Anthem Denies Payment for ‘Non-Emergency’ ER Visits in Ohio

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    Millions of Ohioans at Risk for Denial of ER Visit Claims by Anthem

    As many as 3.4 million Ohio residents now have to think twice before seeking medical help at Emergency Rooms because they have Anthem Blue Cross Blue Shield insurance.  A new policy, started on January 1, allows the insurance company to deny claims for ER visits if they decide the medical issue was a non-emergency that could have been treated at an urgent care facility. This change is leaving patients with thousands of dollars worth of medical bills they have to pay out of pocket.

    How is this Insurance Change Affecting Healthcare in Ohio?

    Anthem states they are dedicated to “helping improve the health of our communities.” However, patients may now feel forced to self-diagnose their condition out of fear of having their claim denied, instead of simply focusing on getting medical help. For example, patients may not be able to tell the difference between symptoms of a bad headache and a brain aneurysm or appendicitis and an ovarian cyst. In cases such as these, it may not be possible for someone to know if their condition is life-threatening or not.
    Anthem plan participants are faced with a dubious choice – don’t go ER for fear of receiving a medical bill they can’t afford, not knowing if their condition may be catastrophic, or, go to the ER with what seems to be a major issue and turns out to be a non-emergency, and get stuck with a massive bill. Anthem’s new ER policy could result in people not getting the care they need or deterring them from seeking medical help in the future.
    The program is already in place in Georgia, Missouri, Kentucky, Indiana, as well as New Hampshire. When the change happened in Missouri, residents received a card in the mail from Anthem saying, “Save ERs for emergencies – or you’ll be responsible for the cost.”

    Why is Anthem Changing its ER Insurance Policy in Ohio?

    Anthem’s stated reason for the policy change is that ER costs are rising, so the insurer is aiming to reduce non-emergency visits. They’ll deny claims for ER bills if an urgent care location or 24/7 online service could have treated the medical condition. The company wants patients to choose an appropriate level of care. In our view, Anthem’s recommendation to their plan holders for ER visits is troublingly ill-defined. They simply say to go “if you have an injury or illness that you feel is threatening your life or health.”
    In a statement Anthem said their goal “is to ensure access to high quality, affordable health care, and one of the ways to help achieve that goal is to encourage consumers to receive care in the most appropriate setting. Anthem’s ER program aims to reduce the trend in recent years of inappropriate use of ERs for non-emergencies.”
    However, there are some exceptions to this policy. These changes don’t apply to:

    • Individuals who are 15-years-old or younger;
    • Patients who live 15 or more miles from an urgent care location;
    • Holiday or weekend visits to an ER;
    • People who are instructed to go to an ER by a healthcare professional; and
    • Those who have Medicare or Medicaid;

    Did Anthem Deny Paying Your ER Visit?

    If you’re experiencing the frustration and confusion of Anthem denying your claim for an ER visit, or want advice on how to approach your Anthem health insurance plan, call a lawyer to discuss your legal options. At Tittle & Perlmuter we can help navigate your next steps. If you’re ready to discuss your options you can contact us by calling (216) 308-1522.

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