Anthem is changing the rules. Their Emergency Department Review program, launched in 2017, puts a heavy burden on patients. The goal is to stop waste. Emergency rooms are expensive. A 2010 report pegged $38 billion a year in unnecessary spending. Anthem wants to claw some of that back. They want you to use the ER only for real emergencies. If you go for something minor, you might pay the full bill.
How the prudent layperson standard affects your claim
The core of the controversy is the “prudent layperson” standard. Congress passed this in 1997. It protects patients. It says insurance must cover a visit based on symptoms, not the final diagnosis. If you have chest pain, you get checked out. Even if it turns out to be heartburn. You shouldn’t have to diagnose yourself before seeking help.
Anthem’s policy challenges this. Here is how it works. You go to the ER. You leave. Anthem reviews the claim. If they decide your condition wasn’t life-threatening, they send a request. They want medical records from the hospital. They want a statement from you explaining why you went. Then an Anthem medical director reviews it. They use the prudent layperson standard. But they apply it retroactively. If they decide a better setting was available, they deny the claim. You can appeal. But the risk is yours.
“Anthem is forcing the patients to be doctors and completely disregard federal and state laws that protect patients.” — Dr. David Farcy, American Academy of Emergency Medicine
This is dangerous. Symptoms overlap. Chest pain can be gas. It can be a heart attack. Abdominal pain can be appendicitis. Or just indigestion. A headache can be a hangover. Or a ruptured aneurysm. You cannot know the difference without tests. Dr. Ryan Stanton of the American College of Emergency Physicians (ACEP) says the policy creates fear. People are afraid to go. They fear the bill. They fear the denial.
Real-world consequences of ED cost-shifting
Consider Amanda Gorman. She is a nurse practitioner in Baltimore. She had a kidney stone. She needed care. She couldn’t get a urologist appointment. She was married to a physician. She knew the system. She still struggled. She almost went to the ER. She chose an out-of-network specialist instead. Why? To avoid the Anthem review hassle.
She admits the out-of-network cost was high. She estimates a 6:1 ratio. What she paid out-of-pocket for the specialist versus her ER copay. It was expensive. But she preferred it. She didn’t want the administrative fight. She didn’t want the risk of a denied claim. If a nurse practitioner and a doctor’s wife find the system disjointed, imagine the average patient.
Access is the real barrier. Primary care physicians are hard to see. Specialists have long wait times. So people go to the ER. It is the only door open. Anthem calls this misuse. Experts call it a systemic failure.
Which alternative is cheaper: ER vs. urgent care?
Not everyone hates the program. Lindsey Artola from Sage Health Strategy sees a point. The ER is the most expensive place for care. Urgent care centers exist. Nurse triage lines exist. Using the ER for a sprained ankle or a sore throat wastes resources. She supports financial penalties for misuse. She sees the ER as a last resort.
But the trade-off is clear. You save the system money. You risk your health. You risk your wallet. The “prudent layperson” standard is supposed to help. Anthem uses it to scrutinize. The result is uncertainty. You go to the ER because you are scared. You get a bill because you were too smart. Or not smart enough. The line is blurry.
The fear is real. Dr. Stanton says people are now afraid to seek care. That leads to injuries. That leads to deaths. Anthem wants to cut costs. They are cutting access. The question isn’t just about money. It is about who decides what is an emergency. The patient? The doctor? Or an insurance reviewer looking at a chart weeks later?
The system is broken. Anthem is pointing at the symptom. Patients are left holding the bag.
Defining “Avoidable” ER Visits
The data on emergency room misuse is messy. It depends entirely on who is counting and what they mean by “unnecessary.”
A 2017 study in the International Journal for Quality in Health Care looked at visits between 2005 and 2011. The finding? Only 3.3% were avoidable. That aligns closely with a 2015 CDC statistic sitting at 5.5%.
Then there is Truven Health Analytics. Using 2010 insurance claims, they claimed 71% of ER visits were unnecessary.
The gap is massive. The word “avoidable” shifts meaning depending on the source.
When Anthem Covers Emergency Care
Anthem takes a specific stance on this. Their spokesperson, Gaines, says if you reasonably believe you are facing an emergency, go to the ER. Or call 9-1-1.
But coverage isn’t automatic for every walk-in. Anthem has specific conditions where they will cover an ED visit. Many of these rules were tweaked in January 2018 after public pushback against their original policy.
You are covered if:
- A provider, including an ambulance crew, directed you to the ER.
- The patient is under 15 years old.
- You live more than 15 miles from an urgent care center.
- The visit happens between 8:00 p.m. Saturday and 8:00 a.m. Monday, or on a major holiday.
- You received surgery, IV fluids or medications, or an MRI or CT scan.
- You presented with conditions like chest pain, difficulty breathing, convulsions, fainting, or drug overdoses.
Currently, this ER program is active in only five states: Missouri, Georgia, Ohio, Kentucky, and Indiana. There are no plans to expand it elsewhere right now.
“Consumers who reasonably believe that they are experiencing an emergency medical condition should always go to the emergency room or call 9-1-1.”
For deeper dives on navigating these costs, readers often look at resources like Don’t Buy That Health Insurance: Become an Educated Health Care Consumer by K. R. Woodfield. It’s one of the titles recommended by HowStuffWorks for those trying to reduce health care costs. Note that affiliate links generate revenue for the site if you buy through them.
The Hidden Cost of Surprise Billing
The problem isn’t just whether the visit was necessary. It’s what happens after you leave.
Surprise billing is a common side effect of ER care. Here is the trap: you go to a hospital that is in your network. You feel safe. Then you are treated by a doctor who is not.
This happens about 22% of the time.
The result is hefty, unanticipated bills. You paid for coverage, but the provider on the other side of the exam room didn’t have a contract with your insurer. You are left holding the tab.
It’s a structural flaw in how billing works. The hospital is one entity. The anesthesiologist, the radiologist, the emergency physician—they can be separate ones. And if one of them is out-of-network, you pay the difference.
Or your insurer fights it. Or you fight it.
There is no clean fix yet.
