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Should insurance companies be able to deny claims for getting certain non-urgent procedures in a hospital emergency room?

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Anthem, the health insurance company, will limit the procedures it will pay for if they end up being done in a hospital emergency room, starting January 1st.

The New Hampshire Insurance Department said Anthem recently submitted a list of 14 categories of non-emergency services it will deny (with some exceptions) when delivered in an emergency room setting. The list included ingrown nails, pregnancy tests, eyelid disorders, high blood pressure checks, constipation, mild sprains and contusions, rashes, dental disorders, plantar warts and general medical exams.

Also included on the list of services to deny in ER settings were the removal of sutures and the issuance of repeat prescriptions.

Anthem indicated that it would still cover the above services for patients under age 14.

So far, Anthem is the only insurer pursuing this policy. The company does not need to get state approval before it is implemented.

Reasons for limiting ER coverage

Anthem said it is seeking to curb unnecessary use of the emergency room, which is more costly (and therefore more expensive to cover) than a visit to the doctor’s office or an urgent care clinic. Those higher costs can push up premium rates, making healthcare most expensive for everyone.

The insurer argued that too often, emergency rooms are used as a convenient walk-in office for minor ailments.

“Most people would agree emergency rooms should be focused on providing care to those suffering from emergency situations,” said an Anthem spokesman.

Downsides of limiting ER coverage

Some physicians are concerned that Anthem’s policy might have a chilling effect on people going to the hospital to seek care for seemingly mild symptoms, such as a rash, that could be a symptom of something far more serious.

“People cannot be afraid to go to the hospital,” said an emergency room physician at Portsmouth Hospital. “I am mortified by this. If a person has a rash, it could be less serious, but it could be indicative of Stevens-Johnson syndrome, meningococcemia, Kawasaki’s disease, toxic shock syndrome.”

Have your say

What do you think? Should insurance companies limit what emergency room treatments they will cover? Let us know by leaving a comment—yes or no, and why—in the space below.


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