Is it really an emergency? New ER policy costing Georgians thousands

Dozens of Metro Atlantans got stuck with big emergency room bills even though they have insurance.

Blue Cross Blue Shield of Georgia put a new emergency room policy in place in the summer of 2017. Under it, Blue Cross will not pay for ER visits it finds inappropriate.

“I had really sharp, stabbing pain that came with these waves of nausea,” said Brittany Cloyd.  She went to the emergency room at a hospital in Frankfort, Kentucky, in the summer of 2017, thinking she might have appendicitis.

ER doctors ran multiple costly tests, including a CT scan and two ultrasounds. They diagnosed her with pelvic pain.

“The ER doctor had said my ovaries were riddled with cysts,” said Cloyd.

A few weeks later, she got a surprise in the mail -- a bill for more than $12,000. Her insurance company, Anthem Blue Cross Blue Shield, had denied her claim.

“I was very mad because I pay, I think we pay $400 a month for insurance. And to pay that much and know that they’re not going to cover something is absolutely ridiculous,” said Cloyd.

She isn’t alone. Piedmont Healthcare said it has documentation of Blue Cross Blue Shield of Georgia, a subsidiary of Anthem, denying ER claims for about 75 people treated in its ERs.

We checked with Georgia’s insurance commissioner and learned six complaints have come in about the policy.

“I understand the idea of controlling costs, but we think this is the wrong approach because it’s really putting patients in jeopardy,” said Dr. John Rogers, president-elect of the American College of Emergency Physicians.

Rogers said his group has heard from thousands of patients who have had their claims denied in the six states in which Anthem has enacted the policy. Those states are Georgia, Kentucky, Ohio, Indiana, Missouri and New Hampshire.

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“It appears to us that they are only looking at codes, diagnosis codes, rather than at the medical record itself,” said Rogers.

Anthem sent Channel 2 Action News this statement:

“Anthem strives to make health care simpler, more affordable and more accessible, and one of the ways to help achieve that goal is to encourage consumers to receive care in the most appropriate setting. Anthem’s avoidable ER program aims to reduce the trend in recent years of inappropriate use of ERs for non-emergencies as the costs of treating non-emergency ailments in the ER has an impact on the cost of healthcare for consumers, employers and the health care system as a whole. 
 
“If a consumer feels he or she has an emergency they should always call 911 or go to the ER. But for non-emergency health care needs, ERs are often a time-consuming place to receive care and in many instances 10 times higher in cost than urgent care. 
 
“If a consumer chooses to receive care for non-emergency ailments at the ER when a more appropriate setting is available, an Anthem medical director will review the claim information and medical records using the prudent layperson standard. In the event a member’s claim is denied, they have the right to appeal. 
 
“Anthem has made the decision to implement a number of enhancements to ensure that this program is implemented effectively across our participating markets.  We are applying our new and enhanced procedures to previously denied claims and will overturn decisions where the new procedures would have resulted in an approval.”

ADDITIONAL BACKGROUND ON HOW ANTHEM’S ER PROGRAM WORKS

"Anthem will not deny an ER claim based on the prudent layperson standard if it determines that any one or more of the following conditions apply:

• A consumer was directed to the emergency room by a provider, including an ambulance provider
• Services were provided to a consumer under the age 15
• The consumer's home address is more than 15 miles from an urgent care center
• The visit occurs between 8:00 p.m. Saturday and 8:00 a.m. Monday or on a major holiday*
• The consumer is traveling out of state
• The consumer received any kind of surgery
• The consumer received IV fluids or IV medications
• The consumer received an MRI or CT scan
• The visit was billed as urgent care
• The ER visit is associated with an outpatient or inpatient admission

"*Major holidays include New Year’s Day, Martin Luther King Day, President’s Day, Memorial Day, Independence Day, Labor Day, Columbus Day, Veterans Day, Thanksgiving Day and Christmas.

"We will continue to review this list and may expand it."

“It’s easy to somewhat Monday morning quarterback the provider when the entire documentation of the encounter is there,” said Max Reiboldt, president and CEO of Coker Group, a health care consulting company.

We asked Rieboldt what the solution is.

“I think, frankly, and this may not be a very good answer, the three working together in concert,” said Rieboldt, referring to the insurance company, health care providers and patients.

The American College of Emergency Physicians has met with state and federal lawmakers and Anthem to talk about the policy.

Channel 2's Dave Huddleston asked what else the group is doing.

"I can tell you that we are exploring all options to reverse this policy," Rogers said.
"When you say all options are you considering a lawsuit?" Huddleston asked.
 "All options," Rogers replied.
"Does that mean a lawsuit?" Huddleston asked.
"All options," Rogers said.

Piedmont Healthcare took that step, filing a lawsuit in February 2018 against Anthem accusing it of “a national scheme” to save money at the expense of patient safety. But Piedmont Healthcare dismissed the lawsuit as part of a new contract with Anthem Blue Cross Blue Shield of Georgia that it reached in April 2018.

Cloyd appealed her $12,000 bill twice before finally getting a letter stating Anthem would pay her claim. But she told us she never wants to go through this again.

“That’s terrifying, you know, that they have so much control over me as a company to put this fear in me that I’m not going back to the emergency room,” said Cloyd.

Reiboldt said patients who’ve had a claim denied by Anthem can file an appeal. He said they also can hire a lawyer, ask their employer to get involved and file a complaint with the state insurance commissioner.

Cox Media Group