When a health insurer won’t pay for an ER visit

Our 7-year-old daughter awoke screaming and could not be comforted or touched. We took her to the emergency room. Now our insurance company is denying the visit, saying that it wasn’t medically necessary for her to be seen in the ER. Yet the emergency room physician considered a spinal tap to rule out meningitis. How could this visit not be necessary?

The situation you describe certainly seems to qualify as an emergency, and you should fight to have your insurer pay for your daughter’s ER visit.

According to Dr. David John, an emergency room physician in Stafford Springs, Conn., and former chair of quality and patient safety for the American College of Emergency Physicians, it’s quite typical for a patient to enter the ER with symptoms indicating a serious medical condition but leave with a diagnosis that sounds anything but urgent. Imagine, for example, the common scenario of a 50-year old man with a heart condition who comes to the ER complaining of crushing chest pain but, after a medical work up, is found to be suffering from indigestion.

By law, health plans are required to pay for emergency room visits for medical situations in which an average person believes his or her health or life is threatened (called the prudent layperson standard), according to John. Your ultimate diagnosis cannot influence whether your emergency room visit is paid for by your insurer.

As a first step, look into the possibility that a billing error occurred. For example, in John’s scenario, if indigestion were accidentally listed as the admitting diagnosis, the insurer might deny the claim because even someone without medical training would realize that’s not an emergency, says Susan Pisano, a spokeswoman for America’s Health Insurance Plans, a trade group based inWashington, D.C.

“Sometimes the admitting diagnosis is incorrectly communicated to the insurer,” Pisano says. “Make sure the health plan has the right information.”

Call the member services telephone number on the back of your insurance card to speak with a customer service representative. Keep a record of all calls you make, including whom you spoke with and exactly what steps he or she plans to take to help you. Ask whether there is anything you can or should do to help remedy the situation, Pisano suggests.

If that doesn’t clear things up, your next step is to file an appeal with your insurer. Under the Patient Protection and Affordable Care Act, many consumers have the right to challenge their health plan’s decisions. (So-called “grandfathered” health plans, which were already in place when the act became law on March 23, 2010, are exempt from complying.)

When it denied payment, your health plan should have sent you instructions about how to initiate an internal appeal, the process through which the plan reviews its payment decisions — it’s required by law to do so.

If you’re unsatisfied with the outcome of the internal appeal, you can initiate an external appeal. Your case will be reviewed by doctors who do not work with your health plan. In many places, this is handled by the state’s department of insurance; sometimes an independent review organization conducts external reviews. You can contact the department of insurance in your state for assistance.

In California, patients with HMO coverage can request an Independent Medical Review from the California Department of Managed Health Care by calling (888) 466-2219 or visiting healthhelp.ca.gov. Patients with PPO coverage should try the Department of Insurance at (800) 927-HELP (4357) or go to insurance.ca.gov, choose the “Consumers” tab, select “Health Related Insurance Information” from the menu and then click on “Independent Medical Review (IMR) Program.”

“If the doctor [reviewing the case] determines that a reasonable and prudent person in the patient’s circumstances would believe he or she was experiencing an emergency or urgent medical condition requiring emergency or urgent medical services, the health plan will be required to cover the treatment or service provided,” says Marta Bortner, a spokesperson for the California Department of Managed Health Care in Sacramento.

There are a few other things to keep in mind. Under the health reform law, insurers have to pay for an ER visit even if the hospital is not in your plan’s network. (Again, grandfathered plans are exempt.) And they can’t charge you higher co-pays (the flat rate for a medical visit) or co-insurance (the percentage of a visit’s cost) for the visit either.

However, a doctor who doesn’t have a contract with your insurance company might engage in balance billing, hitting you up for any charges that aren’t paid by your insurer. Some states, including California, have banned balance billing. If you receive bills for out-of-network ER services, consult with your state’s department of insurance to learn about the laws where you live.

In addition, 19 states, including California, have set up or strengthened existing consumer assistance programs under the auspices of the Affordable Care Act. Program staffers help people file complaints and appeals, learn about their rights and enroll in insurance. To see whether there’s a program in your state, visit healthcare.gov, go to the tab labeled “Get Help Using Insurance,” select “Managing Your Insurance” and click on “Consumer Help.”

Zamosky has been writing about how to access and pay for healthcare for more than 10 years.

Got a healthcare dilemma? Email health411@latimes.com or write to Health 411, Los Angeles Times Health, 202 W. 1st St., Los Angeles, CA 90012.