Anthem Blue Cross Blue Shield, one of Missouri’s largest insurers, no longer covers emergency room visits that it deems unnecessary.

The policy aims to save costs and direct low-risk patients to primary care physicians and urgent care clinics. But doctors say patients may avoid going to a hospital when they really need it, if they fear a large bill.

“They’re forcing the lay public to make a medical determination,” said Dr. Doug Char, a Washington University emergency physician. “They’re basically telling people you have to decide if this chest pain you’re having is indigestion or a heart attack.”

An emergency room is the most expensive place to see a doctor, and insurers are balking at the cost. Between 15 percent and 30 percent of emergency room visits in the St. Louis region are avoidable, according to a study by the nonprofit Midwest Health Initiative. Missouri hospitals charge an average of $372 for emergency room visits for minor issues, but some charge as much as $1,300, according to data compiled by the Missouri Hospital Association.

"Most non-emergent medical conditions can be easily treated at retail clinics, urgent care clinics or 24/7 telehealth services," Anthem's Missouri spokesperson, Scott Golden, wrote in an email. "The review by an Anthem medical director will take into consideration the presenting symptoms that brought the member to the emergency room as well as the diagnosis."

In mid-May, Anthem sent letters to Missouri enrollees to alert them that from June 1, it would no longer cover emergency room services for non-emergencies. In such cases, people who have health insurance could still be stuck with the full cost of their visit, if the insurer determines that their symptoms did not reach the level of requiring emergency care.

Anthem enforces the same guidelines in Kentucky, and put the rule in place for Georgia policyholders this month. Its officials say there are several exceptions, such as if a patient is under 14, the visit occurs on a Sunday or there are no urgent-care centers within 15 miles.

The American College of Emergency Physicians raised a red flag when Anthem sent out a spreadsheet of 1,908 conditions that it may not deem worthy of coverage in an emergency room. Some of the listed symptoms could indicate a life-threatening emergency, said Dr. Jonathan Heidt, president of Missouri’s ACEP chapter.

“To have them under that threat of not having their bills paid if they’re wrong about what their diagnosis is, it’s really going to harm patients in the long run,” Heidt said. “Our patients have a right to seek emergency care.”

The doctors argue that Anthem’s policy, and similar rules set up by state Medicaid programs, violate the federal Affordable Care Act’s “prudent layperson” standard. The rule asserts that a person with average knowledge of health and medicine should be able to anticipate serious impairment to his or her health in an emergency, and that laws should not assume that a person will know more than that. Anthem contends that it reviews claims using this standard already.

Though Anthem began enforcing the Missouri rule at the beginning of June, patients who visit the emergency room for non-emergencies likely will receive bills in the coming months. Heidt said that if Anthem does not reconsider its policy, ACEP may weigh legal action against the insurer.

“We’re still a little bit early for that," Heidt said. "But at this time, all of our options are on the table.”

According to the Missouri Department of Insurance, Financial Institutions & Professional Registration, the rule is based on previously filed language that was approved by the regulator. Other plans have similar provisions.

"If a consumer believes a claim has been improperly denied, or has questions about how a claim has been handled by their insurer, they can contact the Department's Consumer Affairs Hotline at 800-726-7390 or they can file a complaint online," said Grady Martin, the agency's director of administration.

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