Catch-22: Anthem illegally charging ER patients for not being ER docs themselves.

Last August, I woke up at 3am with excruciating pain in my abdomen on my right side. I tried to "walk it off" (bad cramp?), go to the bathroom (bad gas?), force myself to throw up (low-level food poisoning?) and drank a big glass of water (dehydration?) all to no avail. In utter agony, I finally had my wife wake up our son so she could drive me to the emergency room. I was especially worried because of the location of the pain; I feared I might be suffering from appendicitis, which is, of course, potentially deadly if not treated immediately. Even if it wasn't, it hurt like hell.

About five hours, an IV pain medication drip and a CT scan later, I was sent on my way back home with a less serious diagnosis: A kidney stone. Nasty and painful, but not generally fatal (although they can be if left untreated too long, causing sepsis).

A few weeks later I got the bill: $600. Not a lot of fun to pay of course, but it was much better than the official cost of the ER visit: $6,000. BCBSMI paid the other 90% of the cost.

I bring this up because of a disturbing and anger-inducing story by Sarah Kliff over at Vox about how Anthem Inc. has started refusing to pay for emergency room visits for enrollees, usually to the tune of thousands or tens of thousands of dollars, purely because they (Anthem) don't "think" the ER visits are "necessary".

In fact, the lede case study sounds awfully familiar...

Brittany Cloyd was doubled over in pain when she arrived at Frankfort Regional Medical Center’s emergency room on July 21, 2017.

“They got me a wheelchair and wheeled me back to a room immediately,” said Cloyd, 27, who lives in Kentucky.

Cloyd came in after a night of worsening fever and an increasing pain on the right side of her stomach. She called her mother, a former nurse, who thought it sounded like appendicitis and told Cloyd to go to the hospital immediately.

The doctors in the emergency room did multiple tests including a CT scan and ultrasound. They determined that Cloyd had ovarian cysts, not appendicitis. They gave her pain medications that helped her feel better, and an order to follow up with a gynecologist.

OK, obviously the actual diagnosis differed from mine...but that's not the only thing which turned out a bit differently:

A few weeks later, Cloyd received something else: a $12,596 hospital bill her insurance denied — leaving her on the hook for all of it.

“We have a mortgage, we have bills, we have student loans,” says Cloyd, who works for the Kentucky government and has a 7-year-old daughter. “There is absolutely no way I could pay a $12,000 bill. I don’t even have $1,000 sitting around.”

Cloyd has her health insurance coverage through her husband’s job. His company uses Anthem, one of the country’s largest health insurance plans. In recent years, Anthem has begun denying coverage for emergency room visits that it deems “inappropriate” because they aren’t, in the insurance plan’s view, true emergencies.

The problem: These denials are made after patients visit the ER, sometimes based on the diagnosis after seeing a doctor, not on the symptoms that sent them, like in Cloyd’s case.

Kliff's article goes pretty in-depth into the problem, and it's jaw-droppingly awful because the Catch-22 is blatantly obvious: When you're in a lot of pain, or your hand is turning blue, or you have a high fever or whatever, you usually don't know whether it's a "real" emergency or not. Why? Because you're not a trained medical expert with lots of expensive equipment to tell you what's wrong. That's generally why people go to the emergency room in the first place. If they didn't think it was serious, they'd schedule a regular doctor's appointment.

However, as Chicago ER physician Seth Trueger noted this afternoon, Anthem's policy here isn't only horrible on a moral and ethical level, it's flat-out ILLEGAL:

terrible case and great article but doesn’t mention that @AnthemInc’s denial in this case is not just morally despicable but also *unquestionably illegal* @sarahkliff https://t.co/a5RMughrs6

— Seth Trueger (@MDaware) January 29, 2018

the ACA made the prudent layperson standard federal law, see https://t.co/qq5dsVAyTi

— Seth Trueger (@MDaware) January 29, 2018

the prudent layperson standard is exactly what it sounds like: the definition of a medical emergency is that a normal person with an average knowledge of medicine thinks is an emergency – the patient’s symptoms make it an emergency, not the final diagnosis

— Seth Trueger (@MDaware) January 29, 2018

so severe abdominal pain that turns out to be “just” an ovarian cyst is, by definition, an emergency

— Seth Trueger (@MDaware) January 29, 2018

this is both obvious and good: the patient can’t tell if their severe abdominal pain is something terrible and dangerous like appendicitis or something that’s painful but not dangerous

— Seth Trueger (@MDaware) January 29, 2018

notably:

*severe pain alone* is by law a medical emergency

here’s the reg if you’re interested: https://t.co/8T434tBrcx pic.twitter.com/KBu2Ub1VUb

— Seth Trueger (@MDaware) January 29, 2018

oh and it’s written into the legislation, too https://t.co/n6ZbE4nTtr pic.twitter.com/RSXPL0kIQW

— Seth Trueger (@MDaware) January 29, 2018

in fact most states (32+DC) had state prudent layperson standards well before the ACA made it federal

including Indiana https://t.co/Fm2qC5EJT5

— Seth Trueger (@MDaware) January 29, 2018

and once again, this is very important because we shouldn’t expect people to sit at home and worry about whether their severe pain is “just a cyst” or a ruptured appendix or an ovarian cyst causing an ovarian torsion or massive internal bleeding

— Seth Trueger (@MDaware) January 29, 2018

if the patient is acting like a “prudent layperson” and thinks they are having an emergency, then it is an emergency and the insurer has to cover the ER visit.

full stop.

— Seth Trueger (@MDaware) January 29, 2018

which is really important because there is a huge overlap in symptoms between simple benign problems (ovarian cyst) and serious life threatening problems (appendicitis) https://t.co/rLUB9ZldoK

— Seth Trueger (@MDaware) January 29, 2018

@AnthemInc is breaking the law by denying claims based on final diagnoses in cases like this and it is terrible and people will get seriously hurt

— Seth Trueger (@MDaware) January 29, 2018

tons of patients end up with final diagnoses like “acute viral bronchitis” which sound simple

except when the patient is 80 and has CHF and COPD and it could easily be flu or pneumonia or a serious COPD or CHF exacerbation any or all of which could kill them

— Seth Trueger (@MDaware) January 29, 2018

here is a bunch more resources on how worthless and dangerous it is to try to decrease “unnecessary” ER visits https://t.co/E1u0Ni87PY

— Seth Trueger (@MDaware) January 29, 2018

If you were looking for another "quiet" reason to be thankful for the Affordable Care Act, here it is.

Not every insurance carrier is scum, but lord knows Anthem is doing their best here to promote that image.