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Ask a Lawyer 10-1-17
I went to the ER a few weeks ago with chest pains. My health insurance is refusing to pay. They say it was not an emergency. Louis, Empire
Unfortunately, this will happen more in the future. Insurance companies have decided to dictate medical treatment by refusing to pay for necessary services. Doctors and insured patients are getting letters that have gone out to some Blue Cross/Blue Shield members that threaten a crackdown on reimbursements.
“Save the ER for emergencies — or cover the cost,” reads a letter sent to Blue Cross members. “Going to the emergency room (ER) or calling 9-1-1 is always the way to go when it’s an emergency. And we’ve got you covered for those situations,” it reads. “But starting July 1, 2017, you’ll be responsible for ER costs when it’s NOT an emergency.”
Similar letters have gone out from Anthem Insurance trying to steer patients away from the ER. “What we are really trying to do is make sure that people are seeing their doctors first.” said Anthem. However, Dr. Becky Parker, president of the American College of Emergency Physicians disagrees replies it’s about money. “The insurance company is not on the same plane. They are not here to take care of people. They are here to make money. It’s clear that the insurance companies are looking to make money. It is about the dollar. It is not about high quality care.”
Parker said the letters and the new policies have a chilling effect on patients and could leave some with bills in the tens of thousands of dollars.
“The ‘prudent layperson’ standard requires that insurance coverage is based on a patient’s symptoms, not their final diagnosis,” ACEP said. “If patients think they have the symptoms of a medical emergency, they should seek emergency care immediately and have confidence that the visit will be covered by their insurance.”
As an example, Blue Cross may deny a claim from someone who shows up with chest pain and argue that a sharp pain with a deep breath could be a symptom of the common cold, and is not an emergency. However, Parker said it’s not reasonable to expect a patient to know the difference. “I don’t know and you don’t know if that is a heart attack, a blood clot, or a collapsed lung unless I see you in the emergency room,” she said. “The last thing a doctor wants is for a potentially dying patient to hesitate, worried about a bill. It’s really dangerous for our patients.”
Lastly, doctors want to work during the day and in many cases patients have few other choices outside of those hours. You cannot blame patients for using the ER.
The accident and injury lawyers at Nelson, Bryan & Cross represent clients in most areas including Motor Vehicle Accidents, Wrongful Death Cases, Personal Injury Actions, Social Security Disability, Defective Products, Insurance Disputes and Bad Faith, Fire Loss cases, Trucking Accidents, Worker’s Compensation, Drug Recalls, Employment Law and Property Damage Claims. Call 387-7777 for a free consultation.
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