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When Should You Go to the ER? And, If You Do, Will You Be Stuck With the Bill?

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You are experiencing excruciating pain in your abdomen.  You know there is something really wrong. Your first instinct is to rush to the hospital, it could be appendicitis but you are not sure.  It’s best to let the experts tend to you, right?  After all, they are doctors and you aren’t.  

The above scenario seems logical right?  

But it may not seem like the best course of action according to your insurance company.  

In the article titled: “An ER visit, a $12,000 bill — and a health insurer that wouldn’t pay” (link) describes a similar story and the insurance company didn’t agree that the symptoms, the pain and the final diagnosis weren’t severe enough to warrant an emergency room visit.  In fact, the insurance company deemed the ER visit in appropriate and denied the claim which caused the hospital to demand payment for treatment and tests.  In some cases, insurance companies have begun charging their clients with “penalty fees” for inappropriate ER visits. While some of the more draconian rules have not come to Florida yet, they are in other states and the number of states is growing.  The article suggests: “All of these policies suggest a new and controversial strategy for reining in health care costs: asking patients to play a larger role in assessing their own medical condition — or pay a steep price.”  It is unreasonable to expect patients to self-diagnose and do it accurately.  

What is being done about insurance companies denying emergency room claims?  Congress is getting involved and asking questions.  Specifically, the articles sites that Claire McCaskill (D-MO) sent Anthem a letter stating, her concerns that Anthem is requiring its patients to act as medical professionals when they are experiencing urgent medical events.  Emergency room physicians are also taking a stand.  They are exploring options that allow them to push back to insurance companies like Anthem who have ER policies in place like the one explained here. It doesn’t stop there.  Hospitals are engaging with patient advocacy groups, asking pertinent questions, pressuring legislators to take notice of what is happening in the system and demanding better solutions.

Review your policy to make sure you understand what your policies emergency room coverage is.  If you are unsure what your policy states, get in touch with the insurance company so they can go over it with you.   If you have any questions on it please reach out to me anytime.

To read the entire article referenced in this blog post from Vox, click here.


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