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Sobering look at ER protocols

By Jay MacDonald · Bankrate.com
Friday, May 4, 2012
Posted: 1 pm ET

Did you know that if you're treated at an emergency room while under the influence of drugs or alcohol, your health insurance company may not pay the bill?

It's true in roughly 25 states that permit what is known as the "alcohol exclusion," which gives insurers the option to exclude coverage for medical treatments for buzzed patients, from the falling-down tailgater to the tipsy socialite who sprains an ankle at the opera. Even where no such statute exists, self-insured companies that pay directly for employee health care can refuse to cover alcohol-related claims.

It's no small issue for ERs. According to experts, up to half of all patients who seek emergency treatment have been drinking. On weekends, that number tends to grow.

Unfortunately, in states that recognize the "alcohol exclusion," some emergency room practitioners decline to administer alcohol screening, including blood and urine tests and rudimentary alcohol counseling, on incoming patients for fear they won't get paid for their services.

And that, according to a new Kaiser Family Foundation study, deprives patients of the kind of in-context, one-on-one counseling that's been shown to be especially effective with hazardous and binge drinkers.

"Most of the people who are injured don't need to go into treatment. They aren't alcoholics or alcohol-dependent," trauma surgeon Larry Gentilello told Kaiser Health News. "That's why one counseling session can help them by talking about the risks of drinking."

Lawmakers have been trying to repair this anachronistic disconnect in recent years. According to the National Institute on Alcohol Abuse and Alcoholism, the number of states that allow the alcohol exclusion has diminished from more than 40 to fewer than 25 today. The National Association of Insurance Commissioners called for an end to alcohol exclusions back in 2001.

While health insurance companies are generally mum on whether they invoke the exclusion, "There are tons of these cases," according to Sara Rosenbaum, a health law professor at George Washington University. "There's no reason to think that insurers, eager to hold down costs, wouldn't continue (to deny claims)."

Which should come as sobering news indeed, especially on college campuses.

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