![]() More striking is that Anthem is sneaking these restrictions to emergency care coverage without announcement, such as through Unicare in Massachusetts.ĭenying retrospectively determined “inappropriate” emergency department visits is as unsafe today as it was 25 years ago. Patients will be forced to be their own doctors, weighing a trip to the emergency department for what could be lifesaving care against possible financial repercussions if they guess wrong.ĭespite the outrage by lawmakers and physician organizations, Anthem has continued to expand this dangerous policy nationally, threatening to reverse the progress we’ve made in patient safety and access. Instead, patients may find that their insurance did not cover the visit cost when they receive a bill out of the blue. Individuals covered by health insurance with this restriction won’t have the financial protection they expect when seeking care for a medical emergency. It threatens patients’ safety and their access to emergency care. Simply put, Anthem’s retrospective denial of emergency care coverage is unethical and illegal. In 2010, the Affordable Care Act renewed this standard for emergency care coverage as one of the 10 essential health benefits. Other states followed, and it became federal law in 1997 as part of the Balanced Budget Act. ![]() Maryland passed the first prudent layperson standard in 1992. This standard defines emergency medical conditions as “acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in. In response, states and the federal government passed laws requiring insurers to cover emergency care based on the prudent layperson standard. Patients sometimes deferred lifesaving care for fear that their insurance would not cover it. And insurers tried to discourage patients from going to the emergency department by requiring pre-authorization for such visits. In the 1990s, managed care companies commonly denied coverage for emergency care. This tactic of reviewing emergency department visits after the fact isn’t new. The reason? Those patients had the same spectrum of symptoms that brought nearly 90 percent of patients to the emergency department. A 2013 report in the Journal of the American Medical Association showed that, at the start of emergency visits, they identified as non-urgent only 13 percent of patients who ultimately had diagnoses that didn’t qualify as emergencies. What’s more, this expenditure would not count towards your deductible or out-of-pocket limit.Įven the most experienced emergency triage nurses frequently get it wrong. The company then covers only a fraction of the cost, if any, and you are responsible for most of the bill. Say you went to an emergency department for severe abdominal pain and nausea that sounded like your cousin’s appendicitis, only to find out the cause was a nasty stomach virus.Īfter the dust has settled, Anthem reviews the bill and decides that your visit was inappropriate and could have been treated in your doctor’s office or at an urgent care center. But if you have health insurance through Anthem, a health insurance company that covers an astounding 1 in 8 Americans, watch out: You may be on your own in an emergency.Īnthem has introduced a restriction on emergency care coverage, effectively denying most if not all coverage if they decide after your ED visit that you didn’t have an emergency condition. Most people buy insurance to protect financially against potentially catastrophic events and emergencies. Exclusive analysis of biotech, pharma, and the life sciences Learn More
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