New Insurance Policy Requirements Expect Patients to Diagnose Themselves.

“In A Sense”

Because this requirement takes into account that when individuals show signs of health problems it’s up to them where and when they seek professional care. Who among us have those kinds of diagnostic skills accept medical doctors.

Here is Brittany Cloyd doubled over in pain when upon her arrival at Frankfort Regional Medical Center’s emergency room.

“They got her a wheelchair and immediately got to a room,” said Cloyd, 27, who lives in Kentucky.

Cloyd came in after a night of worsening fever and an increasing pain on the right side of her stomach. She called her mother, a former nurse, who thought it sounded like appendicitis and told Cloyd to go to the hospital immediately.

The doctors in the emergency room did multiple tests including a CT scan and ultrasound. They determined that Cloyd had ovarian cysts, not appendicitis. They gave the pain medications that helped her feel better and in order to follow up with a gynecologist.

A few weeks later, Cloyd received something else: a $12,596 hospital bill her insurance denied — leaving her on the hook for all of it.

Brittany Cloyd, who has a mortgage, bill and student loans as many of us couldn’t pay this bill. Cloyd, who works for the Kentucky government and has a 7-year-old daughter. “There is absolutely no way I could pay a $12,000 hospital bill. I don’t even have $1,000.”

Cloyd has her health insurance coverage through her husband’s job. His company uses Anthem, one of the country’s largest health insurance plans. In recent years, Anthem has begun denying coverage for emergency room visits that it deems “inappropriate” because they aren’t, in the insurance plan’s view, true emergencies.

The problem: These denials are made after patients visit the ER, sometimes based on the diagnosis after seeing a doctor, not on the symptoms that sent them, like in Cloyd’s case.

This policy has so far rolled out in four states: Georgia, Indiana, Missouri, and Kentucky.

“We cannot approve benefits for your recent visit to the emergency room (ER) for pelvic pain,” the letter that Cloyd received from Anthem stated. “Emergency room services can be approved … when a health problem is recent and severe enough that it needs immediate care.”

The Anthem letter goes on to list “stroke, heart attack, and severe bleeding” as examples of medical conditions for which ER use would be acceptable.

Anthem’s new policy mirrors similar recent developments in state Medicaid programs, which increasingly ask enrollees to pay a higher price for emergency room trips that the state determines to be non-urgent.

Indiana implemented this type of policy in 2015, and the Trump administration recently approved a request from Kentucky to do the same. Beginning in July, Kentucky will charge Medicaid enrollees $20 for their first “inappropriate” emergency room visit, $50 for their second, and $75 for their third.

All of these policies suggest a new and controversial strategy for reining in health care costs: asking patients to play a larger role in assessing their own medical condition — or pay a steep price.

Anthem initially agreed to review its new policy and Cloyd’s case, but a spokesperson canceled the day before it was scheduled to take place. Instead, the insurer provided a statement and declined to answer more specific follow-up questions.

“Anthem’s goal is to ensure access to high-quality, affordable health care, and one of the ways to help achieve that goal is to encourage consumers to receive care in the most appropriate setting,” the insurer said in its statement.

Emergency room doctors and patients argue that these new policies can often deprive patients of needed care and deter them from using emergency services in the future. They worry that other insurance plans may follow the lead of Anthem, a giant in the industry with more than 40 million members.

Members of Congress and state regulators are pressing Anthem for additional information about how the policy works and which type of visits no longer receive coverage.

“There is real and justified concern about this,” said Renee Hsia, a professor of health policy studies at the University of California San Francisco and practicing emergency physician. “It’s certainly possible other insurers will pick it up and might do it intentionally because it deters other kinds of care.”

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