The Morning Call, Allentown, Pa., Watchdog column: Insurer settles ER disputes [The Morning Call, Allentown, Pa.]

Dec. 27--The sharp, stabbing pain started on Linda Sheridan's right side and extended around to her belly button. It got worse as each day passed.

After three days, she couldn't bear it anymore and went to Lehigh Valley Hospital-Muhlenberg, where she received $8,200 worth of care and tests.

She was released, then spent the next three months seeing more doctors and undergoing more tests, leading to a hysterectomy to relieve the pain.

That pain soon was replaced by another.

Her insurance company, HealthAmerica of Harrisburg, refused to cover the emergency room visit, something it's done enough to trigger an investigation by state insurance and consumer protection authorities.

"You pay all this money for insurance, and then they don't cover this," said Sheridan, of Palmer Township.

She and her husband, Rick, were told the emergency room visit wasn't "medically necessary." It wasn't an emergency, HealthAmerica said, because the pain had started three days sooner.

"In this case, it is not cost-efficient or appropriate to receive non-emergency services in an emergency facility," appeal coordinator Cindy Gorczyca wrote in March when denying their appeal for the August 2008 hospital visit.

Hundreds of other consumers have run into the same problem with HealthAmerica rejecting emergency room claims, prompting the state investigation.

A settlement was reached earlier this month, under which HealthAmerica will pay previously denied emergency room claims of 631 Pennsylvania residents, totaling about $446,000.

The state attorney general's office and Insurance Department accused Health-America of rejecting claims by using standards higher than the guidelines outlined in its insurance plans.

"These consumers went to emergency rooms because they believed they needed immediate care for serious medical conditions -- something that is supposed to be covered under the HealthAmerica plans," Attorney General Tom Corbett said in a statement.

The guidelines call for emergency room treatment to be covered if prudent people believed they needed emergency care.

"No one should have to worry whether their insurance company will cover emergency care when they believe their life is at risk," Insurance Commissioner Joel Ario said in a statement. "That is why we use certain standards that require health plans to base coverage of emergency care on a patient's symptoms, not the final diagnosis. We are looking at other health insurers now to be sure they are properly applying this standard."

HealthAmerica denied doing anything wrong and did not admit to any violations of law. It said it has adjusted its claims procedure.

"As a good corporate citizen and in an effort to cooperate with the attorney general, HealthAmerica agreed to reprocess these claims," HealthAmerica said in a statement.

It said the settlement covers only a fraction of the 1.7 million emergency claims it received from 2001 to 2007, the years authorities examined.

The Sheridans aren't included in the settlement because their case happened in 2008. But they've filed complaints with the Insurance Department and attorney general's office, hoping authorities can help them, too.

The Sheridans haven't paid the hospital bill and have faced collections calls. They said HealthAmerica, which wouldn't talk to me about their claim because of privacy reasons, said Linda Sheridan should have gone to her primary care physician instead.

Sheridan would have visited her doctor, but her doctor didn't take HealthAmerica, whose insurance products carry the HealthAssurance name. She didn't know what was wrong, and with the pain worsening, felt she needed immediate care and went to the hospital.

The Sheridans can't understand why HealthAmerica won't cover the emergency room, but covered all of the subsequent doctors and tests, including the surgery.

Those subsequent visits, they said, built on the diagnosis she'd received in the emergency room that it wasn't appendicitis, but something else.

The attorney general's office encourages HealthAmerica members who were denied emergency room coverage to file a complaint at 800-441-2555 or http://www.attorneygeneral.gov .

Lehigh Valley area residents probably are included in the Dec. 10 settlement, which will pay previously denied claims for treatment at Lehigh Valley Hospital, St. Luke's Hospital- Allentown, Easton Hospital and hospitals in Reading and Pottsville.

Those emergency room visits were for ailments including sunburn, headache, migraine, foot pain, back pain, arm pain, abdominal pain and insect bites.

In its statement, HealthAmerica said it advises members to seek emergency care in life-threatening or serious situations such as heart attack, stroke, severe bleeding, head injury or other major trauma.

HealthAmerica said it encourages members to call their doctors for guidance when unsure about the severity of a condition, and for treatment of non-urgent conditions.

It said misuse of emergency rooms drives up health care costs for everyone. It cited a 2008 New England Healthcare Institute study that found about half of all emergency room visits were for non-urgent issues or matters that could have been cared for by visiting a physician.

The settlement agreement and HealthAmerica's statement are on my blog at http://blogs.mcall.com/watchdog/ .

The Watchdog is published Thursdays and Sundays. Contact me by e-mail at [email protected], by phone at 610-841-2364 (ADOG), by fax at 610-820-6693, or by mail at The Morning Call, 101 N. Sixth St., Allentown, PA, 18101. Follow me on Twitter at mcwatchdog.

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