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Tuesday, March 2, 1999 - Page updated at 12:00 AM

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Senn Battles Insurers On Er Coverage -- She Faults 4 Major Carriers For Denying Claims Under Law

Seattle Times Business Reporter

State Insurance Commissioner Deborah Senn is waging a battle against health-insurance companies that she says illegally deny coverage of emergency-room visits.

Senn wants the state's four largest health-care carriers, Premera Blue Cross, Regence BlueShield, Qualmed Washington and Aetna U.S. Healthcare, to settle all the reimbursement claims she says they illegally denied during the first four months of 1998.

A survey of 744 claims denied by those carriers in that period showed more than half should have been approved under a state law that went into effect in January 1998, Senn said at a news conference today.

"What we are finding is a clear pattern of denials of emergency-room care," Senn said.

The 1998 law says that if a "prudent-layperson" considers his or her condition an emergency, then emergency-room care must be provided and covered by insurers.

But that's not happening at hospitals in the Seattle area, said Senn and several doctors who joined her today.

Senn told of a 15-year-old girl taken to the hospital with a broken leg, only to have her parents find out later the insurer did not consider it an emergency and refused to pay.

Then there was the Seattle woman who went to the emergency room with chest pains and a severe headache. The doctors thought it might be a heart attack or a ruptured aneurysm in the brain; it turned out to be less serious. The carrier denied the coverage because the woman failed to get pre-authorization for her visit.

Senn estimated that more than 7,000 of the 14,000 denials by the four carriers during those four months were illegal.

In some cases, according to documents kept by carriers, patients did not have a true emergency, or failed to get a referral from the primary-care provider before being treated. Others went to hospitals out of the service area outlined in their insurance policies. And many denials, Senn said, were later attributed to coding errors and paperwork mistakes by company employees.

None of those reasons is acceptable under the law, Senn said.

As of last October, none of the four carriers had made any substantial changes in dealing with ER claims, according to Senn's office.

Nancy Auer, medical director of emergency services at Swedish Medical Center, said she has been told by carriers that certain claims would not be covered, even though her hospital thought they should have been.

She said doctors in the region spend a great deal of time on the phone with carriers trying to get pre-approval and reimbursements for ER care. She said the average visit costs about $350.

Premera spokeswoman Teresa Moore said her company, the second-largest health insurer in the state, has been notified of Senn's concerns, but company officials are still waiting for information about specific cases in question. "To date, we have received nothing from Senn's office to help us determine the legitimacy of the claims," Moore said. She said the company has promised to address any suspected unlawful denials it hears about within two weeks.

The insurance companies also have the right to contest Senn's charges instead of settle the claims.

In the meantime, Senn said her staff would start reviewing member handbooks of all of the state's carriers for any rules that violate the emergency-room law.

Copyright (c) 1999 Seattle Times Company, All Rights Reserved.

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