The Story Behind Insurers Denying ER Coverage

The emergency room is the costliest location for medical care. This means insurance companies push their members to seek out care from places like urgent care facilities and primary care providers whose fees are lower. When insurers pay less, overall healthcare costs also decrease meaning lower premiums; however, many individuals don’t know enough to decide if their situation is critical and there are times where the ER just can’t be avoided.

More often than not those emergency room visits will be covered but, in 2017 Anthem established a new rule in a handful of states that says the cost of ER visits is the responsibility of the patient if that emergency situation is deemed a non-emergency. The goal is to limit excessive use of emergency rooms and promote visits to primary care physicians or urgent care facilities rather than overloading hospitals. The unintended consequence was that many patients went to the ER with substantial pain and only learned after agreeing to care that it wasn’t technically an emergency amounting in them paying large bills. Many appeals have been filed and most have been successful with The American College of Emergency Physicians filing a lawsuit against Anthem’s emergency care rules. More recently, coming in 2022, a federal law will take effect ridding most balance billing for emergency situations even if the care was an out-of-network emergency facility or provider offering more protection against insurance companies footing patients with fees.

The best thing to do is fully understand your insurance policy so when emergencies do arise you have a plan. Read about the deductible and out-of-pockets payments specifically for ER visits and dig into how your plan deals with out-of-network care. It will be good to know about the emergency care facilities in your area and whether their expenses will be covered prior to having an actual emergency. Check to see if prior authorization is required by your insurer to file claims and if a denial for non-emergency use of the ER exists in the plan.

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