Did You Receive An Emergency Room Denial?
Health insurers sometimes implement policies that deny coverage for emergency room visits deemed “non-emergencies” or “non-urgent.” These policies were purportedly created to combat the rising number of emergency room visits for non-emergency situations. In fact, however, according to the CDC, only about 5.5% of ER visits are non-urgent.
Anthem Emergency Room Denial
The most notable insurer partaking in this policy, Anthem Insurance, believes that by sending denial letters to customers following an emergency room visit, it will discourage other patients from going to the emergency room for less serious ailments. The policy started in Kentucky in 2015 and spread to Missouri, Georgia, Indiana, Ohio, and New Hampshire in 2017. In Missouri, Kentucky and Georgia alone, Anthem denied 12,000, or 5.8% of ER claims between July and December 2017. Anthem altered its policy slightly in February 2018. The American College of Emergency Physicians (ACEP) and the Medical Association of Georgia sued Anthem over its policy alleging it violates federal law.
Of course, claim denials don’t just hurt policyholders. Physicians and facilities also don’t get reimbursed for their services. In July 2022, the California chapter of ACEP asked members of Congress to intervene and enforce California law. And in February 2023, the California Medical Association filed a formal complaint with California’s Department of Managed Healthcare regarding Anthem continually denying payment for ER services in violation of California law.
States such as Indiana and Kentucky are following private insurers and are implementing similar policies with Medicaid enrollees. The rise in this health insurance practice is pushing patients to assess their own medical condition, which is very dangerous, or to pay thousands out of pocket.
In a statement, Anthem said that the purpose of the policy is to maintain high-quality health care for those who come into an emergency room, and moving non-emergency cases into the most appropriate setting. Anthem, one of the largest private health insurance providers in the United States, claims that more than a quarter of trips to the emergency room could be treated at a doctor’s office or retail health clinic instead of an emergency department. While this may be true for its members, hindsight is twenty/twenty.
UnitedHealthcare Emergency Room Denial
New York’s Attorney General sued UnitedHealthcare in 2019 for denying ER claims. The lawsuit alleged that UnitedHealthcare utilized a computer algorithm to determine if certain visits were medically necessary, and then retroactively denied ER claims. The AG’s lawsuit claimed this practice violated state and federal laws as well as UnitedHealthcare’s own insurance policies. The insurer didn’t communicate to plan members that some ER visits might not be covered and didn’t have a fair appeals process for denied claims.
UnitedHealthcare released a new policy in June 2021 that was going to start on July 1, 2021. The insurer planned to retroactively evaluate ER claims and, if the visit was deemed non-emergent, provide limited or no coverage. Provider groups, the American Hospital Association, and the American College of Emergency Physicians pushed back. They argued that patients should not be expected to self-diagnose in an emergency and that patients would avoid emergency rooms due to potential large medical bills. UnitedHealthcare then delayed the new policy until at least the end of the COVID pandemic.
In July 2023, the Department of Labor sued a division of UnitedHealthcare that manages self-funded health insurance plans for allegedly violating ERISA by denying all urine drug tests from August 2015 to August 2018 and by denying ER visits after the fact.
Aetna Emergency Room Denial
California’s Department of Managed Healthcare fined Aetna $500,000 in August, 2020 for denying ER claims against state law. The DMHC discovered that of the claims it reviewed, 93% of Aetna’s ER denied claims shouldn’t have been denied according to California’s standards. California laws enabling emergency services are stricter than Aetna’s national ER policy. The law stipulates that health insurers must cover emergency services unless the service didn’t take place or the patient didn’t need emergency care and “reasonably should have known” that they didn’t need emergency help. Moreover, the DMHC previously fined Aetna $135,000 for denying emergency room claims in 2015 and 2016. At the time, the DMHC warned Aetna it must apply California’s standards instead of its own national standards to policyholders in the state.
Critics of Health Insurance Emergency Room Denials
Consumer advocacy groups, such as the American Heart Association, say that these policies could prevent patients from seeking the medical care they may need for life-threatening emergencies. The denial policy Anthem uses comes with a list of exceptions, such as the company will pay for emergency room visits for patients younger than 15, when a customer is traveling out of state, or if the medical event takes place over the weekend or a holiday.
Critics to the policy believe that the emergency department exists to diagnose unknown ailments in an expedited manner. Expecting an untrained individual to gauge the severity of their own symptoms, could lead to illness, disability, or even death.
Summaries of Cases That We Have Filed
- We filed a case against Blue Shield of California for denying medically necessary emergency treatments. When our client got seriously ill with a strep infection while on a trip out of the country, Blue Shield initially lost and then denied his claim for coverage of his emergency treatment. This treatment included hospitalization, an ICU stay, and surgery to remove parts of his lungs. Blue Shield claimed that his treatment wasn’t an emergency, leaving our client with tens of thousands of dollars in medical bills. Our lawsuit alleges that Blue Shield has a system in place that is designed to save money by denying emergency care coverage to its members. It also alleges that Blue Shield doesn’t properly investigate claims before denying coverage and even incentivizes its medical reviewers to deny care. The lawsuit alleges that this conduct violates California law and is unfair, unlawful, and fraudulent. We are suing Blue Shield for breach of implied covenant of good faith and fair dealing, breach of contract, and violations of Business & Professions Code Section 17200.
- We filed a case against Oscar Health Plan for denying medically necessary emergency treatment. Our client, nine months pregnant, had a traumatic injury after a head-on collision and was rushed to the hospital. Oscar denied coverage for these emergency services and our client was left with tens of thousands of dollars in medical bills. Our lawsuit alleges that Oscar’s utilization review system systemically fails to conduct full, fair, and thorough investigations before denying coverage. We are suing Oscar for breach of implied covenant of good faith and fair dealing, breach of contract, and violations of Business & Professions Code Section 17200.
What Can You Do If You Receive a Health Insurance Emergency Room Denial?
The “No Surprises Act,” effective January 1, 2022, provides several protections for policyholders in emergencies and protects against certain emergency room denials. You can learn more about specific protections on this page.
If you or a family member receives a health insurance emergency room denial or other denial of a necessary medical procedure, contact the Law Offices of Scott Glovsky. Our team of knowledgeable attorneys can help assess your situation and support you in appealing a health insurer’s claim denial.