Insurance Denial: Life-Threatening Er Visit, Now What?

It can be worrying to consider that insurance companies may deny coverage for life-threatening emergencies, especially as emergency rooms are the most expensive places to receive medical treatment. In the US, the federal Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA) mandates that emergency rooms treat patients with life-threatening emergencies, regardless of their insurance status. However, some health insurance companies have been known to deny coverage for emergency room visits deemed non-emergencies or non-urgent, which can leave patients with large bills. This has been a controversial practice, with pushback from physicians and consumer advocates, and has been the subject of multiple lawsuits.

The prudent layperson standard

> "A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

> - placing the patient's health in serious jeopardy;

> - serious impairment to bodily functions; or

> - serious dysfunction of any bodily organ or part."

This standard was developed in response to insurance companies requiring prior authorization for emergency department visits or denying payment for visits deemed inappropriate after the fact, often based on a retrospective review or discharge diagnosis. This placed patients' health and well-being in jeopardy, as they were forced to contact their insurance company during a moment of crisis to ask whether they should visit the emergency room.

The No Surprises Act

• Bans surprise bills for most emergency services, even if received out-of-network and without prior authorization.
• Bans out-of-network cost-sharing (e.g. out-of-network coinsurance or copayments) for most emergency and some non-emergency services.
• Bans out-of-network charges and balance bills for certain additional services (e.g. anesthesiology or radiology) provided by out-of-network providers as part of a patient's visit to an in-network facility.
• Requires healthcare providers and facilities to give patients an easy-to-understand notice explaining the applicable billing protections, who to contact if there are concerns about violations of the protections, and that patient consent is required to waive billing protections.
• Ensures that patients can get a "good faith" estimate of how much their care will cost before they receive it if they don't have insurance or pay for care without using their insurance.
• Allows patients to dispute a medical bill if their final charges are at least $400 higher than their good faith estimate, provided they file their dispute claim within 120 days of the date on their bill.
• Provides an independent dispute resolution process for payment disputes between plans and providers.
• Offers new dispute resolution opportunities for uninsured and self-pay individuals when they receive a medical bill that is substantially greater than the good faith estimate they get from the provider.

The Act aims to limit the amount patients pay out of pocket to a level closer to what they would pay if the healthcare provider were in-network. It generally applies to insurance plans' co-pay and cost-sharing percentages. Additionally, the Act outlines a process for insurance companies and providers to settle disputes over charges, ensuring a fair resolution.

State-specific insurance rules

In most states, the "prudent layperson standard" has been adopted, defining a medical emergency as a situation in which a reasonable person would expect their health, bodily functions, or any body part to be in serious jeopardy without immediate medical treatment. This means that you don't need extensive medical knowledge to determine if a situation is an emergency. However, some states, like California, have their own rules that go beyond this standard. For example, California considers whether the patient themselves had a reasonable belief that the situation warranted emergency care.

It's important to note that state insurance rules typically don't apply to self-insured plans, which cover most people in the US with employer-sponsored health insurance.

In terms of specific states:

• In California, the Department of Managed Healthcare has fined insurance companies like Aetna for denying ER claims that should have been covered under state law. California laws regarding emergency services are stricter than some national insurance policies.
• In Indiana and Kentucky, the state is following private insurers and implementing similar policies with Medicaid enrollees, which can push patients to assess their own medical conditions or pay out-of-pocket.
• In New York, the Attorney General sued UnitedHealthcare in 2019 for denying ER claims by using a computer algorithm to determine if visits were medically necessary and then retroactively denying coverage.
• In Georgia, Indiana, Missouri, Ohio, New Hampshire, and Kentucky, Anthem caused controversy with new rules in 2017 that shifted the cost of ER visits to the patient if a review determined that the situation was not an emergency. However, after legal pushback, these rules were largely suspended or not implemented.

Appealing a denied claim

If your insurance claim for an emergency room visit is denied, you can take steps to appeal the decision. Here is a guide on what to do:

Recognise the Reason for Denial

The first step is to carefully review the letter from your insurance company outlining the denial. Common reasons for denial include the insurance company's determination that the visit was unnecessary, the emergency room was out-of-network, the care received was not covered under your plan, or the treatment was categorised as experimental. Understanding the reason for denial will help you formulate your appeal.

Gather Important Information

To submit an appeal, you will need to gather key documents, including a copy of your insurance policy, the denial letter, and your medical records. These documents will provide important information to support your appeal.

Identify the Appeals Process

Each insurance company has its own process for submitting an appeal. It is crucial to follow their specific procedures to ensure your appeal is considered. Some companies may accept electronic submissions, while others may require mailed documents.

Draft a Letter of Appeal

Take the time to write a well-crafted and carefully worded letter of appeal. Reference facts from the documents you have gathered, particularly if you can refute the reasons for denial. It is important to submit your appeal in writing to have a record of all communications.

Submit Your Appeal Package

Once your letter is ready, send it, along with all corresponding documentation, to the insurance company following their requested submission method. Keep a copy of your letter and attachments for your records. If submitting a hard copy, consider sending it via certified or express mail to ensure delivery.

Work with an Attorney

The appeals process can be overwhelming, especially while dealing with the aftermath of an emergency room visit. Consider consulting an insurance claims attorney who can guide and support you through the process. They can help ensure your appeal is submitted appropriately and on time and can handle any pushback from the insurance company.

Act Quickly

Note that most insurance companies have specific time frames for accepting appeals. It is important to work on your appeal as soon as possible to ensure you don't miss any deadlines.

Non-profit organisations that can help

If you are facing a life-threatening emergency and need to visit the ER, it is important to know your rights and what to do if your insurance claim is denied. Here are some non-profit organisations that can help:

Patient Advocate Foundation (PAF)

The Patient Advocate Foundation is a national non-profit organisation that provides case management services and financial aid to Americans with chronic, life-threatening, and debilitating illnesses. They offer resources and support for various health conditions, including breast cancer, cardiovascular disease, and headache disease. They also provide information on understanding health insurance, appealing a denial, and accessing care without insurance.

Centers for Medicare and Medicaid Services (CMS)

CMS is a government organisation that provides information and resources to help individuals understand their rights when using health insurance. They have a website with guides and resources, including information on the No Surprises Act, which protects individuals from unexpected out-of-network bills during emergency room visits. CMS also launched an option on their website where patients can file complaints if they feel they were not treated fairly according to the Emergency Medical Treatment and Active Labor Act (EMTALA).

Gianelli & Morris

Gianelli & Morris is a law firm in California that specialises in insurance law. They help individuals fight wrongfully denied insurance claims and address bad faith insurance practices. They have experience with cases involving emergency room claim denials and can provide legal guidance and support.

American College of Emergency Physicians (ACEP)

The ACEP is an organisation that advocates for the rights of emergency physicians and patients. They have pushed back against insurance companies' policies that deny coverage for emergency room visits deemed non-emergencies. They have taken legal action and worked with lawmakers to protect patients' access to emergency care.

California Medical Association (CMA)

The CMA is a professional organisation that represents physicians in California. They have taken a stand against insurance companies denying payment for emergency room services, filing a formal complaint with the state's Department of Managed Healthcare. They work to ensure that patients receive the care they need and that physicians are properly reimbursed for their services.

Remember, if you are facing a life-threatening emergency, don't hesitate to seek medical attention. You can also reach out to these organisations for guidance and support in navigating insurance-related challenges.

Frequently asked questions