Health insurer plans to deny ER claims if it doesn't think you had emergency

ffemt8978

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For now they've delayed the implementation, but this could be a challenge for EMS. Could be a lot harder to convince patients to go to the hospital.
 

EpiEMS

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Policy seems problematic on a heck of a lot of levels. Curious what metrics they proposed to use.
 

Summit

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Insurance companies are jackholes. Surprise.

THE FUTURE:

Dispatcher: "911, please state your insurance company so we can transfer you to them and they can determine if you are having an emergency in accordance with your policy..."
Caller: "This guy, he dead... send the ambliance!"

Letter from UHC 3 months later:
"Dear Mr. Sucker,

Your claim with Whereverville EMS has been DENIED due to lack of prior authorization for the treatment:
CPR - Unsuccessful

For the diagnosis of:
Cardiac Arrest

We encourage you to contact United Healthcare in advance in the future so that we can authorize appropriate treatment ahead of time and guide you to right care agency.

Get Well Soon,
-Your Caring Insurance Provider

PS Thanks for your premium payment though."
 
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E tank

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There are ER's that prey on the ignorance of the general public....not the ones that are routinely overwhelmed by penetrating trauma and an abysmally ill population (that don't have insurance anyway and so are not part of this discussion) but the ones that see a very good payor mix and throw the diagnostic 'kitchen' sink at every and any complaint that rolls through the door....about time insurance companies start drawing the line somewhere. It is truly becoming absurd in some areas...especially more affluent ones....
 

akflightmedic

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Ahhhh, but only if there were some plan, some concept, some idea for those who do not have insurance, a plan where they have access to routine medical care, or even urgent care. A plan which does not require them to utilize the ER as their PCP.

Maybe one of these nations has an idea or two.

 
OP
ffemt8978

ffemt8978

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Ahhhh, but only if there were some plan, some concept, some idea for those who do not have insurance, a plan where they have access to routine medical care, or even urgent care. A plan which does not require them to utilize the ER as their PCP.

Maybe one of these nations has an idea or two.

Was wondering how many replies it would take for that to come up.
 

PotatoMedic

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To be fair, by function we have universal healthcare... A very unfuctional version, but one none the less. For the most part I call 911 and I go to the er and I'll be transported and treated and technically I don't have to give them any billing information.
 

EpiEMS

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Ahhhh, but only if there were some plan, some concept, some idea for those who do not have insurance, a plan where they have access to routine medical care, or even urgent care. A plan which does not require them to utilize the ER as their PCP.

Maybe one of these nations has an idea or two.


The best evidence on this is that - in the US - insurance doesn’t decrease ED use, it actually increases it. (The Oregon Medicaid experiment is the closest thing there is to a recent RCT on insurance in the US.)

See: https://science.sciencemag.org/content/343/6168/263.abstract
 

akflightmedic

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Cannot access the article. Yes, I did the "register for free" and then it said site down. Tried a second time, and it went to locked page.

If you have the article in its entirety and can share it, please do so. I am not going to buy it.

The headline is interesting, but without all the other data points and breakdown by category, I cannot debate or comment.
 

akflightmedic

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FiremanMike

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You guys should see some of the things that insurance is already calling “courtesy transport” and then not paying.. I’ve seen several with an altered level of consciousness and a few with cardiac symptoms..
 

Fezman92

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To be fair, by function we have universal healthcare... A very unfuctional version, but one none the less. For the most part I call 911 and I go to the er and I'll be transported and treated and technically I don't have to give them any billing information.
Yeah that’s not universal healthcare.
 

Summit

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Maybe this is about the scam health systems are pulling where they can bill Urgent Care as an ER visit if it is affiliated with and close enough to a hospital in the same health system. So patients think they are going to urgent care, but surprise! ER bill! (If you are wondering why a million urgent cares have gone up, it is because this is technically legal and health systems are trying to catch as many of these patientS to bill as ER vi$it$ as po$$ible.

 

PotatoMedic

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Yeah that’s not universal healthcare.
Why not? Anyone and everyone can access it. Is it ideal absolutely not. It's the most ineffective and expensive form.
 

Carlos Danger

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I'm not sure why anyone would think insurers should be forced to pay for EMERGENCY department visits that clearly were not emergent?

Do ED's in countries with universal healthcare use any form of rationing to discourage or prohibit unnecessary ED usage?
 

MonkeyArrow

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I'm not sure why anyone would think insurers should be forced to pay for EMERGENCY department visits that clearly were not emergent?

Do ED's in countries with universal healthcare use any form of rationing to discourage or prohibit unnecessary ED usage?
Outside of a few very obvious examples, how can you reasonably expect the layperson to know if something is emergent without medical training?

That foot pain could be osteomyelitis. The back pain could be a dissection. The sore throat could be a PTA. It's easy to d/c someone home with pharyngitis after three years of residency training you to exclude more sinister alternatives, but Joe Blow at home doesn't have that.
 

Carlos Danger

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Outside of a few very obvious examples, how can you reasonably expect the layperson to know if something is emergent without medical training?

That foot pain could be osteomyelitis. The back pain could be a dissection. The sore throat could be a PTA. It's easy to d/c someone home with pharyngitis after three years of residency training you to exclude more sinister alternatives, but Joe Blow at home doesn't have that.
Because those "few obvious examples" aren't so few.

We all know that life-threatening emergencies are a small percentage of ED visits. We also all agree, I'm sure, that a W-I-D-E leeway for uncertainty or "over self-triage" is quite appropriate. But we also know that even taking that into account, there are a LOT of people who inappropriately use the ED out of sheer convenience. That raises costs for everyone and potentially takes valuable resources from those with more pressing needs for them, and there is nothing wrong with attempts to dis-incentivize that behavior.
 

johnrsemt

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Yea lets all push for Universal Health Care it is so much better than what we have now.

I watched a good You Tube video a few months ago, and if I can find it tomorrow I will post it, But I am at work and can't get onto You Tube.
A 20+ year old was in Canada skateboarding on a Sunday, fell and broke his forearm (his words): obvious fx from the multiple video shots.
He and his brother went to the local ED, waited in the waiting room for 9 hours to be seen, ED doctor told him it was probably broken, but since it wasn't an emergency they had to leave and go to an Urgent Care type clinic (why they weren't told that when they checked in I have no Idea).
They left went to the Urgent Care Clinic, at 1900 on Sunday Evening: They are closed on Sunday's.
Went back Monday. 2nd person in to the clinic. took them 2 hours to do the paperwork, got an X-ray and surprise Radial/Ulna Fracture. Got a Sling and told to go to his family doctor to get a referral to an Orthopedic Surgeon 'if the family doctor thought he needed one'.
It took until Wednesday afternoon to find a 'Family Doctor' That would take him (20 year old's with no medical history do not need family doctors in Canada was the general answer on the phones calls). They went to the Family doctor on Friday who said 'Yes you need an Ortho Consult" I can get you scheduled with one in 3-5 weeks: Or 'you can drive 5 hours south over the border into the US, go to the closest Emergency room and get this set in a few hours'.

Interesting thing to think of Mexico has Universal Health Care, but you don't see Illegal Mexicans going back home for free health care.
 

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