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Ohio insurer stopping payments for non-emergency ER visits

Posted at 3:30 AM, Jan 22, 2018

CINCINNATI -- When Laura Killoran experienced chest pains last July, she went to the emergency room at St. Elizabeth Hospital in Cincinnati, Ohio. 

But when Killoran got her explanation of benefits from Anthem, her health insurer, it said she owed about $1,488. 

Anthem finally paid after a four-month appeal. But the company said it's trying to minimize rising healthcare costs by charging those who go to the ER for a non-emergency.

Now that Anthem has extended its new ER policy to Ohio, hospitals aren't sure what to expect. 

"It's really too early to speculate on the impact that policies like this are going to have on our patients here at Mercy Health," Mercy Health Cincinnati Chief Clinical Officer Dr. Erin Fries said. 

In Kentucky, Anthem also denied cases like a patient bleeding from a surgical incision, a patient with shortness of breath and a patient who was sent to the ER by a doctor, according to data from the Kentucky Department of Insurance. Most of the denials were eventually reversed by Anthem or the state. 

Dr. Michael Argus, a board certified emergency physician with U.S. Acute Care Solutions, reviewed the data from Kentucky. He said the same set of symptoms in a different patient could mean a life-threatening condition.

"In the end, you know, this is just ... cruel," he said. 

Killoran believes one reason her denial was overturned was because she had support from St. Elizabeth's. The state department of insurance can also help. 

Anthem provided Scripps sister station WCPO in Cincinnati with a statement which read, in part: 

"Emergency rooms treat life and limb threatening situations, and if a consumer feels he or she has an emergency they should always call 911 or go to the ER. But for non-emergency ailments, ERs are an expensive and time-consuming place to receive care. Primary care physicians are often the best and least costly option for the treatment of any non-emergency medical concerns, with urgent care, telemedicine, retail clinics available to assist consumers in after-hours situations."

Anthem will also cover non-emergency ER visits under some conditions, they said. Those include:

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