An ER visit, a $12,000 bill – and a health insurer that wouldn’t pay

https://www.vox.com/policy-and-politics/2018/1/29/16906558/anthem-emergency-room-coverage-denials-inappropriate

by jseliger • 8 years ago

79 101 8 years ago

ohazi2• 8 years ago

This makes my blood boil.

This is the sort of thing that health insurance is supposed to be used for - potentially life-threatening emergencies that need a fast response time, and that may require expensive treatment.

Medical insurance companies are dropping support for expensive ER visits, and instead supporting "preventive care" by only covering a $100 annual checkup instead (which is predictably scheduled, and can often be paid for out of pocket).

What's the fucking point anymore? This is no longer health insurance, this is paying $3000 a year for a $100 checkup. Americans should be rioting in the streets over this.

rvo• 8 years ago

Does your blood not boil that the original charge is of 12 thousand dollar?

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.
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.

For a few tests, the hospital charges 12,000 dollars. How is this sane? People should be rioting over this.

Timshel• 8 years ago

The most crazy thing I find, outside of the cost, is the doctors were uncertain and ordered those tests, but then the insurer say : the tests were negative so we will not pay.

It's not like she decided herself to administer those tests ...

Navarr• 8 years ago

They really should. My wife had a similar issue - charges were not nearly _that_ much.

Albeit, one of the larger ones is STILL in negotiations between the hospital and the insurance company.

gutnor• 8 years ago

The worst thing in all of that is how accepted it became in US culture.

Emergency visit or medical treatment requiring remortgaging, debt or spending otherwise life savings are used as a background plot mechanism.

When I was younger, money was the plot (and that was already depressing enough): valiant doctor fighting to avoid their patient to have crippling debts, but now, often it is part of the background. Of course cancer is going to ruin you, everybody knows that, so let's build drama on top of that. Doctor are uninterested in making it cheaper, all is based around choosing health or money.

ohazi2• 8 years ago

Yes, absolutely, this too is insane.

falcolas2• 8 years ago

The bill was based on what insurance company would pay, or as the opening gambit in a round of negotiations to get the insurance company to pay a reasonable amount. An individual could probably get the hospital to knock a '0' off, but even $1,200 for an emergency room visit is too much to expect a person to pay.

It's been demonstrated that when people have to pay for ER visits, they stop going to the ER. And, from past experience, anytime there is pain in the gut, even doing the "right" thing and going to an urgent care clinic first will get you turned around right away and pointed at the ER.

For the record, I don't agree that it's the "right" thing, but it's required by some insurance companies.

jcadam2• 8 years ago

So we all agree we should be rioting. Good. But, um, I'm afraid I can't take the risk of being injured in a riot - I don't have $12k to blow on a trip to the ER (I spent all my money on premiums). So, y'all go ahead without me.

bufferoverflow• 8 years ago

We recently had to do an ER visit. Simple stitches + observation for 3.5 hours. 4 hours in total. $7,900 billed to the insurance. Looks like they will pay most of it.

What pisses me off is they have some bureaucrat walking around the building, walking into various ER rooms, does absolutely nothing, stays for a minute, leaves, and then it shows up on the bill as $1000 with some nonsensical description.

kamaal• 8 years ago

>How is this sane?

Its just one of those functional test cases, capitalism fails as a system.

Hospitals/Doctors/Clinics look at purchased equipment as something they need to make money on. So they have to keep them working. Its really no different than workers doing in 24x7 shifts to keep machinery in the textile mills working all the time. Human labor is cheap, and money gets made by putting in energy into the machine and selling the output of the machinery for profit. So in this sort of a system, you can only make profit by keeping the machines working, as the human labor required to make them work is cheap, and the profit is made by selling the output, keeping the machines idle means loss.

Its just that when you apply this to a hospital the model breaks down. But most of us are ok with this model if we get to buy jeans pants at Costco for $14.

Insurance as a work around doesn't fix anything in this system as you are just passing around the burden of paying for non-productive output of a process around until some one can bear the loss. And no one will.

8draco8• 8 years ago

My wife had exactly the same issue. We went to ER with pain that looked like appendicitis, but after the tests and a night at the hospital (they checked her in for the night) they found out it was just a cysts and we could go home with some painkillers. The twist to that story is that this happen in UK and on the end of the day we just said a big "Thank you" to whole staff that took care of her and that was it.

Couple days ago there was discussion here on HN, how we, Europeans, are so braging about our health and support for citizens systems but we still earn peanuts in comparison to US. Well this is exactly the reason why I prefer to earn £50k in UK rather than $150k in SV. This $12k bill from the article is not that bad, but it could easily end up with $120k if she would have something that require surgery.

mox1• 8 years ago

It really does seem like Health Insurance is heading in a backwards direction. They cover the small, predictable costs (annual checkups, routine blood tests, etc), but continue to find ways to pay less of the "major" events.

Imagine if your car insurance decided to cover oil changes, but not at fault collisions. That would be asinine.

nonbel• 8 years ago

It is interesting to compare the sentiment in this thread and one from a few days ago: https://news.ycombinator.com/item?id=16208210

When considering whether to get a flu vaccination the recommendations of health insurance companies seem to be treated as gospel...

qserpent2• 8 years ago

I agree that Anthem is in the wrong by denying ER coverage in some cases, but let's keep the discussion free of hyperbole like this:

insurance companies are dropping support for expensive ER visits, and instead supporting "preventive care" by only covering a $100 annual checkup instead

This is quite far from the facts of the story and does not belong in an honest discussion (note: I'm not arguing that Anthem is in the right at all, I'm just arguing that this is not a good description of the situation at all).

Retric4• 8 years ago

If you're an anthem customer you can't safely go to the ER to deal with unknown and possibly life threatening issues.

Saying Known issues are covered is meaningless.

The only response to this is to either sue them or switch coverage because they have failed to provide the services you have paid for.

daxorid• 8 years ago

I'm confused by this response. This is par for the course.

Anecdata: I have never had my insurance company cover anything in the last three years.

The best they ever do is claim to negotiate a slightly lower price, for which I still pay out of pocket.

And when the annual "maximum out of pocket" gets surpassed, they gamble (correctly) that I won't incur the costs associated with litigation when they inevitably continue to deny claims after "maximum out of pocket".

There's very very little we can do.

jbob2000• 8 years ago

I'm reminded of a quote and I forget the author and I'll probably bungle it; "Any long running business eventually becomes indistinguishable from a scam".

eesmith2• 8 years ago

That would imply that all of the companies listed at https://en.wikipedia.org/wiki/List_of_oldest_companies are scams. Which seems excessive.

jpollock2• 8 years ago

It seems the problem is not having urgent care at the same location as the ER. Then you triage at the door and route.

mortenjorck• 8 years ago

I don't understand how this can't be standard operating procedure at an ER. Abdominal pain? Immediately go through a list of questions to determine whether it's an emergency or not. This is just as much in the interest of the hospital, which wants to keep the ER open for life-threatening emergencies, as it is for payors, as it is for patients.

jpollock2• 8 years ago

The problem is that in the USA the ER and urgent care can be two different organisations. The ER has no economic incentive to route customers to urgent care because that is lost revenue.

cobookman• 8 years ago

And then the triager messed up and that person died in route to the other hospital....lawsuit!

benjaminjackman• 8 years ago

While I think this is a good idea, I don't believe it would have worked in this case as the patient was highly symptomatic of a ruptured appendix and should have received Emergency Room attention none-the-less.

benmccann• 8 years ago

Unfortunately, it doesn't seem like a hospital has had an incentive to do that in the past. They make less money by charging urgent care rates instead of emergency rates. They also have shifted liability onto themselves. When they get it wrong and tell someone to go to urgent care instead of the ER and the patient gets sicker or dies they now face increased risk of a lawsuit.

The health insurer in this case is actually changing the incentives for the better. Now the hospital risks not getting paid because they didn't triage up front. Unfortunately the patient is caught in the middle here and doesn't have any good option until a less expensive triage option is developed. Hopefully hospitals will respond to insurers denying ER visits to improve their triage as you've suggested.

lostlogin4• 8 years ago

Then the insurance company should punish the hospital and not the patient. Reimburse the hospital at the urgent care rate until they can provide both services.

codegeek4• 8 years ago

"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."

Story of America. It is sad and pathetic. Insurance companies have too much power and even the doctors/hospitals are helpless for the most part. Yes, it is an entire system that needs to be overhauled.

The game is rigged against the consumer right now. You are never sure what the actual cost of your visit will be until you start receiving the bills which could be months after your visit. How dare you ask how much the visit could cost ? The "Admins" in the ER/hospital/clinic wouldn't even know at that time. Yes they won't.

FireBeyond2• 8 years ago

Not to mention the defensive tone they take. "It's not fair that we are having to "massively overpay" (interesting phrasing) for what could have been handled by routine care".

The insurer takes the view that it's _their_ money, that they earned. When it's their customers that are paying, in the insurance pool, after, and only after, Anthem has already taken its cut.

Yes, it's not as black and white as that, and part of that administration cost is ensuring efficient use of the pool's money, but nonetheless, to read insurers defense of these policies, you'd think they were just trying to defend against lazy/greedy customers and ERs trying to milk them out of their money (and with good reason, because they absolutely do view it as their money once your premiums are paid, and the less they pay out, the less they get to keep - pop quiz, say a pool of 1M people pay $5,000/yr for insurance, with a pool of $5B for benefits, and an insurer takes 10% administration costs. Say this insurance pool only pays out $4B that year. What are the odds that the insurer pays out that $500M back to the pool, or as a dividend/rate reduction? Of course you know the answer. Of course the reality is that in theory such money could be kept in the pool "for a rainy day", leaving aside concepts of reinsurance, etc., but that often doesn't happen either, not when there's bonuses to be paid...).

josecurioso• 8 years ago

What I don't really get is how an ER visit can cost 12000$, did she leave with a lamborghini's door or something? Also stating the obvious, the US health system is a joke.

usaphp• 8 years ago

someone has to pay for all those people working in your insurance company and billing dept of the hospital so they can sort out how much to charge each other.

lotsofpulp• 8 years ago

Or the $400k/year doctors and the people who don’t pay because they can’t pay.

codegeek4• 8 years ago

Bingo!!

gricardo993• 8 years ago

"The doctors in the emergency room did multiple tests including a CT scan and ultrasound"

CT scan is expensive. Each scan (CT, ultrasound) is reviewed by a radio-logical expert (i.e. doctor), plus taking up an ER bed for many hours, lab work, IV medications, etc... It adds up pretty quickly.

I'd love to know how much this actually costs in say Canada, or the UK, and I don't mean to the patient (I know they wouldn't pay much if anything), but the actual cost on the system.

seanp2k22• 8 years ago

If going down this route, we must also ask why a CT scanner costs millions of dollars. Medical equipment costs are equally insane. Basically, the costs of everything in the medical field are greatly inflated because they can be.

lostlogin4• 8 years ago

A CT scan in the middle of the night costs less than US$1000 and the ultrasound is about half that in New Zealand. That’s at a private facility with on call staff. At a public hospital where the staff are on a shift it would be considerably less.

DanBC• 8 years ago

That information is available here, I think:

https://improvement.nhs.uk/resources/national-tariff-1719/

This workbook has a sheet for A&E treatment. https://improvement.nhs.uk/uploads/documents/Copy_of_Annex_A...

A&E prices 2017/18 Return to contents

		Tariff (£)	
    HRG code	HRG name	                             Type 1 and 2 Departments	Type 3 Departments
    Emergency Medicine, Any Investigation with Category 5 Treatment	          322 	63 
    Emergency Medicine, Category 3 Investigation with Category 4 Treatment	  293 	63 
    Emergency Medicine, Category 3 Investigation with Category 1-3 Treatment      212 	63 
    Emergency Medicine, Category 2 Investigation with Category 4 Treatment	  192 	63 
    Emergency Medicine, Category 2 Investigation with Category 3 Treatment	  161 	63 
    Emergency Medicine, Category 1 Investigation with Category 3-4 Treatment      113 	63 
    Emergency Medicine, Category 2 Investigation with Category 2 Treatment	  141 	63 
    Emergency Medicine, Category 2 Investigation with Category 1 Treatment	  130 	63 
    Emergency Medicine, Category 1 Investigation with Category 1-2 Treatment       91 	63 
    Emergency Medicine, Dental Care	                                           82 	63 
    Emergency Medicine, No Investigation with No Significant Treatment   	   63 	63 
    Emergency Medicine, Patient Dead On Arrival	                                   91 	63

Prices in GBP.

seanp2k22• 8 years ago

Someone I know was recently in the hospital for heart surgery. Granted, it’s more involved than a “simple” ER visit, but the total time for the operation was ~7 hours with 4 days of in-hospital recovery after. Total cost: $260k

If you look at the per-hour breakdown it’s insane, even when you consider doctors making $500k+/yr . Consider also the actual hours in contact with a surgeon or doctor vs most of the time that was spent laying in their bed.

I also wanted to note that in every instance I’ve seen where the possibility of insurance is involved, medical care providers will give you a no-questions-asked “cash discount” of 30-40% (typically) just because you’re not the insurance. I basically read this as “we charge them more because we can”.

Also in the US: http://mashable.com/2017/12/14/study-shows-people-call-uber-...

Retric4• 8 years ago

No the 'cash discount' is simply the reduced paperwork and non payment risks on their side.

That 7 hour surgery could have literally hundreds of hours worth of back and forth with insurance companies before they get paid including a lot of doctor time. For most private healthcare providers, paperwork is by far their #1 cost for providing car.

alphabettsy• 8 years ago

This is not true on the cash discount. Usually providers and insurers have negotiated rates that can sometimes be lower than cash pricing. Pricing is usually set high enough that there will be no undercharging and discounts can be given for cash.

With Medicaid for example you may be contracted to be paid $12 for a service, but $14 for Blue Cross and $20 for Anthem. The bill says you charge the $20, but you will only be paid what was agreed upon. The cash pricing is usually based on the highest reimbursement, but can be discounted at the providers discretion.

The models are complex, but there is more work and regulation for processing an insurance claim versus cash.

pxeboot2• 8 years ago

It doesn't cost $12k. The insurance company likely ended up paying less than half that amount.

stickydink• 8 years ago

The insurance company didn't pay anything, that's sort of the point of this article.

VLM3• 8 years ago

Health care is run more professionally than tech and is long term sustainable without so much ageism. That means the labor costs are a little bit higher, and the capex is out of control.

If you go to urgent care and there's no waiting x-ray tech or radiologist, you will wait in line until the local guy clears the backlog, which might take awhile, but you're not at urgent care unless its not a medical emergency, patient in stable condition, etc. Stable condition does not mean you're perfectly thrilled and happy with your health, it means you're not in the dying process.

At the ER they're paying on call for zillions of people and if you need an x-ray and they're busy, then as fast as a radiologist can drive in, one will magically appear. This is very expensive, my buddies obgyn wife got $600 per day just to carry a phone and it takes a heck of a lot more than one OBGYN to do everything an ER could possibly need, and the patients as a group will amortize that cost. My wife's friend's husband is an anesthesiologist and they get closer to $2K per day on call. It adds up and you get maybe two of each of the village people and by the time you're done, running a real hospital means you're burning $100K per day on people who aren't working that day... The patients will pay, of course.

A side dish is the capex, merely replacing a CT scanner machine every 8 or so years will cost about $500/day. Not to run it, not to buy supplies, not to power it, not the real estate cost per square, just buying a new machine every 8 years is $500/day and thats a mid-range cost, obviously MRI are more expensive or ultrasound imaging is a bit less. Regardless if you need it or not, because there's like 200 other machines also very expensive and someone has to pay for all that. Then there's the medication expiration scam, can't ever run out of Advil but when it expires annually you buy more. Departments get remodeled or newly built every decade or so and the going rate seems to be around $10M for a new or remodeled department every decade or two. I would guess its another $100K per day to stock an empty building with the capital goods, even if you barred the doors. The patients will pay, of course.

In tech terms a good analogy is you can get a password reset by the helpdesk at 2am for not too much money, but if you expect a level of service such that you can call at 2am on Christmas morning with a wishlist bug and a new bug free safety-of-human-life qualified release will be shipped immediately while you're on the phone, this is possible only because there are people that really like money... lots and lots and lots of money.

Another way to look at it, is its nice to visit an ER where they never ever say "yeah we could in theory save your life, but we had to save money so no XYZ machine or medication or treatment, too bad" but however nice it is to visit, you're not gonna like the bill. The best medical care money can buy is going to be expensive.

eesmith2• 8 years ago

The problem I have with that interpretation is that we know that other countries - eg, those European countries with nationalized health care - have equivalent or better quality of care than the US, for situations like this, and at less cost.

jacinda• 8 years ago

I had to stay in the hospital for 7 days because I was past my due date and needed monitoring. I had 4 rounds of a drug used overnight to help soften the cervix, one injection of Terbutaline (to stop one long contraction that had caused the baby's heart rate to drop prior to being in real labor), less than 1 bag of pitocin, a few bags of saline and an electronic monitor placed on the baby's head to monitor heart rate once they had descended far enough to make the normal telemetry ineffective.

I did not have an epidural or any pain medication during labor and had a relatively uneventful birth once things actually started moving. The doctor was great, but was only there intermittently until the very end. I needed some stitches but was walking unassisted within a few hours and was discharged early (after a week in the hospital, we really wanted to go home).

Total "bill": over $100,000, most of it covered by insurance. It did not cost them almost $15,000 per night for me to stay there. That's just what they send to the insurance company in this absurd game they play with each other.

awjr2• 8 years ago

I watch what the USA is doing with healthcare, and I see this type of model being foisted upon the UK, and it's terrifying.

I recently got into a twitter spat suggesting that it was foolish of the Conservatives to be reducing spending in social services and the NHS as this was directly attacking their voter base as 70% of pensioners vote Conservative and a poorer NHS directly impacts pensioners more. There have been some articles indicating an extra 120,000 people have died in the UK due to austerity measures. http://www.independent.co.uk/news/health/tory-austerity-deat...

So the question is, is this a deliberate unwritten approach to try and kill off 'costlier' members of society? Is it better to encourage people to be fat and die off quicker, than to exercise, eat healthier, live longer, and create a long term social care cost?

I suspect epidemiological analysis the impact of this sort of policy has on a society demonstrates it kills the weak and infirm as well as the financially 'weak' members of society.

Think Norway got it right. Find a resource, tax it and place the tax in a pension fund. https://en.wikipedia.org/wiki/Government_Pension_Fund_of_Nor... Every resident of Norway is now a millionaire in terms of the social care available to each individual.

FilterSweep2• 8 years ago

So the question is, is this a deliberate unwritten approach to try and kill off 'costlier' members of society? Is it better to encourage people to be fat and die off quicker, than to exercise, eat healthier, live longer, and create a long term social care cost?

Social Darwinism has been a running trope with the Cs. The problem is, Social Darwinism is fun until you're on the chopping block...... and so we now see some odd backpedalling in the 2010s now that some have gotten old.

I'd rather pay more to ensure everyone's livelihood is okay.

greglindahl• 8 years ago

Do you find that calling a large number of people foolish generates a useful discussion, either on Twitter or on Hacker News?

awjr2• 8 years ago

Generally no, but it didn't start out that way. I just highlighted the oddity that a political party that relies on old people was implementing policies that were accelerating the death rates of their core voter group, and that this seemed to be an odd thing to do.

I was then accused of making a shameful statement. Data is data. Policy decisions have impact.

For example, when the government introduced mandatory seat belts, there was a rise in the number of pedestrians killed. People wearing seatbelts felt safer driving faster.

rayiner2• 8 years ago

This is a misleading way to write an article. ER overuse is a thing; ER usage has been rising much faster than the population over the last couple of decades. It’s nkt unreasonable to put policies into place to tamp down in that. But here is the thing: any policy you apply to millions of people will have false positives. Picking out a single instance of where the policy triggered when it shouldn’t have doesn’t do anything to help the reader understand the underlying trade offs.

I had a nurse hotline tell me to go to the ER because my daughter was coughing after swallowing some river water. My insurance company paid the bill. Can I get Vox to write an article about this wasteful use of resources?

empath75• 8 years ago

ER overuse is a thing

The ER department should redirect people to less expensive alternatives if they think the patient isn't actually in an emergency situation. If they can't figure out if it's an actual emergency just by asking a few questions, then how is the patient supposed to know?

harryh3• 8 years ago

The trick is that the ER is financially incentivized to treat as many people as possible. How many businesses do you know of that regularly turn away customers to competitors with cheaper solutions?

skj• 8 years ago

Was the nurse wrong? Aspirating water can cause dry drowning.

rayiner2• 8 years ago

“Dry drowning” is not a real thing: https://www.google.com/amp/s/offspring.lifehacker.com/read-t....

codegeek4• 8 years ago

For me, it is not about ER overuse or not. These types of problems are the symptoms of an overall flaw with the US healthcare system which is that it is no longer about the Doctors and Patients directly. Too many things are decided by the insurance company which leaves patients and doctors both at risk. I personally have doctors in my family who tell me straight that they cannot decide what to charge their patients because ultimately the insurance companies decide that for them.

As far as ER overuse is concerned, sure there are folks who may go to ER for everything but majority don't because ERs are a pain the ass. You may have to wait hours before a real doctor actually sees you unless you are literally bleeding to death on the floor. Nowadays there are urgent care centers that are supposed to be ER replacement for smaller issues but they are severely limited. My wife had a severe headache and we wanted to go to urgent care first but they said to go to ER preferably because they don't have CT scan machines. Not to mention that most urgent care centers are not opened after a certain hour in the evening.

harryh3• 8 years ago

The idea that it should only be about the doctors and the patients is a little strange when you consider the fact that the insurance companies are paying. Of course they are going to get a say!

Your family members that are upset that they can't charge more than the people writing the checks are willing to pay are just like any other business people. All sellers of goods would love to be able to charge higher prices than the market will support.

toomuchtodo2• 8 years ago

I had a nurse hotline tell me to go to the ER because my daughter was coughing after swallowing some river water. My insurance company paid the bill. Can I get Vox to write an article about this wasteful use of resources?

Probably not, because that river water could've killed your daughter, depending on the condition of her immune system and the biological composition of the river water (slower and warmer = more bacteria).

toomuchtodo2• 8 years ago

Replying because I can’t edit.

I don’t care about the downvotes, but if you swim in rivers or lakes, please spend 15 minutes reading about the bacteria present in those bodies of water. They can be lethal, and you need to advocate for your own health to ensure you’re receiving treatment if you’re afflicted. Worst case is you’ve consumed some healthcare services, best case is your child isn’t dying at home in their sleep from a bacterial infection.

lowbloodsugar• 8 years ago

The actual issue is that the USA used to be a productive country with an economy that could absorb these kinds of false positives. Now it can't. This is what that looks like.

autotune• 8 years ago

The important part here is this article probably got the patients ER decision reversed and approved. I would argue that alone is worth the article.

wehadfun• 8 years ago

Whats going on the hospital is charging $12K for maybe 1 hour of actual time spent with the patient. Unless most of that $12K is used to cover the non-paying customers I don't understand how it could cost the hospital that kind of money to provide the care.

I bet over half that money went to people who probably never steeped foot in the hospital much less actually provide care.

jws• 8 years ago

Unless most of that $12K is used to cover the non-paying customers…

The industry term is uncompensated care. It is currently at its lowest levels in decades, about 4.2%.†

I suspect the ACA has something to do with that, so we might expect to see the uncompensated care rise in the coming years as enrollment in insurance shrinks.

␄

† http://www.healthcarefinancenews.com/news/uncompensated-care...

beisner• 8 years ago

My question is, why is the system designed such that she would be admitted to the ER in the first place? Why aren't hospitals redirecting patients to urgent care facilities, or better yet, why don't hospitals have urgent care facilities attached?? If costs in emergency rooms are extremely high - and I can understand why they would be higher to a certain extent - why aren't hospitals employing some sort of dispatch mechanism?

singron• 8 years ago

Urgent care facilities often don't have equipment like a CT scanner, so they can end up redirecting patients to the ER anyway.

FireBeyond2• 8 years ago

The thing is, for acute, severe, lower abdominal pain, the ER -is- the place to go, speaking as a health professional.

While the minor issues (constipation, and the like) are indeed resolvable in urgent care, any serious issue is likely to require some form of surgical intervention.

Additionally, the diagnosis of such issues is likely to require sophisticated imaging. While Urgent Care can use US (ultrasound), CT, possibly with contrasts, and such, are still best handled at an ER.

Most likely this patient would have presented at Urgent Care and be transferred, likely by ambulance, to ER anyway.

Now, do I think there is massive reform required to the healthcare _model_ in the US? Absolutely, including the use of more urgent care models.

I work in the system as a paramedic, and I definitely agree with that, and I realize that your question was more broad, but in this instance, ER was the right place to go, even if the final diagnosis was benign.

michaelt• 8 years ago

If hospitals and medical insurers were run for charity, or out of a genuine desire to help people, you may well expect that.

But hospitals and medical insurance are for-profit businesses. If you're running an ER to maximise profit, and today you make $12,000 off a visit, why would you spend money on urgent care facilities that would make you less money?

rdiddly• 8 years ago

If insurance companies could just get out of this sordid business of paying claims (a.k.a. providing insurance... it's ridiculous, all these darn costs!), they could focus on their core business of collecting premiums like God intended.

tastyfreeze• 8 years ago

Seeing some of the reasons that people go to the emergency room and the cost of going to the emergency room I can understand the reasoning behind the policy. Emergency rooms are often crowded with non-emergent ailments. The problem is there isn't any triage before being admitted to the ER. A kid with a fever and a somebody that cut off their finger get treated the same when walking into the ER. The kid with a fever might get put at low priority but the hospital is still going to charge for the visit and every doctor that stopped in to say hi.

FilterSweep2• 8 years ago

That's a triage problem, not a "user" problem.

They're fun and costly ambulance rides up until that hidden blood clot goes unnoticed.

pxeboot2• 8 years ago

This is an extremely common tactic for insurance companies. Deny claims first, then reverse that decision for the small number of customers who dispute the denial.

ransom1538• 8 years ago

Whatever do you save with your blood, sweat and tears will be burned on medical expenses in the end.

Dayshine• 8 years ago

We cannot approve benefits for your recent visit to the emergency room (ER) for pelvic pain,

Pelvic pain could be an indication of an ectopic pregnancy, that's absolutely a ER indicator!

VLM3• 8 years ago

Its agitprop but the truth is not so ridiculous.

The marketing was terrible, urgent care isn't just for coughs and colds, its its pretty much for anytime you're not actively bleeding or can arrive in something other than an ambulance.

"they’ll have to force me into an ambulance to go to the emergency room"

I'm not seeing the tragedy in that, beyond the horrible marketing rollout. She would have gotten the same care a lot cheaper at urgent care. Where I live its merely a different floor of the hospital, which emphasizes the accounting tricks nature of the situation, a chest xray from urgent care is like $300 but from ER is $3000 for magic accounting reasons. There are no uninsured people in urgent care, which ironically means faster service unless you're so sick you scare the ER nurses, which means you're probably not even conscious.

The problem with the ER is bifurcation of tasks. On one hand, infinite labor and capital to save trauma victims, gunshot wounds, car accidents, industrial accidents. That's gonna be expensive, but if you lost a leg in a horrible accident they can probably save your life. And on the other hand the ER is the free clinic for uninsured coughs and colds and aches and pains, so even more money needs to be dropped on triage and the inevitable legal bills when triage is messed up. A lot of problems with the system could be fixed by separating the "trauma clinic" from the "free clinic" departments. Its very expensive to have the same department handle both gunshot wounds and uninsured painkiller pill addicts.

pseudalopex• 8 years ago

This happened at night in a city of 25,000 people. Going to urgent care may have meant waiting until the morning.

sizzzzlerz• 8 years ago

I'm unclear on what the woman should have done if not go to the ER? Had she tried contacting her doctor first or did they immediately go to the ER? What did the insurance company claim she should have done when experiencing severe abdominal pain, take two aspirin? If it had been appendicitis, would that have warranted an ER visit? Did they expect she would be able to distinguish between the two? And as others have asked, how did this visit cost 12 grand?

falcolas2• 8 years ago

In my experience, when I went to a clinic complaining of gut pain, they turned me right back around and send me to the ER. And this was for a relatively mild pain. I'm not sure if that makes a difference to the insurance, but...

UseStrict• 8 years ago

Could you imagine having chest pain for the first time, going to the hospital, them running the whole suite of tests like an EKGs, X-Ray, full blood panel and the like, then determining it wasn't a heart attack but instead something much less severe like pneumonia? I use that example because that is something I went through, I was able to breathe alright, and didn't have any other illness symptoms, but woke up intense chest pain. Thankfully in Canada there was no issue of coverage, but would Anthem determine pneumonia to be non-emergency care?

What if you went in with chest pain, found out it was pneumonia, then got billed $10,000 for all the tests. Would you think twice about going back to the ER the next time you got chest pain? I think this policy will absolutely kill people. But clearly it's fine because it's only a minority of cases (sarcasm).

lostlogin4• 8 years ago

I agree this policy is terrible but the specific situation you describe appears to be covered according to the article.

A list of codes from Missouri is significantly longer, with more than 1,900 diagnostic codes that could indicate non-emergency visits. The list includes multiple types of “unspecified injuries” and “chest pain on breathing.” When asked about the Missouri list, an Anthem spokesperson said the latter diagnostic code regarding chest pain has since been removed from the list, which has been updated and revised.

WkndTriathlete• 8 years ago

That quote makes me skeptical that any medical professional looked over Anthem's list, because every health care professional I've ever heard of has indicated that chest pain justifies an immediate ER visit.

athenot• 8 years ago

One of the problems is poor primary care and a gap in urgent care. In many cases, patients have no way of getting triage advice over an issue that occurs at 3 AM, leaving with a choice of waiting till morning then going to a doctor (after waiting or scheduling), or going to the ED.

This article is the perfect storm of all these dysfunctions combined:

- no triage available, so went to ED (a sane choice in the absence of medical advice).

- the ED is required to make sure the Patient doesn't have some critical condition, so they will be zealous with tests. It's usually not a motivation for profit, it's a desire to make sure they don't miss some condition that may be less common but could cost the life of the patient. That risk assessment is usually different from what many patients are willing to accept.

- the insurer is trying to curb on unnecessary ED visits which, unfortunately is a problem many EDs face. Having a team of critical care workers tend to benign issues is terribly inefficient for both the patient and the hospital. The hospital passes the bill to the insurer who is then scratching their heads when they see so many resources used to treat something so benign.

Now of course there's the issue of very critical issues that present with very generic symptoms: your head ache could be a simple dehydration or some busted blood vessel in the brain; the ED will have to rule out the latter before declaring it to be a non-consequential headache. This is why traditionally insurers have paid up without much of a fuss. But we need to fix all these problems.

If 24h urgent care were more readily available (via tele-health AND in-person), a lot of this could be avoided.

jcadam2• 8 years ago

Yep, I got stuck with a $1000 ER bill because the insurance company decided I wasn't experiencing an emergency and covered me at a reduced rate of 80% or some such.

Despite the fact that I was admonished by both the doctor and the nurses for not calling 911 (I was basically unable to stand/walk and somebody else drove me). This was the one time I had zero wait time when walking into the ER. The staff took one look at me when I staggered in (holding a spent epi-pen), shoved me into a weelchair and wheeled me into the back.

It was apparently coded as allergic reaction, non-emergency. No amount of arguing with either the insurance company or the hospital rectified it, so I ended up paying.

In the end turns out it wasn't an allergic reaction at all, I had undiagnosed asthma (finally figured that out about a year after this incident - had to go through many different doctors until I found someone competent), fun!

firefoxd• 8 years ago

There will need to be a Rosa Parks in the insurance world and suddenly people will realize this is a radically unfair treatment.

Almost everyone knows someone who received a single bill that ruined them, yet we brush it off as a one off.

thirdsun• 8 years ago

The sad thing is that this is a non-issue in most of the rest of the world. When we europeans have to visit a hospital or doctor, the only thing we worry about is our health.

Potential for improvement aside, health insurance is a solved problem in countless countries and the US is refusing to learn from others in this matter. It's painful to watch, even from afar.

wiredfool• 8 years ago

I have two recommendations for anyone in this situation:

1) Talk with the state insurance commissioner. Make sure that your paperwork is in order, and then file a formal complaint. Mentioning this when talking to insurance company reps will get you booted upwards to people who are more able to help you so that the to make their problem go away.

2) If you have a case that's a clear compelling class, talk to a lawyer after the first appeal.

Background: My son had some prescribed therapy for a mental health condition that I was told would be covered when I talked to the insurance company. They subsequently denied the claims, then backpedaled on the first month because "I'd been told that they'd be covered.", but the subsequent months were not covered. I was left with a several thousand dollar bill. Washington State has the Mental Health Parity act, which states that mental health treatments must be covered to the same extent as rehab or surgical treatments. The insurance company ended up losing 2 class action suits, (a federal and a state) and paying $6.4M to repay all the class member's denied claims and an agreement to not deny claims in the future.

joncrane• 8 years ago

I'm cynical enough to believe that the insurance company did a cost/benefit analysis beforehand and understood the regulatory risks of denying that coverage, and in the end, they still saved more than $6.4 million in denied claims to people who didn't have their *%it together enough to be part of the class-action.

mnm1• 8 years ago

Yup, and this is nothing new. In 2008 they tried to decline paying for my emergency treatment and ambulance. I was unconscious, but the ambulance was out of network and therefore I should have chosen one that was in network while unconscious. Then they wanted to not pay for the actual emergency room trip despite the fact that I spent the night there. Only numerous appeals over half a year and the patience of the staff at the hospital helped me to finally resolve this without hitting collections for a few thousand dollars. There will come a point when people are simply fed up with companies like this and they will literally demand blood. I hope scummy companies like this remember that.

Chardok• 8 years ago

I am so fed up with the healthcare situation here. It is absolutely terrifying how this is remotely legal or even acceptable.

The game theory is plainly there: people are going to question or refuse to seek emergency treatment simply because they will be afraid of the cost. Now you get to add the stress of which type of care you should be getting, in the middle of a fucking scary medical emergency!

ordinaryperson• 8 years ago

A policy against frivolous ER visits isn't necessarily a bad thing, it's that Anthem's system for determining what's frivolous was obviously flawed in this case.

Side-splitting abdominal pain is a valid reason to go to the ER. But doesn't mean it's not sensible for Anthem to have a policy against footing the bill for ER visits for ingrown toenails -- an ER doc in Australia was recently telling me too much of his day is wasted seeing patients who aren't really sick, since Australia has a more generous healthcare system.

But to me the bigger issue is a noninvasive visit to the ER cost 12K. It's easy to get riled up about a cabal of penny-pinching insurers cackling on their pile of gold coins while people suffer, but how does the hospital get off blame-free for that kind of gross overbilling?

I'm no fan of the business practices of insurers. But insurance is not magic beans. The money doesn't just fall from the sky. If everyone on the plan goes for 12K ER visits the premiums are going to skyrocket for everyone else. Realistically they have to reign in costs somehow, it's just a matter of finding an ethical balance.

Someone in the industry told me Anthem makes the most money of any insurer and its profit margin is 3%. Most of the profit is being captured elsewhere in the chain.

iLemming• 8 years ago

I had a bicycle accident once. My arm got swollen. I called nearby offices and couldn't find a single doctor who could see me immediately. I went to ER hoping they'd give me some ointment or whatever to sooth the pain.

I refused to undergo x-ray scanning (somehow I was sure there's nothing broken). And it's a good thing that I didn't go to the radiology block.

After about 50 minutes of waiting, doctor came and offered me bacitracin. I asked if there's anything stronger than that, alas there was nothing else he could offer me. I shrugged and said "alright then". Doctor applied it all over my arm and said it should be like that: "don't cover it!". With that I went home. Bacitracin didn't help a bit. The pain was so strong, so I couldn't sleep for a few days.

Week later I got a bill. They charged $2800. Insurance covered only $1200 of that. I tried to dispute it to no avail.

I learned my lesson - in the US, you never, ever should go to ER. Unless there's a knife sticking out of your skull. But even then you should maybe re-consider.

threatofrain• 8 years ago

While your experience is shockingly expensive, I think if you refuse to get an x-ray following a bike accident and swollen arm, then you're basically omitting a major source of information.

An ER visit, a $12,000 bill – and a health insurer that wouldn’t pay

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