Major health insurer stops paying for some emergency room visits

One of Ohio’s largest insurers is denying payment for emergency room claims when it determines policyholders didn’t need emergency care.

The Ohio Hospital Association and state lawmakers are working to combat Anthem Blue Cross Blue Shield’s new practice, which could leave Ohio policyholders with thousands of dollars in ER bills, according to Thursday morning’s Capitol Letter, cleveland.com’s daily Statehouse newsletter.

Anthem began denying non-emergency claims Jan. 1 in response to rising visits to the ER that can be 10 times as costly as an urgent care center, said Jeff Blunt, an Anthem spokesman. There are some circumstances under which Anthem will continue to pay for non-emergency ER visits – such as for patients under 15 years old or if people live more than 15 miles from an urgent care center, he said.

In Kentucky, an Anthem policyholder with stomach pains rushed to the ER, thinking she had appendicitis. Her condition turned out to be ovarian cysts, according to a news report, and the insurer determined her ER visit was unnecessary. She owed the hospital over $12,000.

Cincinnati Democratic state Rep. Alicia Reece said most patients are not doctors and Anthem is unreasonably requiring people to assess whether they need emergency care.

Reece and Democratic colleagues, Reps. Stephanie Howse and Tom West, said at a Wednesday news conference they were writing to Gov. John Kasich, asking for action on the issue. They also said they are drafting a bill that could prohibit insurers that cut ER benefits from getting state contracts and tax credits. Reece said Cincinnati and Hamilton County employees are covered by Anthem.

Anthem told the Ohio Department of Insurance that it was only denying non-emergency claims for large employers who are self-insured. Anthem is a benefit administrator for some self-insured employers, and verifies and pays claims for the employers.

The company covers 3.4 million Ohioans and didn’t answer Capitol Letter’s question about how many of those policyholders were affected by the new rule.

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