All posts tagged financial

Anthem asks Missourians to think twice before going to the emergency room – KCUR

Anthem Blue Cross Blue Shield, one of Missouris largest insurers, no longer covers emergency room visits that it deems unnecessary.

The policy aims to save costs and direct low-risk patients to primary care physicians and urgent care clinics. But doctors say patients may avoid going to a hospital when they really need it, if they fear a large bill.

Theyre forcing the lay public to make a medical determination, said Dr. Doug Char, a Washington University emergency physician. Theyre basically telling people you have to decide if this chest pain youre having is indigestion or a heart attack.

An emergency room is the most expensive place to see a doctor, and insurers are balking at the cost. Between 15 percent and 30 percent of emergency room visits in the St. Louis region are avoidable, according to a study by the nonprofit Midwest Health Initiative. Missouri hospitals charge an average of $372 for emergency room visits for minor issues, but some charge as much as $1,300, according to data compiled by the Missouri Hospital Association.

“Most non-emergent medical conditions can be easily treated at retail clinics, urgent care clinics or 24/7 telehealth services,” Anthem’s Missouri spokesperson, Scott Golden, wrote in an email. “The review by an Anthem medical director will take into consideration the presenting symptoms that brought the member to the emergency room as well as the diagnosis.”

In mid-May, Anthem sent letters to Missouri enrollees to alert them that from June 1, it would no longer cover emergency room services for non-emergencies. In such cases, people who have health insurance could still be stuck with the full cost of their visit, if the insurer determines that their symptoms did not reach the level of requiring emergency care.

Anthem enforces the same guidelines in Kentucky, and put the rule in place for Georgia policyholders this month. Its officials say there are several exceptions, such as if a patient is under 14, the visit occurs on a Sunday or there are no urgent-care centers within 15 miles.

The American College of Emergency Physicians raised a red flag when Anthem sent out a spreadsheet of 1,908 conditions that it may not deem worthy of coverage in an emergency room. Some of the listed symptoms could indicate a life-threatening emergency, said Dr. Jonathan Heidt, president of Missouris ACEP chapter.

To have them under that threat of not having their bills paid if theyre wrong about what their diagnosis is, its really going to harm patients in the long run, Heidt said. Our patients have a right to seek emergency care.

The doctors argue that Anthems policy, and similar rules set up by state Medicaid programs, violate the federal Affordable Care Acts prudent layperson standard. The rule asserts that a person with average knowledge of health and medicine should be able to anticipate serious impairment to his or her health in an emergency, and that laws should not assume that a person will know more than that. Anthem contends that it reviews claims using this standard already.

Though Anthem began enforcing the Missouri rule at the beginning of June, patients who visit the emergency room for non-emergencies likely will receive bills in the coming months. Heidt said that if Anthem does not reconsider its policy, ACEP may weigh legal action against the insurer.

Were still a little bit early for that,” Heidt said. “But at this time, all of our options are on the table.

According to the Missouri Department of Insurance, Financial Institutions & Professional Registration, the rule is based on previously filed language that was approved by the regulator. Other plans have similar provisions.

“If a consumer believes a claim has been improperly denied, or has questions about how a claim has been handled by their insurer, they can contact the Department’s Consumer Affairs Hotline at 800-726-7390 or they can file a complaint online,” said Grady Martin, the agency’s director of administration.

Follow Durrie on Twitter: @durrieB

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Anthem asks Missourians to think twice before going to the emergency room – KCUR

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Anthem asks Missourians to think twice before going to the … – St. Louis Public Radio

Anthem Blue Cross Blue Shield, one of Missouris largest insurers, no longer covers emergency room visits that it deems unnecessary.

The policy aims to save costs and direct low-risk patients to primary care physicians and urgent care clinics. But doctors say patients may avoid going to a hospital when they really need it, if they fear a large bill.

Theyre forcing the lay public to make a medical determination, said Dr. Doug Char, a Washington University emergency physician. Theyre basically telling people you have to decide if this chest pain youre having is indigestion or a heart attack.

An emergency room is the most expensive place to see a doctor, and insurers are balking at the cost. Between 15 percent and 30 percent of emergency room visits in the St. Louis region are avoidable, according to a study by the nonprofit Midwest Health Initiative. Missouri hospitals charge an average of $372 for emergency room visits for minor issues, but some charge as much as $1,300, according to data compiled by the Missouri Hospital Association.

“Most non-emergent medical conditions can be easily treated at retail clinics, urgent care clinics or 24/7 telehealth services,” Anthem’s Missouri spokesperson, Scott Golden, wrote in an email. “The review by an Anthem medical director will take into consideration the presenting symptoms that brought the member to the emergency room as well as the diagnosis.”

In mid-May, Anthem sent letters to Missouri enrollees to alert them that from June 1, it would no longer cover emergency room services for non-emergencies. In such cases, people who have health insurance could still be stuck with the full cost of their visit, if the insurer determines that their symptoms did not reach the level of requiring emergency care.

Anthem enforces the same guidelines in Kentucky, and put the rule in place for Georgia policyholders this month. Its officials say there are several exceptions, such as if a patient is under 14, the visit occurs on a Sunday or there are no urgent-care centers within 15 miles.

The American College of Emergency Physicians raised a red flag when Anthem sent out a spreadsheet of 1,908 conditions that it may not deem worthy of coverage in an emergency room. Some of the listed symptoms could indicate a life-threatening emergency, said Dr. Jonathan Heidt, president of Missouris ACEP chapter.

To have them under that threat of not having their bills paid if theyre wrong about what their diagnosis is, its really going to harm patients in the long run, Heidt said. Our patients have a right to seek emergency care.

The doctors argue that Anthems policy, and similar rules set up by state Medicaid programs, violate the federal Affordable Care Acts prudent layperson standard. The rule asserts that a person with average knowledge of health and medicine should be able to anticipate serious impairment to his or her health in an emergency, and that laws should not assume that a person will know more than that. Anthem contends that it reviews claims using this standard already.

Though Anthem began enforcing the Missouri rule at the beginning of June, patients who visit the emergency room for non-emergencies likely will receive bills in the coming months. Heidt said that if Anthem does not reconsider its policy, ACEP may weigh legal action against the insurer.

Were still a little bit early for that,” Heidt said. “But at this time, all of our options are on the table.

According to the Missouri Department of Insurance, Financial Institutions & Professional Registration, the rule is based on previously filed language that was approved by the regulator. Other plans have similar provisions.

“If a consumer believes a claim has been improperly denied, or has questions about how a claim has been handled by their insurer, they can contact the Department’s Consumer Affairs Hotline at 800-726-7390 or they can file a complaint online,” said Grady Martin, the agency’s director of administration.

Follow Durrie on Twitter: @durrieB

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Anthem asks Missourians to think twice before going to the … – St. Louis Public Radio

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Anthem asks Missourians to think twice before going to the emergency room – St. Louis American

(St. Louis Public Radio) – Anthem Blue Cross Blue Shield, one of Missouris largest insurers, no longer covers emergency room visits that it deems unnecessary.

The policy aims to save costs and direct low-risk patients to primary care physicians and urgent care clinics. But doctors say patients may avoid going to a hospital when they really need it, if they fear a large bill.

Theyre forcing the lay public to make a medical determination, said Dr. Doug Char, a Washington University emergency physician. Theyre basically telling people you have to decide if this chest pain youre having is indigestion or a heart attack.

An emergency room is the most expensive place to see a doctor, and insurers are balking at the cost. Between 15 percent and 30 percent of emergency room visits in the St. Louis region are avoidable, according to a study by the nonprofit Midwest Health Initiative. Missouri hospitals charge an average of $372 for emergency room visits for minor issues, but some charge as much as $1,300, according to data compiled by the Missouri Hospital Association.

“Most non-emergent medical conditions can be easily treated at retail clinics, urgent care clinics of 24/7 telehealth services,” Anthem’s Missouri spokesperson, Scott Golden, wrote in an email. “The review by an Anthem medical director will take into consideration the presenting symptoms that brought the member to the emergency room as well as the diagnosis.”

In mid-May, Anthem sent letters to Missouri enrollees to alert them that from June 1, it would no longer cover emergency room services for non-emergencies. In such cases, people who have health insurance could still be stuck with the full cost of their visit, if the insurer determines that their symptoms did not reach the level of requiring emergency care.

Anthem enforces the same guidelines in Kentucky, and put the rule in place for Georgia policyholders this month. Its officials say there are several exceptions, such as if a patient is under 14, the visit occurs on a Sunday or there are no urgent-care centers within 15 miles.

The American College of Emergency Physicians raised a red flag when Anthem sent out a spreadsheet of 1,908 conditions that it may not deem not worthy of coverage in an emergency room. Some of the listed symptoms could indicate a life-threatening emergency, said Dr. Jonathan Heidt, president of Missouris ACEP chapter.

To have them under that threat of not having their bills paid if theyre wrong about what their diagnosis is, its really going to harm patients in the long run, Heidt said. Our patients have a right to seek emergency care.

The doctors argue that Anthems policy, and similar rules set up by state Medicaid programs, violate the federal Affordable Care Acts prudent layperson standard. The rule asserts that a person with average knowledge of health and medicine should be able to anticipate serious impairment to his or her health in an emergency, and that laws should not assume that a person will know more than that. Anthem contends that it reviews claims using this standard already.

Though Anthem began enforcing the Missouri rule at the beginning of June, patients who visit the emergency room for non-emergencies likely will receive bills in the coming months. Heidt said that if Anthem does not reconsider its policy, ACEP may weigh legal action against the insurer.

Were still a little bit early for that,” Heidt said. “But at this time, all of our options are on the table.

According to the Missouri Department of Insurance, Financial Institutions & Professional Registration, the rule is based on previously filed language that was approved by the regulator. Other plans have similar provisions.

“If a consumer believes a claim has been improperly denied, or has questions about how a claim has been handled by their insurer, they can contact the Department’s Consumer Affairs Hotline at 800-726-7390 or they can file a complaint online,” said Grady Martin, the agency’s director of administration.

Republished with permission of St. Louis Public Radio: http://news.stlpublicradio.org/post/anthem-asks-missourians-think-twice-going-emergency-room

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Anthem asks Missourians to think twice before going to the emergency room – St. Louis American

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Anthem asks Missourians to think twice before going to the emergency room – KBIA

Anthem Blue Cross Blue Shield, one of Missouris largest insurers, no longer covers emergency room visits that it deems unnecessary.

The policy aims to save costs and direct low-risk patients to primary care physicians and urgent care clinics. But doctors say patients may avoid going to a hospital when they really need it, if they fear a large bill.

Theyre forcing the lay public to make a medical determination, said Dr. Doug Char, a Washington University emergency physician. Theyre basically telling people you have to decide if this chest pain youre having is indigestion or a heart attack.

An emergency room is the most expensive place to see a doctor, and insurers are balking at the cost. Between 15 percent and 30 percent of emergency room visits in the St. Louis region are avoidable, according to a study by the nonprofit Midwest Health Initiative. Missouri hospitals charge an average of $372 for emergency room visits for minor issues, but some charge as much as $1,300, according to data compiled by the Missouri Hospital Association.

“Most non-emergent medical conditions can be easily treated at retail clinics, urgent care clinics of 24/7 telehealth services,” Anthem’s Missouri spokesperson, Scott Golden, wrote in an email. “The review by an Anthem medical director will take into consideration the presenting symptoms that brought the member to the emergency room as well as the diagnosis.”

In mid-May, Anthem sent letters to Missouri enrollees to alert them that from June 1, it would no longer cover emergency room services for non-emergencies. In such cases, people who have health insurance could still be stuck with the full cost of their visit, if the insurer determines that their symptoms did not reach the level of requiring emergency care.

Anthem enforces the same guidelines in Kentucky, and put the rule in place for Georgia policyholders this month. Its officials say there are several exceptions, such as if a patient is under 14, the visit occurs on a Sunday or there are no urgent-care centers within 15 miles.

The American College of Emergency Physicians raised a red flag when Anthem sent out a spreadsheet of 1,908 conditions that it may not deem not worthy of coverage in an emergency room. Some of the listed symptoms could indicate a life-threatening emergency, said Dr. Jonathan Heidt, president of Missouris ACEP chapter.

To have them under that threat of not having their bills paid if theyre wrong about what their diagnosis is, its really going to harm patients in the long run, Heidt said. Our patients have a right to seek emergency care.

The doctors argue that Anthems policy, and similar rules set up by state Medicaid programs, violate the federal Affordable Care Acts prudent layperson standard. The rule asserts that a person with average knowledge of health and medicine should be able to anticipate serious impairment to his or her health in an emergency, and that laws should not assume that a person will know more than that. Anthem contends that it reviews claims using this standard already.

Though Anthem began enforcing the Missouri rule at the beginning of June, patients who visit the emergency room for non-emergencies likely will receive bills in the coming months. Heidt said that if Anthem does not reconsider its policy, ACEP may weigh legal action against the insurer.

Were still a little bit early for that,” Heidt said. “But at this time, all of our options are on the table.

According to the Missouri Department of Insurance, Financial Institutions & Professional Registration, the rule is based on previously filed language that was approved by the regulator. Other plans have similar provisions.

“If a consumer believes a claim has been improperly denied, or has questions about how a claim has been handled by their insurer, they can contact the Department’s Consumer Affairs Hotline at 800-726-7390 or they can file a complaint online,” said Grady Martin, the agency’s director of administration.

Follow Durrie on Twitter: @durrieB

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Anthem asks Missourians to think twice before going to the emergency room – KBIA

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Thomas Memorial to crack down on emergency room admissions … – The Exponent Telegram (press release) (registration)

Beginning in July, officials at Thomas Memorial Hospital in South Charleston will be changing the rules for admission to try to discourage patients from going to the emergency room for non-emergencies.

We have a tremendous number of people who seek care in our emergency room on a regular basis, said Dan Lauffer, CEO of Thomas Health System. But he said many of them dont have to go to the emergency room, and many would be better served by going to a health clinic, urgent care center or to their regular doctor.

According to Lauffer, about 35,000 people a year visit Thomas Memorials emergency room. But between 30 and 40 percent of those patients arent really experiencing a medical emergency and would be better served by visiting a health clinic, urgent care or doctor.

Lauffer said patients at the emergency room who dont have real medical emergencies jam up the system and create longer wait times for everyone. So, during July and August the hospital will put into place new patient policies designed to discourage those without medical emergencies from going to the emergency room, and encourage them to seek other forms of care.

To begin with, Lauffer said those coming to the emergency room with non-medical emergencies will be asked to pay a co-pay before they will be seen. Thomas ER co-pays begin at $8 for Medicaid patients and go up from there based on a patients insurance coverage.

Lauffer said emergency room visits are about four times as expensive as other medical services, and wait times tend to be much longer before patients can see a doctor. Co-pays for emergency room visits also tend to be higher than co-pays at clinics, urgent care centers and doctors offices.

Visiting a doctor or a clinic before an emergency occurs is also better for a patients overall health, Lauffer said. Routine follow-up care with a doctor is better for your health than episodic visits to the emergency room, he said.

Regular medical care is also usually cheaper than relying on the emergency room, he said. Were also concerned about their financial health, Lauffer said.

In addition to being asked to pay co-pays up front, Lauffer said patients coming to the emergency room without a real emergency will be given a choice about how they would like to be seen. He said patients will be told they can go to Thomas nearby medical clinic and be seen in the order they arrived, or they can remain in the emergency room but be bumped toward the bottom of the list to be seen in the order of the severity of their injuries.

Thomas staff will be telling patients about the new rules during July and August.

Thomas said many patients are just so used to going to the emergency room for every medical issue they may have that they dont give it a second thought. He said education is the key to breaking the emergency room cycle.

If we dont communicate and educate, the cycle will never change, he said. Once patients are told there may be better, cheaper ways to seek health care than the emergency room, They will begin to understand that they dont have to come into the emergency room for every problem they present with.

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Thomas Memorial to crack down on emergency room admissions … – The Exponent Telegram (press release) (registration)

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Local emergency room visits rise as MediCal coverage increases – Eureka Times Standard

Emergency room visits in Humboldt County have increased substantially over the past five years which local health care officials attribute not only to expanded MediCal coverage under the Affordable Care Act, but also a lack of primary care doctors.

There has been, as I understand it, an exodus of primary care physicians from the area, St. Joseph Hospital Emergency Department Medical Director Marshall Eidenberg said Friday. And so if somebody is unable to get the care that they think they need in a timely matter from their primary care doctor, then the emergency department is always open. For some folks that look at the monetary financial aspects, there is no longer the financial worry as much because they are now covered.

The data comes as the U.S. Senate is considering draft legislation to repeal and replace the Affordable Care Act, including capping federal funding of the Medicaid program known as MediCal in California and shifting more of the programs costs to states. The federal-state program provides health care to the poor, disabled and many nursing home patients.

The bill would also phase out the Medicaid expansion, which covered about 18,600 more Humboldt County residents under the health care plan since 2014, according to Humboldt Countys MediCal provider, Partnership HealthPlan of California.

Local health care officials state that decreased MediCal coverage would result in a reduction in reimbursed health care costs, which they state would likely result in cuts to preventative care programs and lead to an increase in reactive care treatment in emergency rooms.

In 2012, Humboldt Countys four emergency rooms had nearly 46,500 visits, according to state data. Four years later, the number of visits had jumped to nearly 56,400.

California Office of Statewide Health Planning and Development data released this month shows emergency room visits by MediCal patients made up nearly 46 percent of all emergency room visits in Humboldt County in 2016 compared to just 30 percent in 2013 the year before the Medicaid expansion under the Affordable Care Act took effect.

In 2014, emergency room visits by MediCal patients increased by nearly 6,000 patients or about 12 percent compared to 2013, according to the data. The number of people in the county who paid out of pocket also significantly decreased, dropping from 15 percent of all ER visits in 2013 to nearly 7 percent by 2016, according to the data.

Partnership HealthPlan manages MediCal benefits for 14 northern California counties including Humboldt County. Since the MediCal expansion took effect, emergency room visits by individuals covered under the expansion decreased by 37 percent from January 2014 to December 2016, according to Partnership HealthPlan Public Information Officer Dustin Lyda.

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If you read the report, as members get educated on the use of their benefits, the emergency room use starts to go down, he said, adding that he expects emergency room visits to decline through time.

Lyda said they did not have county-specific data on ER use by its MediCal expansion population, but said Humboldt County makes up 29 percent of its membership.

MediCal patients are assigned a primary care physician through Partnership HealthPlan, but Lyda said finding enough physicians to cover the demand has been extremely difficult in rural counties. Wage competition in more populated counties as well as reduced physician residency programs in the county have been cited by local health care officials as reasons for Humboldt Countys difficulty in retaining and recruiting physicians.

While Partnership HealthPlan does assign each patient a primary care physician, Humboldt-Del Norte County Medical Society Executive Director Penny Figas said how soon patients are able to be seen by a physician is limited by the number of available doctors and clinics.

There are only so many hours in the day, and as we lose physicians and whoever is left to absorb those patients, there is only so much absorption that can happen, Figas said. … It may be more convenient for [the patient] to show up at the emergency room. Maybe they may not be able to get to the clinic for an appointment.

Eidenberg said he has been meeting weekly with staff to improve his emergency rooms performance and ensure patients are adequately cared for, but he said progress on that front can be strained by increased emergency room visits.

The episodic care versus the heroic care that the hospital and emergency department does is actually more cost effective, results actually in less testing, less radiation through X-rays, which can result in less long-term problems, Eidenberg said. Episodic care is actually to be preferred over the heroic care that the emergency department provides because we have a very different mandate in the ER: everything is terrible until we can prove it isnt.

But Figas said that the situation is going to improve. She said nine specialists and four primary care doctors have been brought into the county since October and that five new primary care physicians are committed to begin work in county health care clinics between now and September.

Its the first time in a long time that we have more physicians coming than going, she said.

St. Joseph Hospital and local clinics are also working to create a family practice residency program in order to train and retain local doctors, Figas said.

Lyda said that Partnership has brought on 29 new physicians since 2014 across its 14 counties, but said he did not specific data on Humboldt County doctors nor how many doctors have left during that time.

Eidenberg said that increased MediCal reimbursements through the MediCal expansion are a benefit in that they can pay for increasing the number of family care practitioners.

Which is truly whats needed, not just here, but in the country as a whole, he said.

Local health care officials are still reviewing the policies of the Republican health care bill that was released to the public and to most members of Congress on Thursday.

The bill could change in the coming weeks after five Republican senators came out against the legislation last week. The GOP can only lose two of the 52 Republican senate votes for the bill to pass due to Democratic opposition.

Decreased funding of Medicaid has led to opposition of Republicans such as Nevada Sen. Dean Heller, who said Friday that he cannot support legislation that takes insurance away from tens of millions of Americans and tens of thousands of Nevadans.

About 11 million Americans are covered under the Affordable Care Acts Medicaid expansion. The bill proposes to cap federal funding for the expansion, leaving states that participate in the expansion to figure out how to continue to fund their expanded Medicaid populations.

Lyda said that Partnership HealthPlan is currently conducting a review of the Senate bill, but has yet to complete its analysis of the impacts.

For Humboldt County, an immediate repeal of the Medicaid expansion which is not proposed in either the Senate or House of Representatives health care bills would result in a loss of $92.7 million in state and federal funding for MediCal benefits, a loss of $168.2 million in business revenue and over 1,000 jobs, according to Partnership HealthPlan.

By removing access to health care services, families will either have to forego needed care or risk financial uncertainty to unknown health costs, Partnership wrote in a statement about the Senate bill last week. Ensuring access to quality care prevents children from missing school, adults from getting and maintaining employment, and our vulnerable populations from spiraling into a health crisis.

St. Joseph Hospitals Emergency Department receives the majority of emergency room visits in the county. The departments new director of eight months, Eidenberg said that an increase of insured patients whether it be from MediCal or an employee health plan ensures the hospital will receive some form of payment or reimbursement.

But even if a patient is not insured, Eidenberg said they are obligated to treat them.

If someone doesnt pay that bill, that bill ends up getting assumed by the hospital and results actually in higher costs to everyone else that does pay, Eidenberg said. Because the money has to come from some place.

As states like California consider creating single-payer health care systems and Congress considers scaling back government funding to health care, Eidenberg said the nations health care debate has intensified.

Is it a business or is it a human right? And if its a human right then who pays for it? Eidenberg said.

Eidenberg said he thinks it is especially important to cover patients with preexisting conditions so that individuals and their families do not have to live in poverty to obtain health care.

What we should do as a nation is take care of those that are the broken, the poor and figure out what is the level that is necessary, he said. There is a lot to it. There is no one size fits all and Im sure every bill that Congress passes is going to piss off a sizeable portion of people, but we as a country havent figured out what we expect health care to do and to be.

The Associated Press contributed to this article. Will Houston can be reached at 707-441-0504.

ER Visits

Total number of visits to Humboldt County emergency rooms between 2005 and 2016 including the number of visits by patients covered under MediCal and self-pay patients.

2016

Total visits: 56,395

MediCal: 25,913

Self-pay: 3,792

2015

Total visits: 55,452

MediCal: 25,282

Self-pay: 4,603

2014

Total visits: 52,425

MediCal: 22,159

Self-pay: 6,289

2013

Total visits: 53,547

MediCal: 16,482

Self-pay: 8,042

2012

Total visits: 46,455

MediCal: 14,032

Self-pay: 6,793

2011

Total visits: 44,760

MediCal: 14,217

Self-pay: 6,354

2010

Total visits: 44,751

MediCal: 14,828

Self-pay: 6,434

2009

Total visits: 47,059

MediCal: 15,347

Self-pay: 6,671

2008

Total visits: 47,609

MediCal: 14,109

Self-pay: 7,802

2007

Total visits: 48,604

MediCal: 14,977

Self-pay: 7,865

2006

Total visits: 49,195

MediCal: 15,547

Self-pay: 7,534

2005

Total visits: 49,080

MediCal: 15,539

Self-pay: 7,326

Source: California Office of Statewide Health Planning and Development

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Local emergency room visits rise as MediCal coverage increases – Eureka Times Standard

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Investigates: VA calls veterans ‘imprudent,’ denies ER payments – KARE

A.J. Lagoe & Steve Eckert , KARE 10:21 PM. CDT June 12, 2017

As a service-connected disabled veteran, Ben Krause expected the Minneapolis VA would automatically pick up his $6,066 hospital bill. He was mistaken. (Photo: KARE 11)

MINNEAPOLIS Thousands of veterans every year are saddled with medical debt they shouldnt owe some of it even turned over to collection agencies after trips to the emergency room.

A KARE 11 Investigation discovers its happening, in part, because the Department of Veterans Affairs does not consistently apply its own rules.

A Tough Night

When you are parents of a newborn, there can be a lot of sleepless nights. But for Ben and Gretchen Krause, one night last February stands out.

It was a tough night, thats for sure, recalled Ben. It was the night he spent hours in a Woodbury, Minnesota emergency room.

The idea of losing him, Ben, with a little baby here – it was really scary, said Gretchen, fighting back tears.

Ben says he began experiencing severe chest pain and was struggling to catch his breath.

I felt like my chest was about to pop, he said.

I remember he said, ‘Something’s wrong,’ said Gretchen. Something’s wrong!

Fearing her husband was having a heart attack, Gretchen grabbed the baby out of bed and drove the family to the emergency room at HealthEasts Woodwinds Hospital. They spent the next nine hours there.

Doctors determined that instead of a heart attack, Ben was having an extreme form of stress likely exacerbated by a recent death in the family.

Technical term for it is malignant hypertension with neurological and cardiovascular complications, Ben explained. I couldnt dial back the stress from what was going on in the grief process.

As a service-connected disabled veteran, Ben expected the Minneapolis VA would automatically pick up the $6,066 hospital bill.

He was mistaken.

The Prudent Layperson Denial

I got a letter in the mail saying they were going to deny me, said Ben.

Bens case raises the question, just what does the VA believe is a prudent laypersons definition of an emergency?

To find an answer, KARE 11 looked to the VAs Prudent Layperson Fact Sheet.

The letter, which appears to be a boilerplate form, said Ben was being denied reimbursement for his visit to Woodwinds Health Campus because, The treatment provided does not meet the Prudent Layperson definition of an emergency.

Apparently, a prudent normal guy wouldnt have gone to the emergency room if they were experiencing chest pains, exclaimed Ben sarcastically. A normal layperson would have just sat on the couch, I guess.

The Fact Sheet describes a prudent layperson as someone:

possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in placing the patients health in serious jeopardy, cause serious impairment to bodily functions, serious dysfunction of any bodily organ or part, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy.

Gretchen Krause maintains she and her husband did what anyone would have done when facing a similar situation.

Im not a doctor, Im not a nurse, she explained. I know when to go to the ER. You go to the ER when someone is in distress, and he was in distress!

While many veterans might have concerns about challenging the VA denial, Ben Krause happens to be one of the nations most prominent and outspoken veterans rights attorneys.

Ben likens the VAs letter to bad faith insurance denials. This is straight out of the insurance company 101 books on how to deny a claimant, he said.

In fact, KARE 11 discovered the VAs own guidelines spell out an example of when a veteran was acting prudently when they visited an emergency room even if the final diagnosis turns out to be something less serious.

Case Example A describes a patient who goes to the ER complaining of chest pain but is given a diagnosis of mild gastric irritation.

The VAs Prudent Layperson Fact Sheet goes on to state that because chest pain is a potentially serious problem it clearly falls into the category of what any prudent layperson would consider an appropriate use of an emergency department.

When you look at it this, it is almost verbatim your case, KARE Investigative Reporter A.J. Lagoe said to Krause while reading the VA Fact Sheet.

Right, Krause laughed. Its black and white and it is Case Example A!

This is spot on exactly what I experienced, Krause said. Chest pains, going to the emergency room. Im not a doctor! How am I going to know whether Im truly having a heart attack or not?

The idea of losing him, Ben, with a little baby here – it was really scary, said Gretchen Krause of the night she had to bring her husband to the ER. (Photo: KARE 11)

Systemic Pattern

KARE 11 wanted to know, is Krauses case an isolated problem, or a systemic pattern of dubious denials?

If it happened to me, I guarantee its happening to thousands of veterans nationwide, Krause said.

He is right.

During a Congressional hearinglast year, VA Assistant Deputy Undersecretary for Health for Community Care, Dr. Baligh Yehia submitted written testimonyabout veterans being denied payment for emergency room visits.

That statement shows between the beginning of fiscal year 2014 and August of 2015, approximately 98,000 claims were denied because the condition was determined not to be an emergency.

Dr. Yehia wrote, Many of these denials are the result of inconsistent application of the ‘prudent layperson’ standard from claim to claim and confusion among Veterans about when they are eligible to receive emergency treatment through community care.

He added, When denied, the financial responsibility for these claims, which can be substantial, often falls on Veterans

Its absurd, said Krause who wrote about his imprudent layperson denial on his popular veterans blog.

In his article, he served notice to the VA he was working with KARE 11 to get to the bottom of his claim denial.

VA Reversal

The same day KARE 11 emailed the Minneapolis VA asking for an interview to discuss the case, Krause says he received a call from an official saying a mistake had been made and his claim should not have been denied.

The second that they realized that somebody was looking into it, and somebody with the ability to make it into a national story, once they realized that, then they called and said, Oh sorry, we made a mistake, were going to take care of it.

Minneapolis VA officials refused to be interviewed for this report.

However, in an email they blamed the denial on a coding error by the non-VA emergency room that treated Krause. They also stated that at the time of the initial denial, VA did not yet have all his records.

It appears the denial letter was issued without anyone at the VA contacting either the private hospital or Krause to determine the nature and cause of his hospital visit.

The VA spokesman confirmed that Krauses entire claim for emergency medical care is now being covered.

Even so, Krause questions how many other veterans have the ability to quickly get the VAs attention without going through the appeals process, which often takes up to five years.

If you dont have the ability to get your story out there, he said, I mean, youre not going to get the justice you need.

Our investigation started after a tip from a viewer. If you have a suggestion, or want to share records of your VA Emergency Room Claim, email us at: investigations@kare11.com

2017 KARE-TV

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Blue Cross in Georgia to limit emergency room coverage – MyAJC

The Obamacare exchangemay survive next year in rural Georgia. But patients who depend on its last remaining insurer are now learning theres a catch.

Over the past week letters have arrived at homes throughout the state giving patients a jolt. Blue Cross Blue Shield of Georgia, the only insurer on the exchange for 96 of the states 159 counties, is telling patients with individual policies that if they go to the emergency room and its not an emergency, theyll be stuck with the bill.

I am very concerned, said Dr. Matthew Keadey, who leads an organization of ER doctors. He fears patients who need the ER but arent sure they do will avoid it now. If this is fully implemented, I think were going to have deaths out there because of it.

Blue Cross move could stick Keadey and his colleagues with unpaid bills if non-emergency patients continue to come but cant pay. But patients also are concerned.

Really, like what the (heck)? said Sharon Tarver, a patient in Sumter County who has Blue Cross through the exchange, as she described her reaction when she first read the letter.

It was like, OK, well when you think about people that go when they dont have an emergency, they are taking up time for people who have an emergency, that does make sense, Tarver said. But in her area there are only two urgent care clinics, and they close at 8 p.m. and 9 p.m. She recalled two incidents in the past two years when she went to the emergency room, once with chest pain and once with a cough that reminded her of her mothers lung cancer. They both turned out to be something else.

Would she still go now, after the letter?

It depends. Its a half of one hand and half the other, she said.

Trying to change habits

A spokeswoman for Blue Cross said patients with a legitimate fear of an emergency would still be covered and that the company was forced to act by the rising cost of health care.

The policy defines an emergency as what a prudent layperson would think could pose a serious danger, and it says the insurer will decide what makes that cut. It takes effect July 1. Blue Cross says it wont apply to kids 13 and younger, members who dont have an urgent care clinic within 15 miles, or visits on Sundays and major holidays.

This is not to discourage somebody with an emergency condition who needs to go to an ER to go there, said the spokeswoman, Debbie Diamond. Health care is becoming more and more expensive. Its a way to make sure that people are getting quality and affordable care.

Many pressures may have forced the tipping point. Health care prices are always rising, and Obamacare insurance was more expensive to provide at first than companies thought. This year the Trump administration has especially rattled insurance companies by waffling on whether it would continuesubsidies key to funding Obamacare exchange plans.

Blue Cross parent company, Anthem, was reportedly leaning toward pulling out of many states exchange markets. But two weeks ago itsignaled it may stay in Georgias.

And the fact is that patients who use the emergency room like their personal clinic do waste money, a lot of it.

How much is not really known. Keadey quotes data saying a small percentage of ER patients should be getting their care somewhere else.State Rep. Terry England, a co-chairman of a committee that studied how to stabilize rural hospitals, said its much more. But neither disputes that the letter is at least partly aimed at shaking up those people who know they shouldnt be at the ER.

What Im interpreting is its because theyre trying to change habits and get people to focus on going to their physician and not to the ER, England said.

It kind of comes across as cold and callous maybe, the way that theyre doing it, he said. But at the same time, it may be one of the few ways that you actually are able to maintain hospitals andkeep the doors of hospitals openacross the state.

Keadey acknowledged the existence of problem patients. But his larger concern was patients who belong at the ER and may not go.

Patients are not trained to recognize emergencies, he said. What it really is is a barrier to emergency care. Patients will die because theyre going to think twice about going to the emergency department. One person goes and it turns out they just had reflux or a stomach problem; the next person has the symptoms and its a heart attack.

To me its one more way that were seeing the insurance company trying to take their financial responsibility and place it back on the patient.

Sore throat not enough

Diamond said Blue Cross understood patients had to use their best judgment. If you are having chest pains and it turns out to be indigestion, she said, you still thought you were having chest pains. So you could go to the emergency room.

On the other hand, she said, obvious examples where you should not go to the ER would be if you had cold symptoms; if you have a sore throat.

Blue Cross is steering those patients who dont need emergency care to their personal physicians, urgent care clinics or to Blue Cross 24-hour online medical service, LiveHealth Online. The service requires using an app on a computer or on a phone with internet service. It wont work off a rotary phone, for example.

Most people now have cellphones or computers, said Diamond, the Blue Cross spokeswoman.

Not everyone does. Middle-age policymakers might not understand that because a study by the Pew Research Center found that 95 percent to 99 percent of U.S. adults up to age 50 in 2016 used the internet one way or another. But with older people that number falls off a cliff. And with lower-income people and those in rural areas, it can be harder.

We have so many people that come to the library just to have access to a computer and the internet, said Kirk Lyman-Barner, an insurance agent in Sumter County. And thats closed in the evening of course.

Is it an emergency?

In a May 19, 2017, letter to customers, Blue Cross Blue Shield of Georgia said that starting July 1 it would no longer cover non-emergency visits to emergency rooms. This is the definition it gave for emergencies:

Emergency or Emergency Medical Condition means a medical or behavioral health condition of recent onset and sufficient severity, including but not limited to, severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness or injury is of such a nature that not getting immediate medical care could result in:

(a) placing the patients health or the health of another person in serious danger or, for a pregnant woman, placing the womans health or the health of her unborn child in serious danger;

(b) serious impairment to bodily functions; or

(c) serious dysfunction of any bodily organ or part.

Such conditions include but are not limited to, chest pain, stroke, poisoning, serious breathing problems, unconsciousness, severe burns or cuts, uncontrolled bleeding, or seizures and such other acute conditions as may be determined to be Emergencies by us.

Exceptions to the rule

According to Blue Cross, the rule will not apply if:

GOVERNMENT AND POLITICAL NEWS

If it happens in Washington or under the Gold Dome, The Atlanta Journal-Constitution has somebody there to tell you what it means for all Georgians. Follow our coverage athttp://www.myAJC.com/politics.

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Home VA Healthcare The Next 72 Hours 3 Things Veterans Must Do During Civilian… – DisabledVeterans.org

With the changing landscape at VA concerning emergency civilian care, there are a couple easy steps veterans must take in order to not get stuck with the bill.

This issue recently came up for me. Two months ago, I had symptoms of a heart attack. With ourbaby in tow, my wife proceeded to take me to the local emergency room in the suburbs of the Twin Cities for immediate help. Luckily, I did not die and am now feeling better.

But, had I failed to take a couple key steps, my pocket book would have taken a huge $6,000 hit, and that is what I wanted to write about today.

VA has a great program called fee basis that may cover certain veterans when they seek emergency care if entitled to the coverage. Generally speaking, this coverage is only applicable, however, if you provide notice to VA within 72 hours of admission.

Personally, I provided notice to my local VA medical center about the matter within the 72-hour window, but after two months of hearing nothing from VA, I grew a little concerned.

There is nothing like staring a $6,000 ER bill in the face to make you concerned. Again, luckily, I was covered, but many veterans out there get saddled with an ER bill either because they fail to take the required steps for coverage or because VA makes an adverse decision about the nature of their emergency.

I do not intend to discuss the latter scenario here, but I will address the first.

Here was my experience this week and things you need to know to make sure you do not need to cut a huge check to cover your non-VA emergency visit.

First, if you believe you are experiencing a medical emergency, go to the nearest emergency room you believe can provide the care you need.

Second, once there, be sure to inform the financial counselor that you are a disabled veteran who receives health care from the local VA medical center. Usually, the financial counselor is the person who comes into your emergency room to get your insurance information. Provide the actual name of the facility for their records.

The latter step obviously only applies to veterans who are conscious.

Third, be sure to ask the doctor or family member to contact VA to inform the agency that you are in the emergency room.

Personally, I prefer to make communications like this in writing and keep the record in case the inquiry gets lost.

You can use the IRIS system, fax in a letter to the local VA, or do some combination of both. Your emergency room staff should have the contact information for the local VA if it is in that region.

For me, I contacted VA using the IRIS system immediately after I was discharged to provide notice of the incident to VA since I was within the 72-hour window. I then faxed in the IRIS routing number along with a brief explanation of why, when, and where I was seen to the Minneapolis VA.

The billing process usually takes a few months, and I did not hear back.

Today, I was not sure who to contact locally to find out where my claim was at within the process, so I called (877) 222-VETS (8387). An operator at that number transferred me to the correct fee basis office within the Minneapolis VA system.

The local number for that office is (612) 725-2019. This number will be different for each VA facility.

The fee basis operator there provided the name and number of the contact person responsible for my specific claim.

While on the phone, I also asked about a few details about the claim process for the purpose of reporting any new information back to my readers.

There is a new thing I was previously unaware of.

Whenever a disabled veteran hasone rating of 50% or higher, VA is to be listed as the primary payer on the account. The operator informed me this was a newer change.

This may be important for veterans with at least one rating for one disability that is at least 50% disabling. In that instance, such veterans may have an easier time getting coverage than having to haggle with their own insurance, if they have it, and that insurance has a deductible.

Now, there is case law developing in this area, and VA is in the process of adjusting its policies when it comes to payment of emergency room visits.

In the past, problems have arising where veterans were stuck with the cost of the health care. Hopefully, new changes are on the horizon that will help resolve this kind of problem.

This aside, you need to remember that all veterans cases are unique and different. Not everyone will have the same entitlement or similar experiences. Each situation is different.

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