Emergency room doctors have increasingly found themselves in a bind. A patient presents with potentially serious symptoms and the doctor recommends admission to the hospital for a complete work-up and treatment. Then the ER physician’s bill is not paid because the health insurance company denies the claim. In the long run, can insurance denials impact needed medical care?

Recently, there has been an uptick in such claim denials. Many of the claims are made by small emergency medicine groups that contract with a hospital to provide care. The ability of the smaller groups to fight a large insurance carrier is limited, so the physicians are simply having to swallow the financial loss.

Emergency physicians are required to treat anyone, without regard to health insurance or ability to pay.  Some of the health insurance companies are employing “pre-payment review,” which means the company can deny payment if, in its judgment, the care provided does not match the severity of the illness or injury.

The problem appears to be most serious in California, where Anthem Blue Cross California is increasingly denying payment for emergency department care. An example is a patient who is suspected of having a spinal epidural abscess, who is admitted to the hospital for an MRI and potential treatment. If the MRI turns out to be negative, and the eventual diagnosis is a herniated disk or other less serious spine condition, the emergency doctor’s time spent in evaluating the condition and arranging admission to the hospital is then denied, because the patient did not need to be admitted. 

Dr. John Wallace, president of the independent Emergency Physicians Consortium in California, said that when health plans don’t pay the doctors, “they hurt the hospital, patients, and the community.” He and other emergency medicine physicians are calling on the American College of Emergency Physicians to urge the state and federal governments to intervene.