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US insurer Anthem aiming to reduce 'avoidable' ER visits

New York

JIM Burton was lifting a box in his garage last August when he felt a jolt in his back.

He thought he'd slipped a disk. At the emergency room, Mr Burton, a 37-year-old resident of Lexington, Kentucky, was found to have a back sprain and was sent home.

He soon got another surprise. His health insurer, Anthem, refused to pay medical bills totalling US$1,722, saying his care in the emergency room had not been needed "right away to avoid a serious risk to health".

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To rein in emergency medicine costs, Anthem is reviving an old, contentious tactic: pushing back on patients who visit the emergency room for ailments deemed minor.

Anthem denied thousands of claims last year under its "avoidable ER programme", according to a sample of emergency room bills analysed by the American College of Emergency Physicians. The programme, which Anthem has been rolling out in a handful of states in recent years, reviews claims based on the final diagnosis of patients.

Emergency room physicians say that, last year, the company did not routinely request medical records for denied patients, and therefore could not review the symptoms that brought them to the emergency room. Anthem says it is now reviewing such records before issuing denials. The company says the policy goal is to reduce use of the emergency department, one of the most expensive places to receive medical care. Anthem recommends that patients with sprains and upper respiratory infections instead consider a visit to a primary care doctor or an urgent care centre.

"The costs of treating non-emergency ailments in the ER has an impact on the cost of health care for consumers, employers and the health care system as a whole," Jill Becher, a company spokeswoman, said in an email.

But doctors and consumer advocates argue that the policy forces patients to diagnose their own illness, and may discourage people with serious problems from seeking care.

Karen Englert, the government relations director at the Missouri branch of the American Heart Association, said her organisation has worked for years to teach women to look for early, unconventional signs of a heart attack, like indigestion, nausea or arm pain.

"For some women, those are absolutely the precursors to a heart attack," she said. "We can't look inside ourselves to know this is what I have. And patients shouldn't be expected to - they aren't doctors." NYTIMES