you know what's an emergency and what's not."

Jeff Blunt, an Anthem spokesman in Ohio, said in a statement, "Anthem's goal is to ensure access to high quality, affordable health care, and one of the ways to help achieve that goal is to encourage consumers to receive care in the most appropriate setting."

The statement continued, "Anthem's ER program aims to reduce the trend in recent years of inappropriate use of ERs for non-emergencies. If a consumer feels he or she has an emergency, they should always call 911 or go to the ER. But for non-emergency health care needs, ERs are often a time-consuming place to receive care and in many instances 10 times higher in cost than urgent care."

"It's going to force patients or clients to self diagnose," said State Representative Mike O'Brien.

O'Brien is co-sponsoring legislation to either cut Anthem's contracts with cities and counties or somehow penalize the company.

"The fear is since Anthem is so large of a company and if successful, other companies will follow Anthem's suit," he said.

Anthem said that there are exceptions that include those under 15 years old, if you are traveling out of state and certain weekend hours or major holidays.

The full list of cases when Anthem will always cover non-emergency ER visits is below:

o   The consumer was directed to the emergency room by a provider (including an ambulance provider)
o   Services were provided to a consumer under the age 15
o   The  consumer's home address is more than 15 miles from an urgent care center
o   The visit occurs between 8:00 pm Saturday and 8:00 am Monday or on a major holiday*
o   The consumer is traveling out of state
o   The consumer received any kind of surgery
o   The consumer received IV fluids or IV medications
o   The consumer received an MRI or CT scan
o   The visit was billed as urgent care
o   The ER visit is associated with an outpatient or inpatient admission

*Major holidays include New Year's Day, Martin Luther King Day, President's Day, Memorial Day, Independence Day, Labor Day, Columbus Day, Veterans Day, Thanksgiving Day and Christmas.
Anthem said that the company will continue to review this list and may expand it.

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