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Think you need to go to ER? If your insurer doesn’t agree, you could pay – WHAS 11.com

(Photo: Thinkstock / Getty Images, Custom)

(INDYSTAR.com) – Indiana Anthem policyholders may soon discover that what they consider a medical emergency does not necessarily align with what their insurer considers a medical emergency.

Under a new program, Anthem will require Indiana policyholders who seek emergency care for certain nonemergency ailments to foot the emergency room bill. The insurer would still pick up the tab if the patient opted to go to a retail health clinic, urgent care center or doctors office.

Concerns over the high costs of emergency room care, combined with overcrowded emergency rooms, led to the new policy, said company spokesman Tony Felts in an email.

The ultimate goal of this is to encourage more efficient utilization of health care resources, relieve pressure on ERs that are already stretched thin and strengthen the relationship between our members and their primary care doctors, who are in the best position to influence the health of their patients, Felts wrote.

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Emergency room care costs 12 to 18 times as much as a visit to a retail health clinic, eight to 12 times as much as a visit to a doctors office and six to seven times more than an urgent care visit.

While Anthem officials say they have not yet set the date for when the program will begin in Indiana, it is already in place in three other states.

Emergency room doctors and patient advocates decry the new policies, saying they put patients in the uncomfortable position of making critical decisions about their health, when time may be of the essence.

Patients will be too often forced to be their own doctors, said Scott Mulhauser, board member of the advocacy group Consumers for Quality Care. Consumers shouldnt be evaluating their care in these tense moments . You dont want to guess wrong because the consequence can change your life forever.

With the new policy, patients may delay getting care they need, afraid of incurring a hefty bill, said Dr. Chris Burke, a board member of the Indiana American College of Emergency Physicians.

Because many nonemergent conditions present with similar symptoms to emergency ones, identifying the true emergencies can be challenging for a lay person, he added.

The problem is that many diagnoses, their symptoms overlap, and without a thorough evaluation by a physician, you cant tell until that evaluation is complete, said Burke, an emergency room physician with Medical Associates who practices at Community Hospitals East and North. Its wrong to insist that patients should self-diagnose. Most are not able to do that. I think most who come to the emergency department believe that they have a problem.

A patient could misinterpret a bad headache, for instance, as a migraine, failing to recognize it as a stroke that requires emergency care. Or nausea or indigestion could be mistaken for a gastrointestinal condition rather than a heart attack.

If a patient with the same symptoms wrongly concludes a heart attack, the good news that the condition was not more serious could lead to the bad news of being saddled with the full bill for the emergency care.

This past week, the advocacy group sent Indiana Insurance Commissioner Stephen Robertson a letter asking that he reject the policy.

The insurance department conducted a review and decided not to act further, said Jenifer Groth, director of communication and outreach.

“IDOI completed its review and determined the program is not changing any prior coverage and does not constitute a procedural or benefit change,” she wrote in an email. “The program is to make policyholders aware of the process for payment of ER claims by sending information that outlines how coverage of claims will be handled.”

Anthem officials say that they decided to implement the policy after studies showed that about 75 percent of the 6.5 million emergency room visits made by those younger than 65 annually are for conditions that do not actually require immediate medical care.

Four emergency room doctors helped the insurer draw up a list of about 300 medical codes that would be considered nonemergencies, such as suture removal, athletes foot and the common cold, Felts said in an email.

A medical director will review any claim made for care delivered in an emergency room rather than a more appropriate setting. The symptoms that drove the patient to the emergency room also will be taken into account, he said.

Only about 10 percent of all 190,000 emergency room visits in Indiana annually would be reviewed, and likely only about 4 percent would be denied, Felts said.

But according to the companys own research of its policyholders, many patients dont necessarily know where to go for immediate care. About two-thirds go to the emergency room if they are sick and the doctors office is closed. One-quarter think the emergency room is the best place to go no matter their ailment or the time of day.

Half of those surveyed said they knew about retail health clinics and walk-in centers and opt for the emergency room and just under three-quarters of people who have made emergency room visits are familiar with urgent care centers.

While Anthem said that concerns about rising health costs and overcrowding contributed to the development of the new policy, Burke, who has been in practice for three decades, said that this policy will likely have little impact on either of those.

Emergency room care nationwide only accounts for about 2 percent of health costs, he said. While crowded emergency rooms do exist, its often because theres no room in the hospital to admit patients, rather than rampant overuse.

Anthem has already put the program into effect in Kentucky, Missouri and Georgia and could eventually extend it to additional markets. Each state market determines its own list of what will and wont be covered, Felts said. In Indiana about 300 out of 2,000 diagnoses considered to be nonemergencies are included in the new policy.

The policy will not apply to pediatric patients younger than 14, those referred to the emergency room by medical providers, visits made on Sundays or holidays when other clinics and offices are closed and for patients who live farther than 15 miles from an urgent care facility.

Ideally, the new policy will strengthen the relationship between patients and their primary care providers, Felts said in a statement.

[W]e are committed to promoting care delivery in the most appropriate clinical setting; for nonemergent care, generally this is the patients primary care provider, he said. Anthem believes that primary care doctors are in the best position to have a comprehensive view of their patients health status and should be the first medical professional patients see with any non-emergency medical concerns.

But health care advocate Mulhauser said that the policy could actually lead to high health expenditures if people wind up delaying needed care and end up worse off than if they had seen a health professional in a timely fashion.

When time matters and in those crisis situations, you want to feel the comfort of knowing that youre getting best medical care possible and not worrying about whether or not your insurer will cover your visit in a split second, he said. Forcing patients to make their own medical decisions that create incentives for them not to get the care they need can create real problems.”

Call IndyStar reporter Shari Rudavsky at (317) 444-6354. Follow her on Twitter and on Facebook.

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Think you need to go to ER? If your insurer doesn’t agree, you could pay – WHAS 11.com

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