What you need to know about the forces reshaping our industry.


February 7, 2018

How an insurer's policy to cover ED care for 'emergencies only' plays out in practice

Daily Briefing

    Brittany Cloyd rushed to an ED last July for what she thought was a ruptured appendix, only to leave with a different diagnosis—and a $12,596 hospital bill that her insurer initially denied because Cloyd's final diagnosis, rather than her initial symptoms, did not qualify as a "true emergency," Vox reports.

    Learn more: Get the primers for reducing avoidable ED utilization

    The story is part of an ongoing Vox investigation into ED billing.

    A new policy

    Last year, Anthem notified members in Georgia, Indiana, Kentucky, and Missouri that it would no longer cover ED visits for non-emergency conditions that could "safely [be] treated in less acute facilities." In its notifications, Anthem urged members dealing with non-emergency conditions to seek out medical help at urgent care facilities or retail clinics, or to contact Anthem's telehealth services and 24/7 nurse hotline.

    • The ED policy does not apply if:
    • The patient is younger than 15;
    • The patient was directed to the ED by a physician;
    • An urgent care center is not within 15 miles of the patient; and/or
    • The visit occurs over the weekend or on a major holiday.

    But according to Vox, the new policy can pose a problem for patients. Under the new policy, coverage "denials are made after patients visit the [ED], sometimes based on the diagnosis after seeing a doctor, not on the symptoms" that prompted them to seek emergency care, Vox reports. In addition, members in some states do not have access to the list of diagnosis codes that could prompt a review. According to Vox, Anthem has released its list of diagnosis codes that could prompt review only for members in Indiana and Missouri. Insurance regulators in Georgia have sought a copy of the list but it has not been provided, Vox reports.

    Anthem's new protocol is similar to recently implemented policies in state Medicaid programs, Vox reports. Indiana, for instance, charges beneficiaries for ED trips that the state deems non-urgent, and Kentucky in July will begin charging beneficiaries for "inappropriate" ED trips. According to Vox, the trend indicates insurers are looking to control costs "by asking patients to play a larger role in assessing their own medical condition—or pay a steep price."

    A trip to the ED—and an unexpected bill

    Cloyd, a 27-year-old who lives in Kentucky, went to Frankfort Regional Medical Center on July 21, 2017, after experiencing a rising fever and growing pain on the right side of her abdomen. Cloyd went to the ED at the advice of her mother, a former nurse, who said Cloyd's symptoms sounded like appendicitis.

    At the ED, Cloyd underwent a CT and ultrasound and was diagnosed with ovarian cysts. Doctors prescribed pain medication and directed Cloyd to follow up with a gynecologist.

    Cloyd, who has insurance with Anthem through her husband's employer, later received a $12,596 bill for her ED visit. In a letter to Cloyd, Anthem stated, "We cannot approve benefits for your recent visit to the [ED] for pelvic pain. … [ED] services can be approved ... when a health problem is recent and severe enough that it needs immediate care." The letter cites "stroke, heart attack, and severe bleeding" as instances when ED use is warranted.

    Cloyd immediately appealed the decision, citing her responsible use of coverage in the past and the nature of her symptoms. Anthem denied the first appeal. However, one week after Vox spoke with Cloyd about the bill and reached out to Anthem, Cloyd received a letter that Anthem would pay the claim, Vox reports.

    In a statement to Vox, Anthem said, "We deeply regret if we caused Ms. Cloyd any concern." It continued, "Anthem has made, and will continue to make, enhancements to our [ED] program to ensure more effective implementation of this program on behalf of consumers."


    Patients and ED doctors have said Anthem's stricter ED coverage requirements could discourage patients from getting needed care. For instance, Jonathan Heidt, president of the Missouri chapter of the American College of Emergency Physicians (ACEP), said his hospital "was receiving denials within days" of the policy taking effect.

    Currently, ACEP is considering what it can do to challenge the existing policies, Vox reports. The group met with the insurer in December 2017, but ACEP President-elect John Rogers, who practices in Georgia, said, "There were a couple of questions I had but couldn't get answers to, like what does success look like? And how many patients are actually being denied?"

    The group is now mulling possible lawsuits or legislation at the state or national level, according to Rogers. "We're starting to sit down with legislators to say, 'This is happening, we don't think it's a good idea, and these are other, better solutions," Rogers said.

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

    Cloyd agreed, saying the experience left her with a totally different view of the ED. She said while she would still take her 7-year-old to the ED in the event of an emergency, when it comes to herself, Cloyd said, "I'll go to primary care, and they'll have to force me into an ambulance to go to the [ED]"  (Kliff, Vox, 1/29; Haefner, Becker's Hospital Review, 1/30; Baker, "Vitals," Axios, 1/30).

    Next, get primers for reducing avoidable ED utilization

    Are specific patient populations making up a significant proportion of your ED visits? Each installment in our Right-Sizing ED Use primer series takes a lens to one of these frequent user subgroups.

    We analyze the reasons these patients seek care in the ED, the business case for intervening, and solutions for reducing unnecessary ED use. The primers also feature in-depth case studies which highlight the operational details of successful and targeted programs from leading health care organizations.

    Download Now

    Have a Question?


    Ask our experts a question on any topic in health care by visiting our member portal, AskAdvisory.