[downandout]

This story is couched in terms of how bad things were before Obamacare, but I’d like to point out that things aren’t great now either. To prevent Obamacare from bankrupting them, insurance companies are resorting to legally dubious mass-denials, one of which affected me personally.

A few months ago, I woke up the next morning after eating some fast food and began vomiting. I couldn’t stop throwing up, and I couldn’t eat anything, for 2 straight days. I had a 101 degree fever at the worst point. At the beginning of day 3, when I vomited so hard that I passed out for a few seconds and fell on the floor, I went to the ER. They gave me IV fluids and anti-nausea medication, which worked.

About 2 months later, I received a letter from my insurance company (Anthem). They had determined that my situation didn’t qualify as an “emergency,” and therefore they were denying the entire bill for this ER visit. I have appealed, and so far it has not been overturned. I am now on the hook for thousands of dollars, even though I had already covered my entire deductible for the year.

I thought that this had to simply be a mistake, but then I learned this is actually a new policy that insurance companies are implementing in the era of Obamacare [1]. Patients are expected to self-diagnose whether or not their situation meets their insurance company's definition of an “emergency,” and are rolling the dice as to whether or not an ER visit will be covered.

[1] https://www.vox.com/policy-and-politics/2018/1/29/16906558/a...

[magicalist]

> To prevent Obamacare from bankrupting them, insurance companies are resorting to legally dubious mass-denials, one of which affected me personally.

What does the policy has to do with Obamacare? Completely unfair denials obviously happened before the ACA (see: this article), and the idea that Anthem is doing this to stave off bankruptcy is laughable (just see their financials since the ACA was enacted).

[downandout]

It seems to be happening more and more post-Obamacare. Further, this is an actual policy now, and this policy was created post-Obamacare (my incident occurred in Nevada, where they have not received permission to deny these claims like they have in other states, so apparently they feel the need to roll it out nationwide without telling anyone). There was no need for the policy before, but now apparently there is in an Obamacare world. But they can't expect people to diagnose themselves and determine whether or not a situation is an "emergency" under insurance company rules, since the symptoms of many non-life threatening conditions feel like they may be life threatening.

Unfortunately, in capitalist economies, when you use the law to put the hurt on companies, they will pass that hurt onto unsuspecting consumers. The money will come from somewhere, and it's not coming out of executives' pockets. Perhaps this is why Nancy Pelosi urged lawmakers and the public not to read Affordable Care Act before it was passed it into law [1]. Had everyone read it, they would have known that problems like this would eventually arise.

[1] https://www.youtube.com/watch?v=hV-05TLiiLU

[lostlogin]

The fact that this cost that much is alarming too. I get that the staff and bed bay aren’t cheap, but the consumables for the situation you describe would probably cost less than $10, and at bulk buy prices perhaps on a couple of dollars.

[downandout]

True, but as patients we obviously have no control over that. Also, ironically, if my insurance had simply processed the claim as they were supposed to, they would have paid far less than I'm being billed. ER cash prices are purposely inflated because insurance reimbursements are typically 1/3rd or less of the billed amount. But when the claim gets denied, they come after the individual for the full cash price.

[ams6110]

Call the hospital and offer to settle. They will cut the price almost certainly. Almost anything they can get you to pay will be more than they will get selling the debt to a collector.

[downandout]

Thanks for the advice. If all of my appeals are denied, I will follow it and try negotiate the price down. In any event, this won’t be a catastrophic financial event for me. But it sucks that it is happening to so many people under our current insurance regime, and not not all of them can handle it when their insurance decides not to pay.

[salawat]

It's interesting that you mention that. I have Blue Cross, and I've been dealing with seemingly procedural denials every month for a chronic condition.

It's getting to the point where I'm genuinely thinking there is some bad faith activity going on.

[downandout]

There's more likely than not some bad faith activity going on. They are essentially watering down what it means to have insurance, since they are required to sell it to people that they wouldn't otherwise have and are trying to make up the difference. One way or another, we're all paying drastically higher expenses than we would have before. If I have to pay the denied claims in my case, I'm looking at a $9800 out of pocket expense, on top of the $5K/yr premium I pay as a healthy nonsmoker.

Anthem pulled out of my state altogether for 2018, so I also had to switch providers at the beginning of the year (this claim was from late 2017). I think that's another reason they are giving me issues with this claim - they simply don't care because they no longer have to deal with my state's insurance regulator. The new insurance provider (which was the only choice I had in my area, regardless of price) so far appears to be even worse and more expensive. Something has to be done about all of this. I don't pretend to have the answer, but the ACA was apparently not it.