Jim Burton thought he was dying after lifting a box in his garage last and feeling a large jolt in his back. When his health insurer, Anthem, refused to pay for his E.R. visit of $1,722, citing that care was not needed right away, Jim learned that Anthem denied thousands of claims last year under its “avoidable E.R. program.”

Question:

1. What is this program and why are doctors and consumer advocates arguing against that policy?
2. Why is the E.R. the place where the incentives in health care break down? Explain.
3. State insurance commissioners have received some complaints about Anthem. What law or laws could they enforce against the avoidable E.R. policy?
4. What is the primary documentation basis used by Anthem to reject bills?
Source:
Ableson, R., M. Sanger-Katz, and J. Cresswell. (2018). As an Insurer Resists Paying for ‘Avoidable’ E.R. Visits, Patients and Doctors Push Back. (Retrievable online at https://www.nytimes.com/2018/05/19/upshot/anthem-insurer-resists-paying-emergency-room-visits-if-avoidable.html)