More Health Insurers Are Refusing to Pay ER bills

This is absolutely amazing.  The title of this entry is the exact title from the paper. If you need any more reason to hate the insurance companies then here it is.  Here is the example they gave:

Brittany Cloyd of Frankfort, Kentucky, said she experienced pain “worse than childbirth.” Her mother — who had been to nursing school — drove her to the nearest emergency room. Brittany thought her appendix had burst, but tests at the ER found she had ovarian cysts. She was given pain medication and told to follow up with her primary doctor.

Cloyd had an Anthem Blue Cross PPO health insurance plan and thought she would get charged just a co-pay for her ER visit. Instead, 15 days later she received a letter from health insurer Anthem. “Your condition does not meet the definition of emergency,” read the letter. She was responsible for the total ER bill — $12,596.

I get that ER care is way too expensive for some of the reasons why people go there.  That beings said, the above story is unbelievable.

What Brittany endured is becoming more common in the health insurance industry, according to a Doctor Patient Rights Project (DPRP) study. It highlighted Anthem, which through its affiliated networks is the nation’s largest private health insurer. The DPRP contends that Anthem has instituted an organized policy of denial designed to make its subscribers — particularly those who are poor and reside in rural areas — too afraid to go to an ER for fear of receiving a bill like Cloyd’s, or more, for the visit.

This has to stop.  After losing the appeal, Brittany kept fighting and got reimbursed.  How many others have the persistence to do that?  It is time to walk from these companies.  We need real competition in this crooked industry.

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Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  10 comments for “More Health Insurers Are Refusing to Pay ER bills

  1. Jeff Frederich
    December 5, 2018 at 5:13 pm

    I agree that $12,500 is entirely too much for an ER visit for acute abdominal pain. I’m quite sure this included a CT of the Abdomen/Pelvis and appropriate labs. I’m an ER doc in KY, have been for many years, and am well aware of the local nuances. This is a very litigious state, and though there are some places you might not have done the CT, here you would. I’m sure she was hot at McBurnie’s, and the majority of hospitals here don’t have US at night.

    Exacerbating this (likely the biggest factor) is the Obamacare fiasco! There is NO COMPETITION in KY regarding health insurance! There are only two carriers in this state, and they have broken up the territory so that no county has a choice. I went from having good insurance at $600/month to now where I pay >$2600/month for crappy coverage! I use GoodRx because it is much cheaper to pay cash than my copay for pharmaceuticals. In a few years, it’s Medicare primary with a VA secondary! That’s the only good thing about being old. If they came to their senses and lost Medicare (and the rest of the Great Society), I’ll just quit and go with whatever the VA offers. $40k/year out the gate is not reasonable, EVER!

    I’m very displeased at the Republicans. They have had both houses and the Executive and haven’t been able to return us to a free market system. I’ve been a solid red vote since ’76, but there is one turtle I wouldn’t vote for regardless of what that could mean for the balance of power.

  2. Robert Braun
    December 5, 2018 at 5:10 pm

    This sort of thing has been going on for some time. It’s a way of making people feel as if it is their fault so that they don’t fight back. The fallacy at the heart of it is that they’re saying that it is the responsibility of the untrained and uneducated patient to correctly diagnose their problem without any equipment or performing any tests or scans. Sudden unexplained extreme internal pain is an emergency that should always be immediately examined by a doctor because it could be something requiring immediate attention. Even though in this case her condition wasn’t life-threatening, it still needed immediate attention. It is unreasonable to expect a patient to know a situation is not life-threatening. Especially when a doctor wouldn’t know either before examination.

  3. PW
    December 5, 2018 at 12:27 pm

    We have Anthem it does deny a lot. Fortunately they paid for my wife’s ER visit for a kidney stone which would have cost $8500.

  4. Benjamin Van Raalte
    December 5, 2018 at 10:36 am

    The ridiculousness is a $12,000 emergency room bill for a evening visit. Something is very very wrong. I feel sorry for the patient caught in the middle of this but the reform needs not to be on the health insurer which will just pass on cost to all of us the remaining few of us that pay for health insurance. She probably saw a nurse practitioner and that warranted a $12,000 bill. Furthermore emergency room physicians despite having a three year residency and regular hours now command the highest dollar amount per hour of any specialty. yet half the time you see a nurse practitioner in the bill is not reduced. The reform needs to come on the pricing Lee services first. There is no justification for a $12,000 emergency room bill. There’s time for a national reimbursement scale in these outlandish charges need to be formed first then we can work on reforming the insurers. Not that I like insurance companies for without the first reform just having a blank check will lead to the hospital charging 24000 the next time

    • Barb
      December 5, 2018 at 9:55 pm

      Yes! It’s pathetic.

    • Dave
      December 9, 2018 at 10:16 am

      Benjamin, I’m not going to argue whether the charge for this visit in question is appropriate or not, but you’re going to try and blame this on the salary of the emergency physician?!?! I guarantee you that the professional fees are only a small fraction of that amount!!!
      Furthermore, I would love to see your data as to EP’s having the highest dollar amount per hour of any specialty…on a cursory Google search I found nothing to support your statement.
      What about those “regular hours?” How about working a constantly changing shift map combining days, evenings and overnights, and constantly trying to adjust your circadian rhythm? Oh, and then there’s the weekends, and holidays. My “office” is open 365 days a year, 24 hrs a day, and is never closed on holidays. We take care of every other specialty’s problems when they are closed…Or even when they’re open, if the complaint is chest pain, or abdominal pain, or simply if their schedule is too full to fit in an urgent complaint.
      The PA or NP who may see you? There’s a doc behind their care, and they often consult us on the care that you receive, even if you don’t physically see us. If we don’t actually see you, the visit is billed under the practioner’s NPI, and Medicare/Medicaid do reduce the pro fee (80%, I think). Some commercial insurers may, too, but I’m not sure.
      The bottom line is that everyone wants to try and blame healthcare costs on the physician’s salaries, but this only is a very small amount of healthcare costs….

      • RSW
        December 11, 2018 at 1:57 pm

        Good post. As an explanation of why everyone “dumps” their chest and abdominal pains on the ER docs, see my comment below.

  5. Vincent
    December 5, 2018 at 10:21 am

    I’m glad that this patient continued fighting the denial of payment by the insurer. That denial is in clear violation of the “prudent layperson” standard. There is another aspect to this story- why is the bill over $12,000? That is an unreasonable amount for determining that her acute pain was not appendicitis. Of course, Anthem didn’t pay that much to the hospital- I’m sure that they reached an arrangement with the hospital to pay much less. Why is the the hospital billing this poor patient so much when the real cost of the services was much less than that? The answer is that the patient is perceived to have no power to fight that unreasonable bill.

  6. RSW
    December 5, 2018 at 8:37 am

    Anthem wants to keep people out of the ER, but they’ve made it impossible for docs to treat acutely ill patients in their offices. They won’t pay for anything (injections, IV fluids, oxygen, etc.) and if you need a stat scan, you have to close down the office for a couple hours trying to get the pre-auth.

  7. JRDO
    December 5, 2018 at 7:08 am

    Why the hospital charged 12.6k for the visit is another issue….

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