When Insurers Deny Emergency Department Claims for Non-Emergency Care

If you've just cut your finger off in a table saw, it's pretty clear that the emergency room should be your next stop. But not all emergencies are quite that clear-cut.

Emergency rooms are the most expensive places to receive medical treatment, so for non-emergency situations, insurers want their members to utilize other, lower-cost venues, including urgent care centers or a primary care provider's office.

When patients use non-ER facilities, it's less costly for the insurer, and that translates into lower overall healthcare cost—and lower insurance premiums—for everyone. But in the case of a life- or limb-threatening situation, an emergency room will likely be the only place that's properly equipped to handle certain situations.

And the conundrum is that most people aren't trained in emergency medicine, so if in doubt about the severity of a medical situation, erring on the side of caution (i.e., going to the emergency room) generally seems like the most prudent solution.

Anthem and UnitedHealthcare Have Announced Controversial ER Rules

For the most part, insurers pay for those trips to the emergency room. But Anthem caused controversy in 2017 with new rules in six states (Georgia, Indiana, Missouri, Ohio, New Hampshire, and Kentucky ) that shift the cost of ER visits to the patient if a review of the claim determines that the situation was not an emergency after all.

A patient profiled by Vox went to the emergency room in Kentucky with debilitating abdominal pain and fever. Her mother, a former nurse, had advised her to go to the emergency room, as her symptoms were associated with appendicitis, which is considered a medical emergency. But it turned out that she had ovarian cysts instead, something that was only pinpointed after medical care had been provided in the ER.

Anthem then sent her a bill for more than $12,000, saying that her claim had been denied because she had used the emergency room for non-emergency care. The patient appealed, noting that she had no way of knowing that her pain wasn't an emergency until the ER physicians diagnosed her. Eventually, after her second appeal (and after the patient discussed her story with Vox), Anthem paid the bill.

The American College of Emergency Physicians filed a lawsuit over Anthem's emergency claim rules, which is still pending as of 2021. But Modern Healthcare reported in 2018 that when patients appealed their emergency claims that Anthem had denied, the majority of those appeals were successful.

UnitedHealthcare generated headlines in 2021 with the announcement of a similar policy that was slated to take effect as of July 2021. But amid significant pushback from emergency physicians and consumer advocates, UnitedHealthcare quickly backpedaled, announcing just days later that they would delay the implementation of the new rules until after the end of the COVID pandemic.

ER Bills Often Cause Headaches 

Anthem and UnitedHealthcare have generated plenty of headlines over their new claims rules, but surprise medical bills triggered by a trip to the ER are not new.

Some states have similar rules for Medicaid enrollees, with higher copays for non-emergency use of the emergency room (although in keeping with Medicaid rules, the copays are still nominal when compared with the cost of the care provided in the ER).

And people who inadvertently find themselves at an ER that's outside of their insurance plan's network can end up with substantial medical bills, despite the fact that the ACA requires non-grandfathered health plans to cover out-of-network emergency care as if it's in-network.

Those claims have long been subject to scrutiny, with the insurers double-checking to ensure that the care was actually an emergency before paying the out-of-network ER bills. And even if the insurer does pay the claim as if it were in-network, the out-of-network ER is not obligated to accept the insurer's payment as payment in full, since the ER has no contract with the insurer, and can balance bill the patient for the portion of the bill left over after the insurer pays.

If it were an in-network facility, the ER would have to write off a portion of the bill, under the terms of the contract with the insurer. But there's not—yet—any such requirement for out-of-network facilities unless a state has stepped in with its own rules.

A new federal law will take effect in 2022, however, eliminating most balance billing for emergency situations. It won't protect patients who received out-of-network ground ambulance services, but balance billing will be prohibited for other emergency treatment, even f the patient received their care at an out-of-network emergency facility or from an out-of-network emergency medical provider.

The nature of emergency care makes it difficult for patients to jump through insurance hoops that would otherwise be fairly straightforward. In non-emergency situations, people routinely call their insurance company to ask about prior authorization or check with a primary care doctor or nurse hotline to see what care is recommended. But in an emergency—or what appears to be an emergency, from the patient's perspective—those things may be overlooked.

And for the most part, that's the way it's supposed to be. If your spouse is having a stroke, you're not supposed to worry about calling your insurance company—you're supposed to call 911 or get to the ER as quickly as possible.

But when consumers hear stories about insurers denying ER bills because the insurer later deemed the situation a non-emergency, it's understandably worrying. The patient in the Vox article noted that after the experience she had with her ER bill and the Anthem claim denial, in the future she'll "go to primary care, and they’ll have to force [her] into an ambulance to go to the emergency room."

Understand Your Policy Before It's an Emergency

The more you know about how your health insurance plan works, the better prepared you'll be for situations when you end up needing to use your coverage. So, the first step is to carefully read and understand your policy. People tend to stick it in a drawer and forget about it until they need to use it, but there's no time for that in an emergency situation. So, at a time when you're not facing an imminent need for health care, sit down with your policy and make sure you understand:

• The deductible and out-of-pocket costs on your plan, and any copay that applies to ER visits (note that some policies will waive the copay if you end up being admitted to the hospital via the ER, and the charges will instead apply to your deductible—these are the sort of things you'll want to understand ahead of time, so call your insurance company and ask questions if you're unsure how your plan works).
• Whether your plan covers out-of-network care, and if so, whether there's a cap on your costs for out-of-network care. In addition, if there's more than one ER in your area, you'll want to determine which ones are in your plan's network and which are not, since that's not the sort of thing you want to be worrying about in an emergency situation. The new federal rules that take effect in 2022 will eliminate surprise balance billing in emergency situations, but it's still less hassle to just use an in-network ER if it's just as convenient as an out-of-network ER.
• Whether your plan has a rule that would result in a claim denial for non-emergency use of the ER. If so, familiarize yourself with your insurer's definition of emergency versus non-emergency. If the guidelines don't seem clear, call your insurer to discuss this with them, so that you can understand what's expected of you in terms of the type of facility you should utilize in various situations (Anthem outlined the guidelines in a letter they sent to members in 2017, when their new rules took effect in several states ).
• What your insurer's requirements are in terms of prior authorization for subsequent medical procedures that stem from an ER visit. Prior authorization cannot be required for emergency situations, but if you need additional follow-up care, you may need to get it authorized by your insurer ahead of time.

What Should You Do If You Get an Unexpected ER Bill?

If you get a larger-than-expected bill after a visit to the ER, reach out to your insurer and make sure you understand everything about the bill. Is it a balance bill from an out-of-network ER? Or is it a claim denial because your insurer deemed your situation a non-emergency? The former tends to be much more common (until it's federally banned as of 2022), but it's also, unfortunately, a situation where the patient has less in the way of recourse.

If you've received a balance bill from an out-of-network ER (i.e., your insurer has paid part of the claim, but the ER is billing you for the rest of it, and not writing off any of the charges because they don't have a contract with your insurer), there are a couple of things you'll want to do:

• Check with your state's insurance department to see if there are consumer protection laws or regulations in your state that address balance billing in emergency situations. The federal regulation preventing balance billing from out-of-network emergency providers won't take effect until 2022, but many states have already addressed the issue. (Note that state regulations don't apply to self-insured group health plans; the majority of people with employer-sponsored health insurance are in self-insured plans.)
• If there's nothing that your state can do, reach out to the out-of-network ER directly and see if they'll negotiate with you. They may be willing to accept a smaller amount as payment in full.

If you've received a notice that your claim has been denied because your insurer has determined that your situation was not an emergency (and you believe that it was, indeed, an emergency situation or at least one in which a prudent person would consider it an emergency), you have more leeway in terms of the appeals process: 

• If your plan isn't grandfathered, the ACA guarantees you the right to an internal appeal process, and if the insurer still denies your claim, you also have access to an external review by an independent third party.
• You can start by initiating the internal appeal process with your insurer, and also by reaching out to your state's insurance department to see if they have any guidance for you.
• Keep track of what happens during the appeals process, including the names of people you speak with and any communications you receive from your insurer. You'll also want to keep the hospital in the loop, as they may need to submit additional information to the insurance company in order to demonstrate that your situation warranted a trip to the ER.
• If the internal and external appeals are unsuccessful, you'll want to address the situation with the hospital. They may be willing to reduce their bill or set up a manageable payment plan. 

The Controversy Around Surprise ER Bills

The news of Anthem's new ER guidelines in Georgia, Indiana, Missouri, and Kentucky in 2017, and then in Ohio in 2018 (a planned expansion into New Hampshire was canceled), was met with an outcry from patients and consumer advocates.

The American College of Emergency Physicians pushed back with a video created to highlight the flaws in a system that essentially tasks patients with understanding what is and isn't an emergency, when some situations simply can't be assessed without running tests.

An analysis from JAMA Network indicated that if Anthem's policy were to be adopted by all commercial insurers, claims could potentially be denied for one in six emergency room visits. UnitedHealthcare projected in 2021 that the implementation of their proposed ER claims rules (now on hold until after the COVID pandemic ends) would result in claim denials for about 10% of emergency room visits. Most visits would still be covered, but that's still a significant number that would be rejected.

Anthem has said that their approach is based on language that was already in their contracts and that the "prudent layperson" standard has always been used but is now being enforced (i.e., if a "prudent layperson" would consider it an emergency, then it's an emergency).

But clearly, both insurers' decisions are controversial. Patients, medical providers, and consumer advocates worry that patients could be faced with indecision (at a very inopportune time) about whether to seek care in the ER, resulting in potentially poorer health outcomes. But Anthem and UnitedHealthcare are focused on reining in the cost of health care—a task that virtually everyone agrees is necessary, but few agree on how to accomplish.

And although claim denials for retroactively determined non-emergency use of the ER are generating confusion and concern, the issue of surprise medical bills following an ER visit has been an ongoing problem that far predates Anthem's new policy. Individual states have been working to address the issue in some cases, but it will remain a problem in many areas of the country (and for people enrolled in self-insured employer-sponsored coverage) until federal protections take effect in 2022.

Although the solutions seem obvious when looked at from the perspective of a patient or consumer advocate, it's challenging to get all of the stakeholders on board. For the time being, consumers need to understand as much as they can about how their coverage works and what their appeal rights are if they find themselves with an unexpected bill after a visit to the ER.

A Word From Verywell

if you feel that you or a loved one is facing an emergency medical situation, the best course of action is still to head to the emergency room. It's unlikely that your insurer will dispute the claim based on a later decision that the situation was not an emergency. But if they do, you can appeal and have fairly good odds of winning your appeal.