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Is it Really an Emergency?

On January 1, 2018, Anthem Blue Cross Blue Shield enforced that they are no longer covering emergency department visits in their policies in the states of Ohio, Indiana, Georgia, New Hampshire, Missouri, and Kentucky. Emergency Department visits are the number one cause of the rise in healthcare costs. In other words, your decision to go to the Emergency Room for treatment can cost you thousands. The “ED Program” was created to diminish emergency department misuse. Many patients do not realize that they could go to an urgent care or walk in doctor’s office for many of their symptoms. Anthem is striving to make healthcare more within your means. Since ER visits are very expensive, they are trying to point the patients in the direction of clinics, urgent cares, or doctor’s offices where the expense will be much lower. Allegedly, proper alignment of care will help lower everyone’s healthcare costs.
This program is meant to encourage patients to pursue care in the proper place, but the providers do fear that the policy will cause patients to avoid the ER, even when essential, out of fear of receiving a medical bill. Anthem has made it ‘clear’ that they will cover your visit to the emergency department if;
• You are under 15 years old;
• If you live more than fifteen miles from an urgent care;
• If you are out of state during your emergency;
• If you are admitted to the hospital for inpatient or outpatient treatment or observation; or
• If you visit the ER between 8 am in Saturday or 8 am on Monday.
If you do go to the ER for any reason and Anthem later determined your condition was not an emergency, you will then be charged for the visit and must pay that on your own. These charges can be significant and budget busting. When Anthem is reviewing a claim, they will request medical records to help determine if the condition was emergency or not. Recently, Alicia Reece (Ohio representative) stated that she and other representatives want to introduce a new bill that prohibits any state government agency from doing business with any insurance agency that has a selective ER policy for Ohio residents with commercial insurance policies.
Insurance policies are complex legal documents and our attorneys at Lardiere McNair are skilled at insurance policy review. Get us involved early; however, if you have already received a finding that your care was not an emergency and wish to review your options, please contact us directly to set up an initial consultation. We are here to help you and your family.

Kerbey Gregg is a Law Clerk at Lardiere McNair, LLC. To read more about our firm, please visit www.lmcounsel.com.

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