A subsidiary of the nation’s second-biggest health insurer wants to crack down on unnecessary emergency room visits, and they’re hitting consumers where it hurts the most to get the job done — in the wallet.
Why your ER claim may go unpaid
You may have heard recently that Anthem exited the state health care exchange in Ohio because of low enrollment and the possibility that they may get stiffed by the federal government on low-cost plans amid changing health care laws.
But here’s one you may not have heard about Anthem: The company has decided that it will stop paying claims for some customers who show up at the ER with non-emergent symptoms, according to a report in The Los Angeles Times.
Beginning July 1, Blue Cross and Blue Shield of Georgia — an Anthem subsidiary — says it won’t pay up for ER care that’s determined to be unnecessary after the fact.
That may leave thousands of Georgians stuck with a bill that could easily have three zeros attached to the end of it.
The hope is that instead of seeking ER care that may or may not be paid for, those customers will go to urgent care centers or to a doctor’s office.
Exemptions are available for patients younger than 14; those who don’t live within 15 miles of an urgent care clinic; or if the medical event takes place on a Sunday or holiday.
BCBS of Georgia is the only insurer offering individual insurance plans in nearly two-thirds of the state’s counties.
Anthem has similar restrictive policies on paying ER claims in three other states including New York, Missouri and Kentucky.
Posing a serious treatment conundrum
So what exactly constitutes a “necessary” ER visit?
According to The Los Angeles Times, the Affordable Care Act defines that as anything that “a prudent layperson, possessing an average knowledge of medicine and health,” would believe to be emergent and in need of immediate attention.
The problem is, of course, that definition leaves a lot of gray area.
Patients would have to essentially self-diagnose and weigh the risks of not going to the ER when they truly need emergency care vs. going to the ER and later learning it was nothing serious…and then facing a massive bill.
To complicate matters, physicians and ER staff themselves admit they can’t readily tell when an ER visit is truly necessary without a full examination of the patient.
Sure, we all know that going to the ER for a cough, a sore throat or a head cold is simply ridiculous. But other common ailments like headaches and earaches could be symptoms of larger and more serious issues.
In fact, research published last year in the Journal of the American Medical Association found that six of the 10 top reasons for unnecessary visits — including back, abdominal and chest pain; sore throats; and headaches — are also among the top 10 symptoms of true emergencies.
What you need to know before heading to the ER…
Consider a virtual visit
Though telemedicine has been around for about 15 years, it is just now starting to gain some traction. See if it would make sense for your life.
Choose a nurse-in-a-box clinic instead of an ER
Look for retail clinics typically located in drug stores, discount stores or supermarkets. See how much money they can save you vs. the ER.
Don’t be fooled by standalone ERs
Stand-alone emergency departments are just what they sound like — emergency rooms that aren’t attached to a hospital. They have fancier equipment, in-house labs, additional 24/7 staff…and a hefty price tag that runs into the thousands for a procedure as simple as treating a cut without stitches!
Look at a faith-based program for help
You would have to be a member of a particular religious group to qualify, but this may help with those hefty ER bills should you decided to go. Watch Clark discussing this option.
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