This major health insurer could deny your ER bill in 6 states

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This major health insurer could deny your ER bill in 6 states
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There’s a general trend in America of emergency care being covered less and less by insurance companies while patients pay more and more for ER care than ever before.

But nowhere is that seen more clearly than when you look at one insurance company — Anthem.

RELATED: New pharmacy discounts may lower your prescription drug bill

ER bill crackdown: What you need to know

Back in 2015, Anthem decided that it would stop paying claims for some customers who show up at the ER with what later turn out to be non-emergent symptoms.

That policy, which first launched in Kentucky, has since been rolled out to five other states — Georgia, Missouri, Indiana, New Hampshire, and Ohio. According to its website, Anthem serves 14 states overall across the country.

By refusing to pay for emergency care that’s deemed unnecessary after diagnosis, Anthem is hoping to cope with the chronic overuse of emergency rooms that create long waits and higher prices for everyone.

In fact, one recent study from the American Journal of Managed Care found that a third of ER visits are for non-urgent problems.

Anthem does provide a few loopholes through which you can get your ER bill covered in the six states where it’s implemented this denial policy. But the insurer allegedly doesn’t always play by its own rules. More on that later.

First, let’s review the exemptions to Anthem’s ER bill denial policy. The insurer says it will pay for ER treatment under any circumstances for:

  • Patients younger than 15
  • Those who don’t live within 15 miles of an urgent care clinic
  • When you’re told to go to ER by a doctor
  • When you’re traveling out-of-state
  • If the medical event takes place on a Sunday or holiday

Consumer Reports finds there’s no question that Anthem’s decision to disallow payments for emergency room care is having a demonstrable effect on claims.

Here’s a look at which states have been hit hardest by the policy:

  • Missouri – 25 ER insurance denials a month since the policy took effect last June
  • Georgia – 580 denials since the policy took effect in July
  • Kentucky – 1,000+ denials since the policy took effect in 2015

Yet to make matters worse, a new analysis of claims in Georgia by a medical industry trade group finds that at least some of those claims denied by Anthem in the Peach State should have been paid.

Consumer Reports says that’s because the denied claims actually met the exemption requirements that Anthem itself put in place!

What’s still not clear is if Anthem will extend its punitive policy on ER bills to the eight other states where it does business — often as a Blue Cross and Blue Shield licensee.

Those states include California, Colorado, Connecticut, Maine, Nevada, New York, Virginia and Wisconsin.

But this much we do know: The policy leaves tens of thousands of American with ER bills that could easily have three zeros attached to the end of them!

Let’s make one thing perfectly clear — this is not about beating up on Anthem; it’s about helping you protect your wallet. To that end, here’s what you can do to get the care you need as some insurers crack down on ER claims:

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!

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.

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 decide to go. Watch money expert Clark Howard discussing this option.

Hire a medical billing expert

If you do get stuck with a big ER bill, you have one last chance before you roll over and pay up. Try hiring a medical billing advocate.

These professional know how to understand the hieroglyphics of medical bills and can check your ER tab for errors.

You’ll pay up to $50 an hour for a good medical billing expert. But considering how expensive ER bills can be, this would probably be money well spent!

RELATED: 9 states consider reviving penalties for not buying health insurance

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Theo Thimou About the author:
Theo has co-written several books with Clark Howard, including the #1 New York Times bestseller "Living Large in Lean Times."
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