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. This article will explain what constitutes a medical emergency, and the rules that health plans are required to follow in terms of coverage for emergency care.

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.

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.

Indeed, the "prudent layperson standard" has been adopted in most states, defining a medical emergency as a medical condition that a prudent layperson could reasonably expect to result in serious jeopardy to their health, bodily functions, or any body part, if medical treatment isn't received immediately.

In other words, you don't have to posses extensive medical knowledge or know what the actual diagnosis is in order for the situation to be accurately considered an emergency.

Insurers Suspend Controversial ER Claim Review Practices

For the most part, insurers cover trips to the emergency room under their emergency coverage rules. This includes out-of-network coverage, even if the health plan doesn't otherwise cover out-of-network care.

But Anthem caused controversy in 2017 with new rules in six states (Georgia, Indiana, Missouri, Ohio, New Hampshire, and Kentucky ) that shifted the cost of ER visits to the patient if a review of the claim and the patient's diagnosis (as opposed to symptoms) 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.

It's noteworthy that Modern Healthcare reported in 2018 that when patients appealed their emergency claims that Anthem had denied, the majority of those appeals were successful.

However, the American College of Emergency Physicians filed a lawsuit over Anthem's emergency claim rules. The suit was eventually withdrawn in 2022, after Blue Cross Blue Shield Healthcare Plan of Georgia agreed to discontinue the practice of reviewing emergency department claims to see if the ultimate diagnosis (rather than symptoms) constituted an emergency.

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.

Ultimately, UnitedHealthcare clarified in 2022 that they would not move forward with implementing the new ER claim review protocol.

ER Billing Headaches Now Less Common

Anthem and UnitedHealthcare generated plenty of headlines over their ERfclaims rules, and they were ultimately either suspended or not implemented. But surprise medical bills triggered by a trip to the ER were not new. Fortunately for consumers, those are much less common now than they used to be.

This is because the No Surprises Act prevents balance billing from out-of-network providers in emergency situations. This applies to both out-of-network emergency rooms as well as the medical providers who work in an emergency room.

For people enrolled in Medicaid, some states impose 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).

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."

This is why it's important to understand that the scenarios that were making headlines in 2017 and 2018 have largely been reversed by the insurance companies, after significant legal pushback from physicians and consumer advocates.

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 No Surprises Act has eliminated 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. (Again, the health plan rules that generated headlines several years ago have largely been suspended, but claims processing protocols still vary considerably from one insurer to another. Although the prudent layperson standard provides you with protections, it's important to note that if you use the ER for a situation that a prudent layperson wouldn't consider an emergency, your health plan might question your use of the ER.)
• 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? If so, the No Surprises Act should allow you to get it sorted out without having to pay out-of-network charges.

Or is it a claim denial because your insurer deemed your situation a non-emergency? 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 layperson would consider it an emergency), you may find that the claim gets paid if you appeal: 

• 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 (which were never implemented) would result in claim denials for about 10% of emergency room visits. Most visits would have still been covered, but that's still a significant number that would have been rejected.

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

But clearly, both insurers' decisions were controversial, and they ultimately backed off from the new approach to processing ER claims. Patients, medical providers, and consumer advocates worried 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.

Anthem and UnitedHealthcare were focused on reining in the cost of health care—a task that virtually everyone agrees is necessary, but few agree on how to accomplish.

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. 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.

Summary

Health plans are required to cover emergency room care even if it's out-of-network. And the "prudent layperson" rule protects patients in situations where the symptoms indicate an emergency, even if the ultimate diagnosis is a condition that isn't actually an emergency.

Some health plans have made waves in recent years with new claim-processing protocols that involve reviewing ER claims to see if the situation was truly an emergency. However, they have largely backed off on these protocols due to pushback from physicians and patient advocates. But a health plan can still reject an ER claim if a "prudent layperson" would not consider the symptoms to be an emergency (e.g. a runny nose).

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.

The prudent layperson standard is useful to understand if you find yourself needing to appeal a claim that's being denied because the health plan is looking at the final diagnosis rather than the symptoms you were experiencing that caused you to go to the ER.