Brittany Cloyd is like plenty of other 27-year-olds: married with a mortgage, student loan payments, and less than $1,000 in the bank. Which made a $12,596 hospital bill all the more distressing. Cloyd has insurance, but as Sarah Kliff explains in a larger look at the issue for Vox, it didn't end up doing her much good when she went to Frankfort Regional Medical Center's emergency room last July with "potentially lethal" symptoms: Her mother, a former nurse, thought Cloyd's fever and abdominal pain could be signs her appendix had burst or was about to. Tests showed it was actually ovarian cysts, which she'd need to see her gynecologist about. Then came word that her insurer, Anthem, wouldn't cover the ER visit because it wasn't, well, an emergency. It's a policy Anthem—which covers 40 million Americans—is now testing in Georgia, Indiana, Missouri, and Kentucky, where Cloyd lives.
The rub, writes Kliff, is that in these cases it may not matter if the symptoms justified an ER visit. The denial can rely on the diagnostic code, so if chest pain ends up being indigestion, not a heart attack, the patient could be on the hook. But "it's not fair to expect the patient [to come] in knowing their diagnosis," an ER physician tells Vox. The letter Anthem sent Cloyd states that the ER would be the sensible choice if she was experiencing "stroke, heart attack, [or] severe bleeding," but that benefits wouldn't be approved for her visit for "pelvic pain." The goal appears to be to keep costs down by decreasing pricey ER visits when a trip to, say, urgent care could more cheaply address the situation, though Vox got no numbers from Anthem on the policy's impact thus far. Cloyd had the denial reversed after she appealed twice; she says she won't go to an ER again unless she's forced to. Read Vox's full story here. (Read more Longform stories.)