As more insurers deny unnecessary emergency room visits, hospitals are scrambling to deal with revenue cycle implications.  So, if you admit someone for care deemed “unnecessary”, and the patient ends up with a big bill who is going to pay?  The answer is that the big insurance providers think the patient will pay. They also think that occurrences like this are quite high — a claim disputed by hospital ER physicians. And so the argument continues.

Unnecessary Emergency Room Visits and InsurersHere’s the basic position one huge insurer is taking.  According to the LA Times, “Anthem is the nation’s second-largest health insurer, with thousands of medical professionals on its payroll. Yet its Blue Cross and Blue Shield of Georgia subsidiary has just informed its members that if they show up at the emergency room with a problem that later is deemed to have not been an emergency, their claim won’t be paid.”

In Missouri, The St. Louis Post-Dispatch explains that “Should members choose to receive non-emergency care in the ED [emergency department], they will be responsible for the charges incurred,” the letter states, according to a copy that was shared with the Post-Dispatch by the Missouri Hospital Association.”

As you might expect, there are a lot of unhappy folks because of this decision. Becker’s Hospital Review reports that “Donald Palmisano, president of the Medical Association of Georgia, told WABE (an NPR affiliate) the policy disproportionately affects the elderly, rural residents and children over the age of 14. He added physicians are concerned the policy places “the patient, who doesn’t have the clinical background, to determine whether their condition is of an emergency nature.”

And the LA Times story uncovers a major problem with this policy — how can physicians know what is wrong before admitting a patient? “Patients don’t come with a sticker on their forehead saying what the diagnosis is,” said Renee Hsia of the Institute for Health Policy Studies at UC San Francisco, who has studied the difficulty of making snap diagnoses at the ER. “We as physicians can’t always distinguish necessary from unnecessary visits.”

The insurance spokespeople are seeking to reassure some concerns about how this might work.  “We’re not trying to steer people away from the emergency room if they have a serious condition,” Debbie Diamond, director of publications for Blue Cross Blue Shield of Georgia, told Becker’s Hospital Review. “If a member is having chest pain that they think is a heart attack, they should still go to the emergency department.”

Meanwhile, in Missouri, the state hospital association is questioning whether the unnecessary emergency room visits policy is even legal. In a related Post-Dispatch article, we learn about a letter signed by Herb Kuhn, CEO of the Missouri Hospital Association; Dr. Jonathan Heidt, president of the Missouri College of Emergency Physicians; Brian Bowles, executive director of the Missouri Association of Osteopathic Physicians and Surgeons; and Thomas Holloway, executive vice president of the Missouri State Medical Association.  The letter plainly states that “We think this policy is unfair to policyholders, and downright dangerous for patients,” according to their letter dated July 27 and addressed to the State’s Insurance Director Chlora Lindley-Myers.  The signers write in their letter that they believe that Anthem’s policy violates the “prudent layperson” standard. In other words, there are legal protections for people with limited medical knowledge who need what they believe is immediate care.

But so far, it doesn’t look like Anthem is backing off.  As Fierce Health reports, “In Indiana, where Anthem dominates the market, Joseph Fox, M.D., the insurer’s medical director for its Indiana operations estimated that about 8% of visits would be flagged for review under the policy, and about 4% of claims would likely be rejected.  It’s not a draconian program that we’re rolling out here,” Fox said. “We don’t want that to be misunderstood or misconstrued.”

The American College of Emergency Physicians (ACEP) disagrees.  In a recent release, they made their case like this:  “This new policy will mean that patients experiencing emergencies will not go to the ER because of fear of a bill, and could die as a result,” said Rebecca Parker, MD, FACEP, president of American College of Emergency Physicians (ACEP). “Health plans have a long history of not paying for emergency care.  Now, they are trying to roll over a federal law that emergency physicians fought for to protect patients from this ‘profits first, people last’ behavior by insurers.” And in a related release the ACEP presents a study that shows that “avoidable” ER visits are a very small percentage of what happens at hospitals, hovering around 3.3% of all visits.

Their final reply to the big insurance companies about unnecessary emergency room visits?  “Despite a relentless campaign by the insurance industry to mislead policymakers and the public into believing that many ER visits are avoidable, the facts say otherwise,” said Parker. “Most patients who are in the emergency department belong there and insurers should cover those visits. The myths about ‘unnecessary’ ER visits are just that – myths.”