SAN FRANCISCO (KGO) -- Imagine you are very sick and head to the emergency room, only to later be told by your insurance company that it was not a true emergency. Even worse, you're now responsible for the bill.
A new investigation from Consumer Reports finds more patients are getting stuck with big surprise bills from the ER. 7 On Your Side's Michael Finney explains.
When Kimberly Fister-Mesch woke up in the middle of the night with head pain so severe, she thought she was having a stroke. Her husband rushed her to the ER. "The pain was so intense that I knew something had to be wrong," she said.
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To her relief, the pain wasn't from a stroke, but a serious inner ear infection. Later, she received a bill around $4,300 because her diagnosis was not considered a medical emergency by her insurer, Anthem.
Instead, Anthem said she should have called the company's 24/7 online doctor service, or gone to her own doctor or urgent care.
Anthem is not the only health insurance company trying to discourage costly emergency-room care. Many insurers charge a higher co-pay for ER visits, compared with urgent care centers or walk-in retail clinics. But Anthem's approach takes those efforts to a potentially dangerous new level.
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Medical experts along with Consumer Reports say policies like Anthem's are leaving consumers with huge medical bills, and could keep patients from going to the ER when they should. "People don't come to us because they want to come to us," said Dr. Ryan Stanton, an ER Physician. "They come to us because they need us."
How can you make sure this won't happen to you? Consumer Reports says the first step is to understand your insurance.
"Check your insurer's "emergency service benefits" coverage to see how it defines an emergency and what your plan will and won't cover," said Margot Gilman, Consumer Reports Money Editor. "While most insurers offer general guidelines as to what constitutes an emergency, they don't limit policy holders to specific injuries or illnesses."
And if you're insurer rejects a claim, you have the right to do what Kimberly did, file an appeal. She sent a letter to her insurer, along with her medical records, and filed a complaint with her state's insurance regulator.
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Anthem ultimately reversed its decision. They told Consumer Reports that it is simply trying to rein in the overuse of Emergency Rooms for minor problems. The insurer says the ER is a time-consuming and costly place to get care that could be handled elsewhere.
Anthem has many exceptions to their ER policy, such as, if a patient is under the age of 15, and if they were told to go to the ER by their doctor.
Here is a link where you can find out more about Surprise Medical Bills.
All Consumer Reports material Copyright 2017 Consumer Reports, Inc. ALL RIGHTS RESERVED. Consumer Reports is a not-for-profit organization which accepts no advertising. It has no commercial relationship with any advertiser or sponsor on this site. For more information visit consumer.org.
Click here for a look at more stories by Michael Finney and 7 On Your Side.
Written and produced by Justin Mendoza
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