Patients can dispute when emergency bills are not covered by insurance :: WRAL.com

What happens when your insurance company doesn’t think your trip to the emergency room was truly an emergency? There are ways to fight back when your insurer won’t foot the bill.

Severe pain in the middle of the night landed Kimberly Fister-Mesch in the emergency room. She thought she was having a stroke.

“The pain was so bad I knew something was wrong,” she said.

Much to her relief, it wasn’t a stroke, but a serious inner ear infection.

“And then I saw the bill, and that’s when my blood pressure went up,” she says.

Fister-Mesch was billed $ 4,300 because his diagnosis was not considered a medical emergency by his insurer, Anthem. Anthem said she should have called the company’s 24/7 online medical service or seen her own doctor or emergency care.

Anthem isn’t the only health insurance company trying to discourage expensive emergency room care. Many insurers charge a higher copayment for emergency room visits, compared to emergency care or walk-in clinics.

But Consumer Reports believes Anthem’s approach takes those efforts to a potentially dangerous new level. Consumer Reports and medical experts say policies like Anthem leave consumers with huge medical bills and could prevent patients from going to the emergency room when they should.

“People don’t come to us because they want to come to us. They come to us because they need us, ”said Dr. Ryan Stanton.

Before a health crisis hits, subscribers should make sure they understand what their insurance policy will cover.

“Check your insurer’s ’emergency service benefits’ coverage to see how it defines an emergency and what your plan will and will not cover,” said Margot Gilman, editor of Consumer Reports.

Although most insurers offer general guidelines on what constitutes an emergency, they do not limit policyholders to specific injuries or illnesses. Anthem makes many exceptions to its emergency room policy, including for patients under the age of 15 or for those who are directed to an emergency room by their doctor.

And if your insurer denies a claim, you have the right to do what Fister-Mesch did: appeal. She sent a letter to her insurer, along with her medical record, and filed a complaint with her state’s insurance regulator. Anthem ultimately overturned his decision.

Anthem told Consumer Reports it was just trying to curb the overuse of ERs for minor issues. The insurer says the emergency room is a long and expensive place to get care that could be treated elsewhere.

About Sally Dominguez

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