WEBVTT - Can an Insurance Company Label an ER Visit 'Avoidable'? 0:00:02.040 --> 0:00:07.080 Welcome to brain Stuff from How Stuff Works, Hey, brain Stuff, 0:00:07.160 --> 0:00:10.240 Lauren Bogle bam here. Navigating the health care system is 0:00:10.320 --> 0:00:13.440 already pretty dicey, and a new program put forth by 0:00:13.440 --> 0:00:16.640 insurance giant Anthem is muddying the waters even more for some. 0:00:17.280 --> 0:00:20.640 Known as the Emergency Department Review, the company's program launched 0:00:20.640 --> 0:00:24.239 in teen with the intent of reducing unnecessary visits to 0:00:24.280 --> 0:00:27.880 the nation's emergency rooms. In and of itself, the idea 0:00:28.000 --> 0:00:31.240 isn't such a bad thing, since emergency departments are sometimes 0:00:31.240 --> 0:00:35.440 ill used. Report found thirty eight billion dollars per year 0:00:35.440 --> 0:00:39.280 in wasteful spending thanks to emergency department over use. However, 0:00:39.520 --> 0:00:42.080 per Anthem's policy, if a person goes to the emergency 0:00:42.120 --> 0:00:44.559 department with symptoms or a condition that turns out to 0:00:44.560 --> 0:00:47.080 not be life threatening, they could wind up holding the 0:00:47.120 --> 0:00:50.000 bag for a whole lot of money. We spoke with 0:00:50.080 --> 0:00:54.760 Christina Gaines, communications director for Anthem Incorporated, via email. She 0:00:54.840 --> 0:00:57.800 said if a consumer chooses to receive care for non 0:00:57.840 --> 0:01:01.040 emergency conditions at the emergency department, when a more appropriate 0:01:01.040 --> 0:01:04.760 setting is available, Anthem will request more information, including additional 0:01:04.800 --> 0:01:07.200 medical records from the hospital and a statement from the 0:01:07.200 --> 0:01:09.759 consumer as to why they went to the emergency department. 0:01:10.160 --> 0:01:13.000 Then an anthem medical director will review the additional information 0:01:13.160 --> 0:01:16.440 using the Prudent lay Person standard, and the claim might 0:01:16.480 --> 0:01:19.039 be denied as not a covered service. In the event 0:01:19.080 --> 0:01:21.520 of consumers claim is denied, they have the right to appeal. 0:01:23.480 --> 0:01:26.320 Much of the controversy surrounding this program lies with that 0:01:26.360 --> 0:01:30.279 Prudent lay person standard, Gains mentioned. The standard was enacted 0:01:30.280 --> 0:01:33.800 by the US Congress back in with forty seven states 0:01:33.800 --> 0:01:36.440 opting to work it into state law as well. It 0:01:36.480 --> 0:01:38.400 was done to add a layer of protection for healthcare 0:01:38.480 --> 0:01:40.840 consumers so they can seek care without working up a 0:01:40.920 --> 0:01:45.040 huge emergency department bill. We also spoke via email with 0:01:45.120 --> 0:01:48.960 Dr David Farcie, president of the American Academy of Emergency Medicine. 0:01:49.520 --> 0:01:52.800 He said the Prudent lay Person standard requires health insurance 0:01:52.800 --> 0:01:55.600 companies to cover visits based on the patient's symptoms, not 0:01:55.720 --> 0:01:58.880 the final diagnosis. This means if a patient has chest 0:01:58.920 --> 0:02:01.080 pain but turns out to have a non urgent medical 0:02:01.080 --> 0:02:04.480 condition such as gastritis or muscular pain, the insurance company 0:02:04.600 --> 0:02:07.120 must still cover the visit. We have a duty to 0:02:07.120 --> 0:02:09.840 safeguard patients and cannot expect our patients who have little 0:02:09.840 --> 0:02:12.080 to no medical training to be doctors and know the 0:02:12.080 --> 0:02:15.000 difference between a minor or life and death medical condition. 0:02:15.520 --> 0:02:18.320 Anthem is forcing the patients to be doctors in completely 0:02:18.360 --> 0:02:22.520 disregard federal and state laws to protect patients. Anyone who's 0:02:22.520 --> 0:02:25.880 ever been in a potential emergency situation knows that sometimes 0:02:25.960 --> 0:02:29.160 the most logical choice isn't always the most obvious. This 0:02:29.280 --> 0:02:31.440 is further convoluted by a health care system in which 0:02:31.480 --> 0:02:34.040 it's often difficult, if not impossible, for a person to 0:02:34.040 --> 0:02:36.880 see a primary care physician or specialist in a timely manner, 0:02:37.280 --> 0:02:40.399 hence emergency department visits that could have been handled elsewhere. 0:02:41.720 --> 0:02:44.640 Such was nearly the case for nurse practitioner Amanda Gorman. 0:02:45.160 --> 0:02:47.200 She recalled, I was almost forced to go to the 0:02:47.280 --> 0:02:49.880 emergency room this week because of a kidney stone and 0:02:49.919 --> 0:02:53.200 couldn't get a new appointment with a urologist. Gorman is 0:02:53.200 --> 0:02:54.800 married to a physician and was trying to go to 0:02:54.840 --> 0:02:58.000 the hospital where her husband works. She said, so if 0:02:58.000 --> 0:03:00.360 we're having trouble navigating this, I can't badge of the 0:03:00.360 --> 0:03:04.520 struggles for regular patients. Gorman ended up finding an appointment 0:03:04.520 --> 0:03:08.280 with an out of network specialist, potentially costly risk in itself. 0:03:08.360 --> 0:03:10.600 She estimated that it was about six times as expensive 0:03:10.600 --> 0:03:12.240 as an e R cope would have been, but she 0:03:12.280 --> 0:03:14.000 didn't want to deal with the hassle of an e R. 0:03:15.520 --> 0:03:18.720 Many emergency medicine experts don't mince words about the potentially 0:03:18.800 --> 0:03:22.160 damaging effects of the plan. We spoke with Dr Ryan Stanton, 0:03:22.320 --> 0:03:25.359 a Lexington, Kentucky based emergency physician and spokesman for the 0:03:25.400 --> 0:03:28.320 American College of Emergency Physicians the a c e P. 0:03:29.320 --> 0:03:32.200 He said this will harm people and lead to injuries 0:03:32.200 --> 0:03:35.040 and deaths. The goal of this program is not the denials, 0:03:35.120 --> 0:03:37.800 it's about the fear people will be afraid to seek 0:03:37.840 --> 0:03:42.040 emergency care. A CEP feels this policy is incredibly dangerous 0:03:42.040 --> 0:03:44.080 and puts people at risk in the name of profits. 0:03:44.480 --> 0:03:46.320 I've talked to a number of people that were denied, 0:03:46.320 --> 0:03:48.520 and the common theme is how upset they were, but 0:03:48.560 --> 0:03:50.480 more importantly, they are now afraid to go to the 0:03:50.520 --> 0:03:53.440 emergency department even if they feel they have an emergency. 0:03:53.720 --> 0:03:56.640 Many conditions present with similar symptoms, whether they wind up 0:03:56.640 --> 0:04:00.600 being benign or truly life threatening. Stanton said, chess pain 0:04:00.640 --> 0:04:03.480 can be a heart attack or heartburn. Abdominal pain can 0:04:03.480 --> 0:04:06.120 be a pendicitis or gas. A headache can be a 0:04:06.200 --> 0:04:09.600 ruptured aneurysm or a hangover. The challenge with medicine is 0:04:09.600 --> 0:04:11.720 that it deals in shades of gray and rarely black 0:04:11.800 --> 0:04:13.840 or white. The key is that if you feel your 0:04:13.880 --> 0:04:16.040 life or health or at risk, go to the e ER. 0:04:17.800 --> 0:04:20.839 Not everyone thinks Anthem's program is completely off base, though. 0:04:21.360 --> 0:04:23.960 Lindsay Artola is a health policy expert with Sage Health 0:04:24.000 --> 0:04:26.760 Strategy who supports some type of penalty for unnecessary use 0:04:26.800 --> 0:04:30.440 of the emergency department. She said via email, the emergency 0:04:30.520 --> 0:04:33.120 room is by far the most expensive way to get healthcare, 0:04:33.360 --> 0:04:36.280 and with the advent of urgent care centers, nurse triage lines, 0:04:36.320 --> 0:04:39.000 and other alternatives, it's a poor use of health system 0:04:39.040 --> 0:04:41.159 resources for folks to use the e R as a 0:04:41.200 --> 0:04:44.640 primary care office. I think a financial penalty for misuse 0:04:44.640 --> 0:04:49.159 of health system resources isn't necessarily a bad idea. So 0:04:49.320 --> 0:04:51.840 how bad is the problem of misusing the e R? 0:04:52.400 --> 0:04:55.600 Statistics very widely? A study using data from e ER 0:04:55.680 --> 0:04:58.600 visits from two thousand five eleven found that only three 0:04:58.600 --> 0:05:01.400 point three percent of e R visit were avoidable, which 0:05:01.440 --> 0:05:04.800 is in line with the CDC statistic of five point 0:05:04.839 --> 0:05:09.119 five percent. Meanwhile, Truven Health Analytics, drawing on insurance claims 0:05:09.160 --> 0:05:12.640 data from said that seventy of e R visits were 0:05:12.680 --> 0:05:17.000 unnecessary and avoidable. Clearly, the word avoidable has different meanings 0:05:17.000 --> 0:05:21.720 for different people. Anthem spokesperson Gains said consumers who reasonably 0:05:21.760 --> 0:05:24.719 believe that they are experiencing an emergency medical condition should 0:05:24.720 --> 0:05:27.480 always go to the emergency room or call nine one one. 0:05:27.920 --> 0:05:30.640 She points out that Anthem will always cover emergency department 0:05:30.680 --> 0:05:34.359 visits under certain conditions. For example, if a consumer was 0:05:34.360 --> 0:05:37.880 directed to the emergency room by provider, including an ambulance provider, 0:05:38.200 --> 0:05:40.640 if the patient is under the age of fifteen, if 0:05:40.640 --> 0:05:43.000 the patient's home address is greater than fifteen miles from 0:05:43.000 --> 0:05:45.760 an urgent care center, if the visit occurred during off 0:05:45.800 --> 0:05:48.760 hours that's between eight p m Saturday and eight am Monday, 0:05:49.040 --> 0:05:51.760 or on a major holiday. If the patient received surgery 0:05:51.800 --> 0:05:53.960 I V fluids, I V medications or an m R 0:05:54.040 --> 0:05:56.920 I or CT scan, or if the patient had conditions 0:05:56.960 --> 0:06:00.520 such as chess pain, difficulty breathing, convulsions, fainting, or was 0:06:00.560 --> 0:06:04.919 experiencing a drug overdose. Many of these exemptions were added 0:06:04.960 --> 0:06:09.200 in January eighteen after public objections to the original policy 0:06:09.640 --> 0:06:13.000 it gains. Adds that Anthem's Emergency Department program is currently 0:06:13.040 --> 0:06:17.599 in effect in five states Missouri, Georgia, Ohio, Kentucky, and Indiana, 0:06:17.960 --> 0:06:25.760 with no current plans to extend its reach. Today's episode 0:06:25.800 --> 0:06:28.000 was written by Elliot Hoyt and produced by Tyler Clang 0:06:28.040 --> 0:06:30.200 for iHeart Media and How Stuff Works. For more on 0:06:30.240 --> 0:06:32.240 this and lots of other topics, visit our home planet, 0:06:32.320 --> 0:06:44.960 how stuff Works dot com.