Insurers Begin Denying Payment for 'Unnecessary' ED Care

https://goo.gl/j6wFn8

In May 2017, Blue Cross Blue Shield (BCBS) of Georgia announced it will no longer cover "unnecessary" emergency department (ED) care, starting July 1. According to BCBS Georgia President Jeff Fusile, "...we have got to find a better way to do some of this stuff, taking some unnecessary spending out of the system." Fusile would rather patients use urgent care, retail clinics, and their online app, instead of costly EDs for conditions treatable in those settings. The BCBS policy follows similar ones enacted by Anthem in New York, Kentucky, and Missouri.

To many, these policies seem well-intentioned for a fiscally responsible insurer in a country with out-of-control healthcare costs. The simple goal: drive low-acuity illness to cheaper settings, which will control costs and in turn, allow for lower premiums.

Insurers are partly right: inefficient setting selection is a real issue. It is not uncommon for emergency physicians to face situations where a panicky ED patient realizes their perceived health emergency was a false alarm. Some well known examples: a toddler with a fever and listlessness who perks up after a weight-appropriate dose of ibuprofen; a bout of severe, unrelenting abdominal pain that resolves spontaneously right after the patient is triaged and passes gas; the allergic reaction which initially felt like "throat closing" with not even a hive after some Benadryl.

Some ED patients could potentially be served elsewhere. Some patients come to the ED when they didn't need any medical attention at all. But the reality is there is no systematic way for patients to reliably and safely determine whether their symptoms represent an emergency. Many patients are referred to the ED by their doctors, others have no easy access to physicians, and many do not know about or think they should use telemedicine during a potential health emergency.

Bottom line, it is playing with fire for BCBS and Anthem to systematically discourage ED use. Sometimes, fever and listlessness is meningitis, unrelenting abdominal pain can be a bursting appendix, and allergic reactions occasionally result in life-threatening anaphylaxis. All are potentially lethal if untreated. Insurers' new ED deterrent policies create a new, unfair responsibility for patients: self-diagnose accurately, or else. Patients choosing incorrectly face steep financial penalties after seeking care in settings deemed "non-ideal," decided after the fact by their insurer using their final


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