Insurers Begin Denying Payment for “Unnecessary” ED Care


New coverage policies by Blue Cross Blue Shield of Georgia and others could bankrupt patients – or worse.

In May 2017, Blue Cross Blue Shield (BCBS) of Georgia announced it will no longer cover “unnecessary” emergency department (ED) care, starting July 1. According to BCBS Georgia President Jeff Fusile, “…we have got to find a better way to do some of this stuff, taking some unnecessary spending out of the system.” Fusile would rather patients use urgent care, retail clinics, and their online app, instead of costly EDs for conditions treatable in those settings. The BCBS policy follows similar ones enacted by Anthem in New York, Kentucky, and Missouri.

To many, these policies seem well-intentioned for a fiscally responsible insurer in a country with out-of-control healthcare costs. The simple goal: drive low-acuity illness to cheaper settings, which will control costs and in turn, allow for lower premiums.


Insurers are partly right: inefficient setting selection is a real issue. It is not uncommon for emergency physicians to face situations where a panicky ED patient realizes their perceived health emergency was a false alarm. Some well known examples: a toddler with a fever and listlessness who perks up after a weight-appropriate dose of ibuprofen; a bout of severe, unrelenting abdominal pain that resolves spontaneously right after the patient is triaged and passes gas; the allergic reaction which initially felt like “throat closing” with not even a hive after some Benadryl.

Some ED patients could potentially be served elsewhere. Some patients come to the ED when they didn’t need any medical attention at all. But the reality is there is no systematic way for patients to reliably and safely determine whether their symptoms represent an emergency. Many patients are referred to the ED by their doctors, others have no easy access to physicians, and many do not know about or think they should use telemedicine during a potential health emergency.

Bottom line, it is playing with fire for BCBS and Anthem to systematically discourage ED use. Sometimes, fever and listlessness is meningitis, unrelenting abdominal pain can be a bursting appendix, and allergic reactions occasionally result in life-threatening anaphylaxis. All are potentially lethal if untreated. Insurers’ new ED deterrent policies create a new, unfair responsibility for patients: self-diagnose accurately, or else. Patients choosing incorrectly face steep financial penalties after seeking care in settings deemed “non-ideal,” decided after the fact by their insurer using their final diagnosis.


These policies will dissuade some patients from using the ED. They will also save insurers a boatload of money, allowing them to happily keep more of their members’ hard-earned premium dollars.

Yet for many, the perception of a potential health emergency will be too great to bear. The fact is most patients do not consider costs when they think they are having an emergency. No doubt, many patients in Georgia, New York, Kentucky, and Missouri will continue to pile into EDs at all hours for conditions that end up being nothing serious. But later, they will punched in the gut by their insurer with a “surprise coverage gap”: a large out-of-pocket bill, despite already having responsibly paid their insurance premiums. Their insurers will recast this travesty as “surprise billing” by greedy physicians and hospitals.

Given the large numbers of people these policies affect, some hapless patients will err on the side of fiscal responsibility, risking their safety and well-being. They may initially think they need care, but will think twice and make the wrong decision. Deferring life-saving care will cause them to experience a poor outcome or even die.

These insurance policies ignore the realities and uncertainties that patients face during illness and injury. Patients with minor symptoms not uncommonly have serious illness, and many patients with symptoms that first seem serious end up being nothing. A 2013 JAMA article described this phenomenon: the 6% of ED patients with “primary care treatable” conditions had the same chief complaints as 89% of overall ED visits. Even for expert emergency physicians and nurses armed with advanced equipment, the art of accurate diagnosis can be deceivingly difficult. It sometimes takes an ED visit to figure out whether a condition is “primary-care treatable.”


For the American College of Emergency Physicians (ACEP), this is not its first rodeo with insurers over fair coverage. This came to a head in the late ’90s with repeated denials for ED visit claims: for example, crushing chest pain ultimately diagnosed as gastro-esophageal reflux. In the end, ACEP’s work along with patient outcry led to the “prudent layperson standard.” This requires insurers to pay for emergency conditions that, according to a person who “possesses an average knowledge of health and medicine,” potentially places someone in serious jeopardy from impairment of bodily function or dysfunction to bodily organs. The prudent layperson standard was written into federal law in the Patient Protection and Affordable Care Act of 2010. The intention of prudent layperson was to not allow insurers to make post-hoc coverage decisions. Specifically, by reviewing limited information (i.e. the discharge diagnosis), an insurer has no way of knowing what brought the patient to the ED or whether a prudent layperson would have considered their symptoms a medical emergency.

The trouble is that now BCBS Georgia thinks that it can read their beneficiaries’ minds, apply the prudent layperson standard fairly and reliably, and not pay for “non-emergencies.” Think again.

Take a 43-year old female who whacks her foot into the door jam at 1 a.m., which is immediately painful and she can’t bear weight. The toes turn dark purple, and appear swollen and deformed. After ibuprofen, the pain becomes unbearable. She goes to the ED (the only place open), gets an x-ray and some pain control. She goes home comfortable, reassured there’s no fracture, with a surgical shoe and a prescription for painkillers. Weeks later, insurance staff reviews her claim and sees the ICD-10: “S90.1 Contusion of toe without damage to nail.” Nowhere in her insurance records did it say she had severe pain, ibuprofen was ineffective, or that she couldn’t walk. The conclusion: another “unnecessary” ED visit for a stubbed toe. She is left paying $1200 out of pocket. One night, several months later, she is awoken by chest pain. Still stinging from her “surprise coverage gap,” she goes back to sleep, hoping it’s nothing and dies from a heart attack. The only winner is her insurer, who got out of paying for not one, but two ED visits.

Where and when people should seek care when sick and injured is thorny business. The terms “inappropriate” and “unnecessary” are commonly invoked, yet never defined reliably. A recent study found that experienced emergency physicians only agreed on “ideal” settings for about half the time, even with detailed clinical information about the ED visit.  Therefore, it is impossible for insurers to know with any reasonable certainty whether any particular case was “unnecessary” with the limited data they review or whether a prudent layperson would have sought medical care.

So where do we go from here? Like the many prior attempts to implement similar policies, the BCBS and Anthem coverage shell game will ultimately fail. Patients will not stand for it. ACEP and other hospital groups will fight it. However, along the way many patients who trusted their insurance company to cover their medical bills will experience a “surprise coverage gap.” For everyone who this happens to, the bill will certainly sting. Some will go bankrupt. And a few will experience avoidable medical complications or die off in the process.


HEALTH POLICY SECTION EDITOR Dr. Pines is a practicing emergency physician and a Professor of Emergency Medicine and Health Policy at the George Washington University.


  1. Thank you Dr. Pines, I’m concerned about your 2am stubbed toe example because Anthem will push back and say they allow such ED visits on review if they occur during nights and weekends when a PCP is not available.

    • Thanks for the clarification. I know this is a moving target and there are considerations about lists of diagnoses, times of day, weekend, etc. The example is meant to demonstrate that visits that may seem minor in retrospect are actually very urgent for the patient.

  2. How many docs will “buff” the chart so that the complaint becomes billable? Many I presume. That cough with chest pain we diagnose as “URI” will now become “URI” and “Pleurisy” or just “Chest Pain.” With that will become many expensive tests and possibly increased radiation exposure. This will backfire on them. But of course they will admit no fault. Disgusting.

  3. Jim Mensching, DO on

    Not surprising at all.

    I’d be fascinated to know if any ED physicians working for BCBS helped develop this policy, or resigned over it. Additionally, what is BCBS liability if their “online app” causes a patient to delay in seeking care, resulting in death or disability?

    • michael gross on

      None. Patients make the final decision. It’s a reboot of Wickline, where a CA physician was liable for injury to a patient who was discharged when insurance coverage for mental health was denied, despite the MD’s insistence that the patient was ill.
      This must be fought at a governmental level. One solution would be to mandate a 24 hour line that patients call, run by the insurance company, to get advice from them. This would put them on the hook for missed diagnoses and injuries. It’s still a half-assed solution, though. Post hoc coverage denials should be outlawed. They are an example of profit-seeking that trumps reasonable care.

  4. I feel compelled to play Devil’s advocate a little here. I’ve been practicing in an overwhelmed ER for the last 9 years and having metrics of throughput and Yelp, Facebook reviews, Google Reviews, JL Morgan and Press-Ganey scores shoved in my face as measures of my competency, and as constant threats to our contracts with hospitals. At the end of my day when I review my patient list and encounters, I would not be exaggerating if I said that 25% of the patients I see did not need immediate care. While I acknowledge your points about potential for patients to hesitate next time a complaint arises, out of fear of financial ownership, I am not sure that is such a bad thing. The pendulum has swung so far in the direction of patients having no ownership and the demand for instant gratification and answers. Even the community physicians abuse the ER. I am certain that the answering machines in every pediatric office and primary care office, begin with, “if you are concerned, go to the Emergency Room”.
    I also understand that the billables for my group will inevitably go down, as our visits will decrease. Again, from a societal perspective, where is the greater good? The majority of patients that abuse the system have no co-pay because they are on some form of Medicaid, whether it be straight Medicaid or managed care. For them, there is no disincentive to come to ER. No appointment, minimal wait, immediate access to diagnostics that would otherwise require authorization and another appointment, and no financial obligation. While they’re there, they ask for Rx for motrin, benadryl, pedialyte, tylenol and hydrocortisone cream because “Medicaid pays for it”.

    • You are totally right about the ED being overwhelmed and also correct that most of these unnecessary visits are by people with no copay such as Medicaid. I’ve seen medicaid patients come to the ED for a pregnancy test and I can’t afford to buy Tylenol and I get it free in the ED…. Ridiculous . On the other hand in many rural communities there are no urgent care facilities and local doctors aren’t taking new patients as there is a severe lack of rural medical care. The meddle class should not have to go bankrupt when they are paying for insurance while the Medicaid patients who are usually not working and many fraudulently obtaining Medicaid pay nothing and have much better access to care.

  5. Thanks for this informative essay Jesse! It was circulated across Missouri today by the Missouri chapter of ACEP ( As with most things in life, I believe that the best answer probably resides somewhere in the middle. I wish that Americans would explore additional alternatives to the ACA or the GOP health bill. For example, over 10 years ago David Gratzer suggested some interesting ideas pre-Obamacare ( Unfortunately, our politicians seem to believe that there can be only two choices – the Democratic way or the Republican way. I think that a greater emphasis empowering patients via economic freedom and fiscal responsibility, as outlined by Dr. Gratzer, is worth exploring in theory if not in policy. Additionally, I think that the current Anthem approach to reducing ED visits is particularly short-sighted without first significantly increasing access to primary care and reimbursing primary care providers in line with specialists. As noted on a recent episode of Primary Care Medical Abstracts (, for too long our primary care colleagues have been paid platitudes by multiple stakeholders but remain among the lowest paid specialties.

  6. Thomas Benzoni on

    Could we have an informed discussion:How much money would be saved under varying circumstances? Publish this using % of US healthcare.
    Having exposed the absurd, we can move on to important topics.

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