I understand what they are trying to do, but as usual there seems to a lack of common sense on the part of Anthem. They are basing their denial on the diagnosis instead of the symptoms.
My son was TOLD to go to the ER if his symptoms got worse…not to return to the urgent care. So…when he passed out (he was eventually diagnosed with flu), he went to the ER…as told. His insurance, the dreaded United Health Care, flatly refused to pay that ER bill…saying he should have gone to the urgent care.
@thumper1 did he appeal that decision? This is absolutely crazy!! If you are having severe stomach pains how are you supposed to know it’s ovarian cysts and not appendicitis???
As my husband said, this is asking regular people to practice medicine without a license, which they cannot do. He said that when he was in medicine, there was a time when people were being asked to get prior approval before going to the ER, which was eventually thrown out in court. Hopefully that will happen here, too.
Also he said fight the refusal–they may eventually cave.
He appealed the decision…more than once. Eventually worked out a fee with the ER. They were a LOT easier to deal with!
I went to the ER twice in 2016 because I was having bad chest pain. Both times they couldn’t figure out what was wrong with me but my heart was fine so they sent me home.
Eventually found out that a joint in front of my heart gets inflamed during flares.
Being denied ER coverage is one of ny biggest fears. I have to go in sometimes when I’m in so much pain I can barely move. I need pain killers and anti inflammation drugs. The diagnosis is usually one of my connective tissue diseases which I could see being denied because why should a chronic condition require the ER?
This should be illegal. I hate insurance companies and our system so much.
I’m not thrilled to hear your story about United Health Care, @thumper1. When my husband retires (which he’s planning to do in January), I’m going to have to go on the health insurance offered by my employer, and it’s United Health Care.
I had better sharpen my claws now for the inevitable arguments and appeals.
@Marian maybe others have positive experiences with UHC. We didn’t.
In our experience…other companies said “let me look into this” as their first response. UHC said “No”.
To be fair, most things did get covered eventually…per the plan DS had. Maybe they have gotten better in the last three years.
We’ve had UHC for 10+ years now with not one denial. But two personal stories - good or bad - aren’t statistically relevant, so who knows what your experience will be?
I can see both sides of this issue. Insurance needs to cover emergency services that are truly emergencies. Individuals don’t always know what’s an emergency. One way insurers could help themselves and their clients is to provide greater access to emergency remote consultations. With the number of people who have smart phones and/or internet access via computer, a significant number of insurance clients should have the technical capability to use an online consultation service provided by an insurer. Although many insurers advertise they have a nurse phone line and other similar services, my experience has been that those either aren’t terribly helpful or always as available as advertised.
Agree that expecting most non-physicians to guess correctly all the time what is an actual emergency medical situation and what is not is expecting far too much.
Decades ago, I remember an insurance company sending all covered people a book with a list of symptoms and recommendations about whether one should go to the emergency room or just contact your physician. Presumably, they were concerned about people going to the emergency room for non-emergencies (this can be a problem from both the cost standpoint that insurance companies are concerned about, and overloading the emergency rooms so that actual emergency cases may have difficulty getting timely treatment). But it probably was not successful (who is going to think to go find the book and look up the symptoms when something that can appear to be an emergency medical situation occurs?), since I have not seen any such thing again.
United Health care is the worst!
I saw something recently that urgent care centers are getting overloaded with people who don’t even consider going to their PCP when sick. In the old days, you would call you doctor’s office for a sick visit if you thought you had strep or twisted your ankle, now most people just go to urgent care for these situations.
I understand the need to stop people from going to the ER for routine medical care, but not for possible serious medical conditions.
We have had UHC for many years with no problems (including one family member with an expensive on-going condition). My daughter has Cigna and they have denied PT visits and then covered them after the therapist appealed the decision.
Note in the article they did eventually win their appeal.
One trick somebody taught me, was if you think you need to go to the ER call 911. If the EMTs agree, you will be taken care of first in the ER and your claim will not be denied (since the EMTs as medical professionals deemed the visit necessary).
Isn’t that what urgent care is for?
I met my new primary care MD and as part of the visit, brought list of Qs. Among them I had cut and pasted what iñone emergency room MD wrote as when to see urgent care vs emergency room.
She mentioned that she or someone in the 13-person practice she shares will be able to fit me in if I call, same day. She also said their clinic has an urgent care connected to the hospital so you can start at the urgent care if we need emergency they will quickly transfer you as needed.
My folks are in their late 80s/early 90s. In the past few years they’ve had a few overnights at the ER where they’ve been admitted for observation. So far, no problem getting our BCBS and Medicare A/B to pay. My relative who is an MD is often involved in decision for them to go to ER. Their symptoms are irregular, weak pulse, unsteadiness, sometimes dizziness. Neither has been diagnosed with anything from these ER visits or overnights or subsequebt cardiac work ups.
Agreed @“Cardinal Fang”
I know folks who don’t really have a PCP. Many use the Minute Clinic for routine stuff…but for more “serious” would head to an urgent care.
We have friends who have an internist but still go to urgent care if it’s more convenient and they just want to walk in and get a diagnosis and treatment recommendations, and go on with their day.
On the other hand, I’ve seen and been told about many, many folks who just use the ER/ED as their primary care. Many of them are uninsured or on Medicaid so they don’t care about the cost—it’s free to them either way. This new policy by insurers will make them have less competition in the emergency room. They go when they run out of their medicine that they can’t afford any other way, need a “tube up” or want to see a medical professional.
Here’s a thread discussing how to minimize ER/ED visits and expenses:
That is LITERALLY the purpose of urgent care. Urgent care = I need care today but I’m not critical.
I’ve never had a doctor who could get me in same-day unless MAYBE I call the minute they open in the morning.
Maybe because of where we live, both my doctor and the practice my daughter uses (different locations), will see you same day. The same was true with the pediatricians we used.
Of course we have used urgent care - after hours, when the doctor is booked, for stuff that seems to cross specialty (is this rash something for a dermatologist or an allergist type of thing), for stuff that needs more immediate care (but not the ER).
A few years ago, I went to the ER for chest pains. It turned out I was having an attack of GERD/reflux. The insurance company (not UHC) tried to deny. I wrote an appeal in which I asked them if they would have been happier if it HAD been a heart attack that would have cost them thousands of dollars to treat and might have led to long term chronic care rather than something that could be more easily treated. I also reminded them that the literature furnished to us said to go to the ER for chest pains. They covered it.
I now have a $200 copay for ER visits. My son hurt his hand playing basketball one Sunday afternoon. I found an urgent care that was further away but still open but idiot H (who doesn’t pay any of the bills) insisted that he had to go to the ER because the closest urgent care was closed. I had to pay $200 just to walk in the door. To say I was furious is an understatement. Urgent care is $40.