Don’t Fall Prey to the Insurance Company Fear Campaign
A study from the Doctor Patient Rights Project (DPRP) has revealed a disturbing trend amongst large insurance companies.
In the study, the DPRP singled out a company named Anthem Blue Cross – Blue Shield, which through its affiliated networks is the nation’s largest private health insurer. The findings in the study claim that Anthem has been retroactively denying insurance claims for emergency room visits from its clients, especially those who are from low income or rural areas.
The DPRP concluded that the purpose of Anthem’s policy is to make its clients too afraid to go to the ER out of fear that they will not be covered and must pay the whole bill out of pocket, which most patients are unable to do.
This conclusion is widely shared by the physicians and administrative staff of Emergency Rooms across the country as put in evidence by the comment of Dr. Ryan Stanton a critical care and emergency medicine specialist in Lexington, Kentucky,
“The purpose of this program is to spread fear.”
What is Anthem Blue Cross – Blue Shield Doing?
Last year, Anthem started notifying its clients in certain parts of the country, that if their ER visits end with a diagnosis for something that isn’t an emergency, they would be responsible for 100% of the cost of their visit.
The problem with this policy is that most of us don’t have enough medical knowledge or training to self-diagnose before going to the ER. According to The American College of Emergency Physicians (ACEP), there is nearly a 90-percent overlap in symptoms between emergencies and non-emergencies, according to a study in the Journal of the American Medical Association (2013). These symptom overlaps make it extremely difficult for any of us to determine the difference between abdominal pain that is life-threatening and abdominal pain that isn’t.
The fear factor that Anthem is creating with their denial policy means more people will choose to wait and see if their symptoms improve before seeking immediate emergency medical attention, a decision that could lead to lifelong disabilities or even death.
PROTECT YOUR RIGHTS!
The Law is on Your Side
The policy is so outrageous and dangerous to the public, that it has even reached the Senate. As reported by CBS News, Sen. Claire McCaskill, D-Missouri, sent a letter to both the U.S. Department of Health and Human Services and the Department of Labor asking them to investigate whether certain health insurers had violated the Prudent Layperson Standard.
The Prudent Layperson Standard which was added to the group and individual health insurance plans in 2010, and it requires health insurance companies to cover emergency room visits based on symptoms and not the final diagnosis. It also eliminates the requirements for prior authorization before seeking emergency care.
In our state, the Texas Department of Insurance requires insurance companies to pay emergency facilities like Altus Emergency Centers, the same way they would bill a facility which is part of the insured’s in-network. In other words, your insurance company should cover the same amount regardless of what type of emergency facility you visit, they cannot provide you with a lower benefit level.
The Patient Protection and Affordable Care Act also added numerous patient protections, most notably, they now require health plans covering emergency services to provide such coverage without the need for prior authorization.
Furthermore, health plans are required to pay for emergency visits for medical situations in which an average layperson believes his or her health is threatened. The final diagnosis should not influence whether the insurer pays for the emergency room visit or not, and insurance companies cannot legally apply the claim towards the out-of-network benefits.
What Can You Do If Your Claim is Denied?
The first thing you should do is contact our Patient Advocate Department. Our staff will review your denial and process an appeal on your behalf; they will submit documentation and justification for any ER treatment that you received.
If you get denied a second time, you still have the option to request an external review by a third-party, which will most likely be the state insurance regulator.
The appeal process is lengthy and labor-intensive because the goal of the insurer is for you to give up. Regardless of how long it takes you should continue with the process because the law is on your side.
Don’t fall victim to these scare tactics being implemented by insurance companies. If you have any concerns about the emergency medical coverage of your health insurance plan, our Patient Advocate can help clear these and even arrange to speak directly to your health insurance agent on your behalf.
Altus Emergency Patient Advocates are here to help you. We help you decipher the complexity of the medical industry to uncover how it can be most beneficial to you. We have focused our efforts on helping people better understand their insurance plans and how our billing works.
If you have any questions regarding your billing, please don’t hesitate to contact our Patient Advocate Department. Please feel free to call (469) 732-3151 between 8:00 am and 5:00 pm and ask for the Patient Advocate.