To Avoid Surprises, Experts Warn Consumers To Pay Closer Attention To ER Insurance Coverage

Oct 31, 2018

Editor's note: Shortly after this story aired, Rodriguez said St. David's reached out to him to discuss possible financial assistance. According to Rodriguez, the matter has been settled and he now owes only $1,600 as of Nov. 14.

There’s an uptick in health insurance companies not covering emergency room care, according to a consumer advocacy group.

Washington, D.C.-based Consumers for Quality Care said the increase is the result of the Trump administration pushing less regulated health care plans in its effort to undo protections created by the Affordable Care Act, also known as Obamacare.

Milton Rodriguez, who lives in Austin, is trying to find out why his insurance company hasn't paid a recent ER bill.

Rodriguez, who does auditing for a company based in California, said health insurance through his job was “completely outrageous.”

“It was going to be like $500 per paycheck – meaning every two weeks,” he said. “It was going to be almost $1,000 a month.”

Rodriguez didn’t have health insurance for about five years, so he decided to buy it on his own. Every once in a while, he would shop for health insurance, but he couldn’t find anything in his price range with decent coverage. Plus, he had been healthy, so it didn’t feel urgent.

A few weeks ago, though, he started to feel a sharp pain.

“It was really extreme pain that had lasted, by that point, three days,” he said. “It literally feels like somebody is just constantly hitting you in the lower abdominal area.”

If there was ever a time Rodriguez needed health insurance, this was that time. He called an insurance broker who had reached out to him when he was shopping around for a plan.

“I called at night and just needed something that would cover me right away,” Rodriguez said.

"It really does come down to understanding that you are a consumer in the health care marketplace. And you do have power." - Jason Resendez, Consumers for Quality Care

The broker sent a policy, which Rodriguez approved. He then sent a payment to the insurance company, which was through a company called Administrative Concepts, Inc. 

The broker told him he'd be covered starting at 12 a.m.

As soon coverage kicked in, Rodriguez went to the closest hospital, St. David’s in South Austin. It turned out he had appendicitis. While he was waiting for a bed in the ER, hospital staff took his insurance information. He had surgery and was sent home to recover.

Rodriguez started getting phone calls from doctors and the hospital asking about his insurance plan.

“And then the next thing I know is, I get my bills in the mail and it seems like the most important part – which was the emergency room, everything that happened within the emergency room – none of that was covered,” he said.

His bill: $62,620.

At the bottom of that bill, there was a code explaining why coverage wasn’t applied: “This policy does not provide benefits for services provided in the emergency room.”

Rodriguez has just started making calls to figure out what went wrong here. He said he was told his plan held him responsible for only 20 percent of an ER bill, but it looks like nothing was covered. [Since this story first aired, Rodriguez says St. David's reached out to him to offer possible financial assistance. He is currently going through that process.]

“This is a really big concern and these emergency room denials are all symptoms of this larger effort to scale back the quality of care being offered to consumers in the name of cost-savings,” said Jason Resendez, an advocate with Consumers for Quality Care.

Resendez has been sounding the alarm for people to start looking closely at insurance policies. In particular, he said, consumers need to start paying attention to the details of their emergency room coverage.

In the past two years, he said, there’s been a “crawl back of coverage and quality that is in part due to insurers having more flexibility.” For example, he said, insurers are now allowed to sell short-term plans, limited plans and high-deductible plans.

In other words, Resendez said, insurers have "less accountability in the marketplace."

These changes are a result of the Trump administration’s effort to undo Obamacare. There used to be tighter regulations on insurance companies that largely protected consumers from what were pretty stingy plans.

Consumers, unfortunately, have to be stronger advocates for themselves now, Resendez said.

“It really does come down to understanding that you are a consumer in the health care marketplace,” he said. “And you do have power.”

Resendez said the best way to exercise that power is to know the ins and outs of what your health insurance plan covers – and then fight when an insurance company doesn’t hold up its end of the bargain.

Rodriguez said he's been battling a cold and lingering cough for two weeks now, which he thinks is due to stress. He said there’s no way he can pay for a $62,000 hospital bill.

“Isn’t that why you get insurance in the first place?” he asked. "For an emergency?"

Updated: This post was updated to include the name of the insurance company and to note that Rodriguez says St. David's has reached out to him.