Mansell, Engel & Cole

Will Anthem deny insurance claims for emergency visits?

Patients with insurance have an expectation that if there is an emergency, they will receive coverage for an emergency room visit. However, a new policy by one of the nation’s largest insurance companies may not cover these visits.

Last year, Anthem began reviewing emergency room visits after the fact to decide if those visits were “medically necessary.” If the insurer determined the patient didn’t suffer from what the company deemed an “emergency medical condition,” they would refuse to pay for the visits. This led to patients who were expecting coverage to be left with thousands in medical bills.

So far this policy has rolled out in states like Ohio, Kentucky, Missouri and Georgia, but it could spread nationally in the future.

Legal federal requirements to cover emergencies

Senator Claire McCaskill (D-Mo.) recently announced she is asking the Secretary Alex Azar of the U.S. Department of Health and Human Services to review whether or not Anthem’s policy violates federal law. The “prudent layperson standard,” which was applied to all insurance plans in 2010, defines an “emergency medical condition” as one that requires immediate medical attention in the eyes of a prudent person who has an average knowledge of health and medicine.

Anthem’s defense of the policy is that it is designed to combat rising emergency room costs, driven by routine treatments ending up in the ER. However, Sen. McCaskill and others argue that it places too much burden on patients – both medically and financially.

Patients should have the confidence to seek emergency medical care, without worrying about an insurance claim denial, to keep from hesitating in what could be a life-altering situation.

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