Los Angeles Emergency Room Claim Denial Lawyer
Page Contents:
Did You Receive An Emergency Room Denial?
Health insurers sometimes implement policies that deny coverage for emergency room
visits deemed “non-emergencies” or “non-urgent.” These policies were
purportedly
created to combat the rising number of emergency room visits
for non-emergency
situations.
In fact, however, according to the CDC,
only about
5.5%
of ER visits are non-urgent.
If your health insurer denied your ER claim in LA, our firm can aggressively pursue justice. Contact us onlineto request a free case evaluation.
Anthem Emergency Room Denial
The most notable insurer partaking in this policy,
Anthem
Insurance, believes that by sending denial letters to customers following an emergency
room visit, it will discourage other patients from going to the emergency
room
for
less serious ailments. The policy started in Kentucky in 2015
and
spread
to
Missouri,
Georgia, Indiana, Ohio, and New Hampshire in
2017.
In
Missouri,
Kentucky
and Georgia
alone, Anthem denied
12,000, or 5.8% of ER claims between July and December 2017. Anthem altered its policy
slightly in
February 2018.
The American College of Emergency Physicians (ACEP) and the Medical Association of
Georgia sued Anthem over its policy alleging it violates federal law.
Of course, claim denials don’t just hurt policyholders. Physicians and facilities
also don’t get reimbursed for their services. In July 2022, the California
chapter of ACEP
asked
members of Congress to intervene and enforce California law. And in
February 2023, the California Medical Association filed a formal complaint with California’s Department
of Managed Healthcare regarding Anthem continually denying payment for
ER
services
in violation of California law.
States such as Indiana and Kentucky are following private insurers and are implementing
similar policies with Medicaid enrollees. The rise in this health insurance
practice
is pushing patients to assess their own medical condition,
which
is
very dangerous,
or to pay thousands out of pocket.
In a statement, Anthem said that the purpose of the policy is to maintain high-quality
health care for those who come into an emergency room, and moving non-emergency
cases
into the most appropriate setting. Anthem, one of the largest
private
health
insurance
providers in the United States, claims that
more than
a
quarter
of trips
to the emergency
room could be treated
at a doctor’s
office
or retail
health clinic
instead of an
emergency
department. While
this may
be true for
its members, hindsight
is twenty/twenty.
UnitedHealthcare Emergency Room Denial
New York’s Attorney General sued UnitedHealthcare in 2019 for denying ER claims.
The lawsuit alleged that UnitedHealthcare utilized a computer algorithm
to
determine
if certain visits were medically necessary, and then retroactively
denied ER
claims.
The AG’s lawsuit claimed this practice violated state
and
federal laws
as well
as
UnitedHealthcare’s own insurance policies.
The
insurer
didn’t communicate
to
plan
members that some ER visits might
not
be covered
and didn’t have a fair
appeals
process
for denied claims.
UnitedHealthcare
released a new
policy
in June 2021 that was going to start on July 1, 2021. The insurer planned to retroactively
evaluate ER claims and, if the visit was deemed non-emergent, provide
limited
or
no coverage. Provider groups, the American Hospital Association,
and
the
American
College of Emergency Physicians
pushed back. They argued that patients should not be expected to self-diagnose in an emergency
and that patients would avoid emergency rooms due to potential large
medical
bills.
UnitedHealthcare then delayed the new policy until at
least the
end
of
the COVID pandemic.
In July 2023, the Department of Labor sued a division of UnitedHealthcare that manages
self-funded health insurance plans for allegedly violating
ERISA
by denying all urine drug tests from August 2015 to August 2018 and by denying ER
visits after the fact.
Aetna Emergency Room Denial
California’s Department of Managed Healthcare fined Aetna
$500,000
in August, 2020 for denying ER claims against state law. The DMHC discovered that
of the claims it reviewed, 93% of
Aetna’s
ER denied claims shouldn’t have been denied according to California’s standards.
California laws enabling emergency services are stricter than Aetna’s
national
ER
policy. The law stipulates that health insurers must cover
emergency
services
unless
the service didn’t take place or the patient
didn’t need
emergency
care
and “reasonably
should have known” that they
didn’t need
emergency help.
Moreover,
the DMHC previously
fined Aetna
$135,000 for denying
emergency room
claims in
2015 and 2016. At the
time,
the DMHC warned Aetna
it must apply
California’s
standards
instead of
its
own national
standards
to policyholders
in the state.
HMO and Medi-Cal Emergency Room Denial
If you “reasonably believe” your situation is an emergency, then you can go to any
emergency room. Even with HMOs and
Medi-Cal
plans like
Blue Shield Promise Health Plan,
Health Net,
Anthem Blue Cross
and
Molina
that have networks of physicians and hospitals, if you think your situation is an
emergency, then every health plan must cover your care – even if the
hospital is
out-of-network
and even if you are out of your plan’s service areas. California’s Department of
Managed Healthcare defines emergencies in other ways as well including
a
bad
injury,
a sudden serious illness, severe pain, active labor, if
delaying
medical
care
could
be a danger to your life, and
more. If you are admitted into the hospital, then your health insurance plan can move
you to one of its in-network hospitals when you are stable enough to do so.
Critics of Health Insurance Emergency Room Denials
Consumer advocacy groups, such as the American Heart Association, say that these
policies could prevent patients from seeking the medical care they may
need
for
life-threatening
emergencies. The denial policy Anthem uses
comes
with
a
list
of
exceptions, such
as the company will pay for emergency
room visits
for
patients
younger than 15, when
a customer is traveling
out of state,
or
if the
medical
event
takes place over the
weekend or
a holiday.
Critics to the policy believe that the emergency department exists to diagnose unknown
ailments in an expedited manner. Expecting an untrained individual to
gauge
the
severity
of their own symptoms, could lead to illness, disability,
or
even death.
Is An ER Required To Treat Me?
The federal Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA) mandates that emergency rooms treat patients with life threatening emergencies.
This law requires hospitals to give a patient a medical screening exam
to
determine
if they are having an emergency. If the patient is indeed
having
an emergency,
then
the hospital must give stabilizing treatment.
If the
hospital
cannot provide
this
treatment, then it must transfer
the
patient
to a facility
than can provide
this
treatment. In May 2024,
CMS
launched
an option in CMS.gov
where patients can file
complaints
if they were not treated fairly according to EMTALA.
Summaries of Some Cases That We Have Filed
In addition to these example case summaries, please view a full list of
our results and client testimonials.
- We filed a case against Blue Shield of California for denying medically necessary
emergency treatments. When our client got seriously ill with
a strep
infection
while
on a trip out of the country, Blue Shield
initially
lost and then
denied
his claim
for coverage of his
emergency treatment.
This treatment
included
hospitalization,
an ICU stay, and surgery
to
remove parts of
his lungs. Blue
Shield claimed
that
his
treatment
wasn’t
an emergency,
leaving our client
with
tens of thousands
of
dollars
in medical bills.
Our lawsuit alleges
that
Blue Shield has a system
in
place that
is designed
to save
money by denying
emergency care
coverage
to
its
members. It also
alleges that Blue Shield
doesn’t
properly investigate
claims
before
denying
coverage
and even incentivizes
its medical reviewers
to
deny
care. The
lawsuit alleges that
this
conduct
violates California
law and is unfair,
unlawful,
and fraudulent.
We
are suing
Blue
Shield
for breach of implied
covenant
of good
faith and fair dealing,
breach
of contract, and violations
of Business
& Professions
Code Section 17200.
- We filed a case against Oscar Health Plan for denying medically necessary emergency
treatment. Our client, nine months pregnant, had a traumatic
injury
after
a
head-on
collision and was rushed to the hospital.
Oscar
denied
coverage
for
these emergency
services and our client
was
left with
tens of thousands
of dollars
in medical bills.
Our lawsuit
alleges
that Oscar’s utilization
review system
systemically
fails to
conduct
full, fair, and thorough investigations
before
denying coverage.
We are
suing
Oscar for breach of implied covenant
of good
faith
and fair dealing,
breach
of contract,
and violations
of
Business
&
Professions Code
Section 17200.
What Can You Do If You Receive a Health Insurance Emergency Room Denial?
The “No Surprises Act,” effective January 1, 2022, provides several protections for policyholders in emergencies
and protects against certain emergency room denials. You can learn more
about
specific
protections on
this
page.
If you or a family member receives a health insurance emergency room denial or other
denial
of a necessary medical procedure, contact the Law Offices of Scott Glovsky. Our team of
knowledgeable attorneys
can help assess your situation and support you in
appealing
a health insurer’s claim denial.
If you were denied emergency care in Los Angeles, don’t wait to seek justice. Call
(626) 323-8351 to schedule a free consultation.
