Biggest health insurer plans to deny ER bills if it doubts you had an emergency

I've had this concern for a while myself.

I once quit a bay area tech startup job in my 20s due to burn out (5 years no vacation, easily 50+ hour weeks) and in those few months of taking time for myself I got hit by a bout of what I assume was appendicitis. I delayed going to the hospital because I didn't have insurance since I had just left my job. The pain passed that day, but then a few weeks later the same excruciating pain came back -- just really indescribable pain -- to the point where I semi-consciously was asking my partner to make sure I didn't die. Ended up at the hospital, they confirmed appendicitis, did the surgery in less than an hour, and I got hit with a $25k bill. I remember an administrator coming into the room before the surgery and asking me for a credit card while I was completely out of it, because I assume someone told them I didn't have insurance.

After it all happened I was talking to a friend of mine who is an ER doctor and he told me, quite frankly, that if you ever find yourself in a situation like that to just leave your wallet at home and give a fake name. As a doctor they're going to treat you no matter what.

It's horrifying that we have to deal with this system in the United States. It does make me consider seeking citizenship elsewhere, which I consider more seriously the older I get.

One thing I read is public hospitals seem to be overwhelmed with uninsured patients who often come for emergency care because they have no other options. Private hospitals are able to grab the insured patients. Medicaid funding is not enough to pay for the cost of care for low income patients so hospitals survive on those private insurers to balance the books. There was a recent Frontline documentary about this. https://www.pbs.org/video/the-healthcare-divide-rv6npd/

It's weird though, you'd think that would be exactly the kind of risk that would be insurable. Privately or as a whole society. Some of us will keel over on the spot or otherwise incur near-zero end-of-life costs; others will need $2 million of care to make it through the last couple of years. It seems less relevant whether people in society pay their everyday medical costs out of pocket, compared to the fact that any one of us might need rare expensive treatment or complex care. The whole country sharing the risk as a massive national collective self-insurance exercise seems like the best solution.

Well, honestly, doctors can only do so much too.

Serious abdomen pain can be gas or something serious. You can cough hard enough to fracture a rib. Chest pains can be acid reflux or a heart attack: I had gastritis when this happened to me.

And this is a good deal of the issue: You don't know how serious it is until you go to the doctor.

Now, this doesn't cause all of ER misuse, but we aren't doing anything to make that better. A doctor won't see you if you can't pay upfront. This is the same problem with urgent care: Either pay upfront or don't get helped. The ER, though, will bill you. Which does mean that if you are poor - especially just over the income level to get help with a lot of expenses - you either go to the ER when you need a doctor or you don't get seen and have to wait until it IS serious enough for the ER.

We can solve this by making sure everyone can very easily afford health car (I no longer live in the US: My out of pocket is $300 per year, and this includes necessary prescriptions, doctors, physical therapy, some dental stuff, and so on). The rest is paid in taxes, which are less than federal + state + health insurance was in the states: Nevermind having to pay a deductible before the out of pocket. (I know my GP will bill me, by the way).

But another way to handle this is to have something akin to urgent care on hospital grounds - a place that folks can see a doctor/nurse practitioner for non-emergency things and get billed later.

The counter point to this, is that I know of a family member went to the ER after passing out (after the 2nd incident) and was able to diagnose a life threatening condition. If they had a healthcare plan like this, they would have probably not gotten care and would be at risk, because the only reason the diagnosis happened was due to symptoms that only show up immediately after their incident.

The risk here is having patients doing their own triaging. If the insurance company really wants to reduce costs, they can partner with a network of ERs who commit to triaging and transferring to lower cost providers if the issue is not an emergency. The patient is not qualified to make that decision.

I worked at a health tech company where we analyzed bringing down costs through claims data, I can tell you that there are actually hundreds of ways insurance companies can reduce costs that won't risk patient safety, but do not. For example, there are billing mistakes all the time, but insurers do not give a crap. We tried building features to help identify billing mistakes but we never could get insurers to care about it. The amount of times I saw insurers undermine patient safety for "costs" was staggering so I'm really skeptical that the insurers are doing the right thing here. As another example, we saw insurers build "Centers of Excellence" and push patients towards taking care there. Basically what they did was find crappy hospital systems who were willing to take lower rates and they would tailor their insurance plan to push patients that way. Unfortunately when we analyzed claims and outcomes we found these Centers of "Excellence" actually had way worse patient outcomes. We raised this point with the insurers and again, they did not give a crap.