By Linda Carroll

(Reuters Health) – While symptoms like chest or belly pain might reasonably drive you to the emergency room with worries about a heart attack or appendicitis, your insurance company might decide not to pay if it turns out your fears were unfounded, a new study suggests.

With the price of emergency room care going up, U.S. insurance companies have been looking for ways to contain the costs, sometimes by refusing to pay for visits that turn out not to have been emergencies after all.

The new analysis shows that the criteria used by one large insurer, if expanded nationally, could result in denial of payment for nearly 16 percent of ER visits, even though these patients may have the same symptoms when they get to the ER as actual emergency cases, researchers report in JAMA Network Open.

While patients do need to be discouraged from using the emergency room for primary care, “they shouldn’t have to think, ‘is this something I’m going to have to pay for,'” said the study’s lead author, Dr. Shih-Chuan Chou of Brigham and Women’s Hospital in Boston.

“It’s a really unreasonable expectation to have patients self-triage,” he said.

The bottom line, Chou told Reuters Health, is that “there are many solutions out there and this one is not optimal. It’s not fair to patients and it might hurt some people.”

Anthem, which insures one in eight people in the U.S., introduced its policy of denying coverage for ER visits it deems unnecessary in three states in 2017, expanding to three more states so far in 2018.

To get a sense of how many patients might be affected if such a policy were nationwide, and used by more insurers, Chou and colleagues applied Anthem’s criteria to a national database of patients who sought emergency care from 2011 through 2015. Their analysis included 28,304 emergency department visits by commercially-insured patients aged 15 to 64.

In more than one third of these visits, the final diagnosis included a non-emergency condition appearing in a published Anthem list of conditions in the company’s denial policy. Not all of these claims would have been denied, however, because Anthem allows for people seeking emergency care on weekends and after business hours since primary care would be difficult to find then, the study team notes.

After excluding cases with a non-emergency diagnosis that probably would have been covered, the researchers still found that 4,440 claims likely would have been denied.

In the end, Chou and his colleagues calculate that 15.7 percent of all the ER visits included in the analysis would have been affected by Anthem’s retrospective denial policy.

Yet, when the researchers analyzed the patients’ symptoms in all the ER cases, they found that chest pain, abdominal pain and headache were among the most common for those who did ultimately need emergency-level care, and for those who would have been denied.

The policy puts patients in a situation where they essentially have to be their own doctors, Chou said. “If someone presents with belly pain, they’re going to get a CT scan,” he said. “If the pain is very sharp, it could be a ruptured cyst or appendicitis. I don’t know how you could expect patients to be able to differentiate the two on their own.”

There’s no question that there’s a problem when it comes to emergency rooms, said Dr. Albert Wu of the Johns Hopkins Bloomberg School of Public Health in Baltimore, who wasn’t involved in the study.

“A certain proportion of emergency room visits are unnecessary and there are people who use the emergency room as if it were their primary care or only doctor,” Wu said. “And there is a certain amount of resentment as this creates crowding in the emergency room and slows things down for people who have true emergencies. But this situation reflects a constellation of underlying problems for which neither the patients nor the emergency rooms are to blame.”

The problem with a policy of denying claims based on the final diagnosis is that although it will probably decrease inappropriate visits, it will also decrease appropriate visits, Wu said. “While everybody would agree you shouldn’t go to the emergency room for a simple cold, in some cases that simple cold is actually pneumonia. And in some cases, people die from that simple cold that could be pneumonia. In fact, at least one third of patients hospitalized for pneumonia die from that pneumonia.”

One issue that contributes to overuse of ERs is the shortage of primary care doctors, Wu added. Another contributor is the lack of after-hours care.

Moreover, there’s been a lack of effort “to educate both patients and families about health and that has resulted in declining medical and scientific literacy,” Wu said. “To then turn around and require patients to be their own doctors is unfair and probably also unwise from a financial point of view.”

SOURCE: and JAMA Network Open, online October 19, 2018.