
An ER visit, a $12,000 bill – and a health insurer that wouldn’t pay - jseliger
https://www.vox.com/policy-and-politics/2018/1/29/16906558/anthem-emergency-room-coverage-denials-inappropriate
======
ohazi
This makes my blood boil.

This is the sort of thing that health insurance is _supposed_ to be used for -
potentially life-threatening emergencies that need a fast response time, and
that may require expensive treatment.

Medical insurance companies are dropping support for expensive ER visits, and
instead supporting "preventive care" by only covering a $100 annual checkup
instead (which is predictably scheduled, and can often be paid for out of
pocket).

What's the fucking point anymore? This is no longer health insurance, this is
paying $3000 a year for a $100 checkup. Americans should be rioting in the
streets over this.

~~~
rvo
Does your blood not boil that the original charge is of 12 thousand dollar?

> The doctors in the emergency room did multiple tests including a CT scan and
> ultrasound. They determined that Cloyd had ovarian cysts, not appendicitis.
> They gave her pain medications that helped her feel better, and an order to
> follow up with a gynecologist.

> A few weeks later, Cloyd received something else: a $12,596 hospital bill
> her insurance denied — leaving her on the hook for all of it.

For a few tests, the hospital charges 12,000 dollars. How is this sane? People
should be rioting over _this_.

~~~
gutnor
The worst thing in all of that is how accepted it became in US culture.

Emergency visit or medical treatment requiring remortgaging, debt or spending
otherwise life savings are used as a background plot mechanism.

When I was younger, money was the plot (and that was already depressing
enough): valiant doctor fighting to avoid their patient to have crippling
debts, but now, often it is part of the background. Of course cancer is going
to ruin you, everybody knows that, so let's build drama on top of that. Doctor
are uninterested in making it cheaper, all is based around choosing health or
money.

~~~
lostlogin
I would guess that it’s actually that staff are more interested in avoiding
the liability when they don’t order a required test. Like all big problems
there are many parts to it.

------
codegeek
"Anthem has begun denying coverage for emergency room visits that it deems
“inappropriate” because they aren’t, in the insurance plan’s view, true
emergencies."

Story of America. It is sad and pathetic. Insurance companies have too much
power and even the doctors/hospitals are helpless for the most part. Yes, it
is an entire system that needs to be overhauled.

The game is rigged against the consumer right now. You are never sure what the
actual cost of your visit will be until you start receiving the bills which
could be months after your visit. How dare you ask how much the visit could
cost ? The "Admins" in the ER/hospital/clinic wouldn't even know at that time.
Yes they won't.

~~~
FireBeyond
Not to mention the defensive tone they take. "It's not fair that we are having
to "massively overpay" (interesting phrasing) for what could have been handled
by routine care".

The insurer takes the view that it's _their_ money, that they earned. When
it's their customers that are paying, in the insurance pool, after, and only
after, Anthem has already taken its cut.

Yes, it's not as black and white as that, and part of that administration cost
is ensuring efficient use of the pool's money, but nonetheless, to read
insurers defense of these policies, you'd think they were just trying to
defend against lazy/greedy customers and ERs trying to milk them out of their
money (and with good reason, because they absolutely do view it as their money
once your premiums are paid, and the less they pay out, the less they get to
keep - pop quiz, say a pool of 1M people pay $5,000/yr for insurance, with a
pool of $5B for benefits, and an insurer takes 10% administration costs. Say
this insurance pool only pays out $4B that year. What are the odds that the
insurer pays out that $500M back to the pool, or as a dividend/rate reduction?
Of course you know the answer. Of course the reality is that in theory such
money could be kept in the pool "for a rainy day", leaving aside concepts of
reinsurance, etc., but that often doesn't happen either, not when there's
bonuses to be paid...).

------
awjr
I watch what the USA is doing with healthcare, and I see this type of model
being foisted upon the UK, and it's terrifying.

I recently got into a twitter spat suggesting that it was foolish of the
Conservatives to be reducing spending in social services and the NHS as this
was directly attacking their voter base as 70% of pensioners vote Conservative
and a poorer NHS directly impacts pensioners more. There have been some
articles indicating an extra 120,000 people have died in the UK due to
austerity measures. [http://www.independent.co.uk/news/health/tory-austerity-
deat...](http://www.independent.co.uk/news/health/tory-austerity-deaths-study-
report-people-die-social-care-government-policy-a8057306.html)

So the question is, is this a deliberate unwritten approach to try and kill
off 'costlier' members of society? Is it better to encourage people to be fat
and die off quicker, than to exercise, eat healthier, live longer, and create
a long term social care cost?

I suspect epidemiological analysis the impact of this sort of policy has on a
society demonstrates it kills the weak and infirm as well as the financially
'weak' members of society.

Think Norway got it right. Find a resource, tax it and place the tax in a
pension fund.
[https://en.wikipedia.org/wiki/Government_Pension_Fund_of_Nor...](https://en.wikipedia.org/wiki/Government_Pension_Fund_of_Norway)
Every resident of Norway is now a millionaire in terms of the social care
available to each individual.

~~~
FilterSweep
> So the question is, is this a deliberate unwritten approach to try and kill
> off 'costlier' members of society? Is it better to encourage people to be
> fat and die off quicker, than to exercise, eat healthier, live longer, and
> create a long term social care cost?

Social Darwinism has been a running trope with the Cs. The problem is, _Social
Darwinism is fun until you 're on the chopping block_...... and so we now see
some odd backpedalling in the 2010s now that some have gotten old.

I'd rather pay more to ensure everyone's livelihood is okay.

------
josecurioso
What I don't really get is how an ER visit can cost 12000$, did she leave with
a lamborghini's door or something? Also stating the obvious, the US health
system is a joke.

~~~
gricardo99
"The doctors in the emergency room did multiple tests including a CT scan and
ultrasound"

CT scan is expensive. Each scan (CT, ultrasound) is reviewed by a radio-
logical expert (i.e. doctor), plus taking up an ER bed for many hours, lab
work, IV medications, etc... It adds up pretty quickly.

I'd love to know how much this actually costs in say Canada, or the UK, and I
don't mean to the patient (I know they wouldn't pay much if anything), but the
actual cost on the system.

~~~
DanBC
That information is available here, I think:

[https://improvement.nhs.uk/resources/national-
tariff-1719/](https://improvement.nhs.uk/resources/national-tariff-1719/)

This workbook has a sheet for A&E treatment.
[https://improvement.nhs.uk/uploads/documents/Copy_of_Annex_A...](https://improvement.nhs.uk/uploads/documents/Copy_of_Annex_A_-
_National_tariff_workbook.xlsx)

A&E prices 2017/18 Return to contents

    
    
    		Tariff (£)	
        HRG code	HRG name	                             Type 1 and 2 Departments	Type 3 Departments
        Emergency Medicine, Any Investigation with Category 5 Treatment	          322 	63 
        Emergency Medicine, Category 3 Investigation with Category 4 Treatment	  293 	63 
        Emergency Medicine, Category 3 Investigation with Category 1-3 Treatment      212 	63 
        Emergency Medicine, Category 2 Investigation with Category 4 Treatment	  192 	63 
        Emergency Medicine, Category 2 Investigation with Category 3 Treatment	  161 	63 
        Emergency Medicine, Category 1 Investigation with Category 3-4 Treatment      113 	63 
        Emergency Medicine, Category 2 Investigation with Category 2 Treatment	  141 	63 
        Emergency Medicine, Category 2 Investigation with Category 1 Treatment	  130 	63 
        Emergency Medicine, Category 1 Investigation with Category 1-2 Treatment       91 	63 
        Emergency Medicine, Dental Care	                                           82 	63 
        Emergency Medicine, No Investigation with No Significant Treatment   	   63 	63 
        Emergency Medicine, Patient Dead On Arrival	                                   91 	63
    
    

Prices in GBP.

~~~
gricardo99
This is very interesting, thanks for sharing. Although this does list prices,
it seems to me that these are mandated/set prices, and not necessarily
reflective of the true cost of the care provided. Unless... these prices are
set with the goal to reach at least a break-even on any care provided? I
suppose the overall health system has to break-even, unless it's running a
deficit, but I honestly have no idea how that corresponds to the listed
prices.

Apologies if I'm way off on this, I'm by no means an expert or have much
experience/knowledge on this topic, but attempting to make some sense of it
for comparison.

------
UseStrict
Could you imagine having chest pain for the first time, going to the hospital,
them running the whole suite of tests like an EKGs, X-Ray, full blood panel
and the like, then determining it wasn't a heart attack but instead something
much less severe like pneumonia? I use that example because that is something
I went through, I was able to breathe alright, and didn't have any other
illness symptoms, but woke up intense chest pain. Thankfully in Canada there
was no issue of coverage, but would Anthem determine pneumonia to be non-
emergency care?

What if you went in with chest pain, found out it was pneumonia, then got
billed $10,000 for all the tests. Would you think twice about going back to
the ER the next time you got chest pain? I think this policy will absolutely
kill people. But clearly it's fine because it's only a minority of cases
(sarcasm).

~~~
lostlogin
I agree this policy is terrible but the specific situation you describe
appears to be covered according to the article.

> A list of codes from Missouri is significantly longer, with more than 1,900
> diagnostic codes that could indicate non-emergency visits. The list includes
> multiple types of “unspecified injuries” and “chest pain on breathing.” When
> asked about the Missouri list, an Anthem spokesperson said the latter
> diagnostic code regarding chest pain has since been removed from the list,
> which has been updated and revised.

~~~
WkndTriathlete
That quote makes me skeptical that any medical professional looked over
Anthem's list, because every health care professional I've ever heard of has
indicated that chest pain justifies an immediate ER visit.

------
wiredfool
I have two recommendations for anyone in this situation:

1) Talk with the state insurance commissioner. Make sure that your paperwork
is in order, and then file a formal complaint. Mentioning this when talking to
insurance company reps will get you booted upwards to people who are more able
to help you so that the to make their problem go away.

2) If you have a case that's a clear compelling class, talk to a lawyer after
the first appeal.

Background: My son had some prescribed therapy for a mental health condition
that I was told would be covered when I talked to the insurance company. They
subsequently denied the claims, then backpedaled on the first month because
"I'd been told that they'd be covered.", but the subsequent months were not
covered. I was left with a several thousand dollar bill. Washington State has
the Mental Health Parity act, which states that mental health treatments must
be covered to the same extent as rehab or surgical treatments. The insurance
company ended up losing 2 class action suits, (a federal and a state) and
paying $6.4M to repay all the class member's denied claims and an agreement to
not deny claims in the future.

~~~
joncrane
I'm cynical enough to believe that the insurance company did a cost/benefit
analysis beforehand and understood the regulatory risks of denying that
coverage, and in the end, they still saved more than $6.4 million in denied
claims to people who didn't have their *%it together enough to be part of the
class-action.

------
rayiner
This is a misleading way to write an article. ER overuse is a thing; ER usage
has been rising much faster than the population over the last couple of
decades. It’s nkt unreasonable to put policies into place to tamp down in
that. But here is the thing: any policy you apply to millions of people will
have false positives. Picking out a single instance of where the policy
triggered when it shouldn’t have doesn’t do anything to help the reader
understand the underlying trade offs.

I had a nurse hotline tell me to go to the ER because my daughter was coughing
after swallowing some river water. My insurance company paid the bill. Can I
get Vox to write an article about this wasteful use of resources?

~~~
codegeek
For me, it is not about ER overuse or not. These types of problems are the
symptoms of an overall flaw with the US healthcare system which is that it is
no longer about the Doctors and Patients directly. Too many things are decided
by the insurance company which leaves patients and doctors both at risk. I
personally have doctors in my family who tell me straight that they cannot
decide what to charge their patients because ultimately the insurance
companies decide that for them.

As far as ER overuse is concerned, sure there are folks who may go to ER for
everything but majority don't because ERs are a pain the ass. You may have to
wait hours before a real doctor actually sees you unless you are literally
bleeding to death on the floor. Nowadays there are urgent care centers that
are supposed to be ER replacement for smaller issues but they are severely
limited. My wife had a severe headache and we wanted to go to urgent care
first but they said to go to ER preferably because they don't have CT scan
machines. Not to mention that most urgent care centers are not opened after a
certain hour in the evening.

~~~
harryh
The idea that it should only be about the doctors and the patients is a little
strange when you consider the fact that the insurance companies are paying. Of
course they are going to get a say!

Your family members that are upset that they can't charge more than the people
writing the checks are willing to pay are just like any other business people.
All sellers of goods would love to be able to charge higher prices than the
market will support.

~~~
codegeek
"the fact that the insurance companies are paying"

But that's my argument. Why insurance companies need to pay for every visit ?
We need to have a system where prices are transparent and low enough that
patients can directly pay the doctors. Of course, that would also mean getting
rid of crazy premiums being paid to the insurance company for little things
like a simple visit to doctor. If no insurance company for little things, then
doctors don't have to inflate what they bill to insurance company, insurance
company doesn't have to do the "allowed amount" crap and then patients don't
have to worry about getting a final bill in the mail which they don't know
what it would ultimately be.

Insurance needs to exist only for major and catastrophic issues not every
little visit to a doctor. Some people may agree or disagree but that is my
argument to this whole debacle.

~~~
harryh
Ah, in that case I pretty much agree with you. We'd be in a much better world
if middle class Americans and up had higher deductible insurance that only
covered true major issues and then payed for everything else out of pocket.
Let's get some capitalism and price competition on!

Unfortunately we're stuck in this rut where people mostly feel that healthcare
should be "free" (meaning no out of pocket expenses) and also the system
handles private payers very poorly (just try to get a hospital to tell you in
advance what a test will cost). It sucks and have no idea how it gets better.

------
ordinaryperson
A policy against frivolous ER visits isn't necessarily a bad thing, it's that
Anthem's system for determining what's frivolous was obviously flawed in this
case.

Side-splitting abdominal pain is a valid reason to go to the ER. But doesn't
mean it's not sensible for Anthem to have a policy against footing the bill
for ER visits for ingrown toenails -- an ER doc in Australia was recently
telling me too much of his day is wasted seeing patients who aren't really
sick, since Australia has a more generous healthcare system.

But to me the bigger issue is a noninvasive visit to the ER cost 12K. It's
easy to get riled up about a cabal of penny-pinching insurers cackling on
their pile of gold coins while people suffer, but how does the hospital get
off blame-free for that kind of gross overbilling?

I'm no fan of the business practices of insurers. But insurance is not magic
beans. The money doesn't just fall from the sky. If everyone on the plan goes
for 12K ER visits the premiums are going to skyrocket for everyone else.
Realistically they have to reign in costs somehow, it's just a matter of
finding an ethical balance.

Someone in the industry told me Anthem makes the most money of any insurer and
its profit margin is 3%. Most of the profit is being captured elsewhere in the
chain.

------
VLM
Its agitprop but the truth is not so ridiculous.

The marketing was terrible, urgent care isn't just for coughs and colds, its
its pretty much for anytime you're not actively bleeding or can arrive in
something other than an ambulance.

"they’ll have to force me into an ambulance to go to the emergency room"

I'm not seeing the tragedy in that, beyond the horrible marketing rollout. She
would have gotten the same care a lot cheaper at urgent care. Where I live its
merely a different floor of the hospital, which emphasizes the accounting
tricks nature of the situation, a chest xray from urgent care is like $300 but
from ER is $3000 for magic accounting reasons. There are no uninsured people
in urgent care, which ironically means faster service unless you're so sick
you scare the ER nurses, which means you're probably not even conscious.

The problem with the ER is bifurcation of tasks. On one hand, infinite labor
and capital to save trauma victims, gunshot wounds, car accidents, industrial
accidents. That's gonna be expensive, but if you lost a leg in a horrible
accident they can probably save your life. And on the other hand the ER is the
free clinic for uninsured coughs and colds and aches and pains, so even more
money needs to be dropped on triage and the inevitable legal bills when triage
is messed up. A lot of problems with the system could be fixed by separating
the "trauma clinic" from the "free clinic" departments. Its very expensive to
have the same department handle both gunshot wounds and uninsured painkiller
pill addicts.

~~~
pseudalopex
This happened at night in a city of 25,000 people. Going to urgent care may
have meant waiting until the morning.

------
iLemming
I had a bicycle accident once. My arm got swollen. I called nearby offices and
couldn't find a single doctor who could see me immediately. I went to ER
hoping they'd give me some ointment or whatever to sooth the pain.

I refused to undergo x-ray scanning (somehow I was sure there's nothing
broken). And it's a good thing that I didn't go to the radiology block.

After about 50 minutes of waiting, doctor came and offered me bacitracin. I
asked if there's anything stronger than that, alas there was nothing else he
could offer me. I shrugged and said "alright then". Doctor applied it all over
my arm and said it should be like that: "don't cover it!". With that I went
home. Bacitracin didn't help a bit. The pain was so strong, so I couldn't
sleep for a few days.

Week later I got a bill. They charged $2800. Insurance covered only $1200 of
that. I tried to dispute it to no avail.

I learned my lesson - in the US, you never, ever should go to ER. Unless
there's a knife sticking out of your skull. But even then you should maybe re-
consider.

~~~
threatofrain
While your experience is shockingly expensive, I think if you refuse to get an
x-ray following a bike accident and swollen arm, then you're basically
omitting a major source of information.

------
jpollock
It seems the problem is not having urgent care at the same location as the ER.
Then you triage at the door and route.

~~~
mortenjorck
I don't understand how this can't be standard operating procedure at an ER.
Abdominal pain? Immediately go through a list of questions to determine
whether it's an emergency or not. This is just as much in the interest of the
hospital, which wants to keep the ER open for life-threatening emergencies, as
it is for payors, as it is for patients.

~~~
jpollock
The problem is that in the USA the ER and urgent care can be two different
organisations. The ER has no economic incentive to route customers to urgent
care because that is lost revenue.

------
rdiddly
If insurance companies could just get out of this sordid business of paying
claims (a.k.a. _providing insurance_... it's ridiculous, all these _darn
costs!_ ), they could focus on their core business of collecting premiums like
God intended.

------
firefoxd
There will need to be a Rosa Parks in the insurance world and suddenly people
will realize this is a radically unfair treatment.

Almost everyone knows someone who received a single bill that ruined them, yet
we brush it off as a one off.

~~~
thirdsun
The sad thing is that this is a non-issue in most of the rest of the world.
When we europeans have to visit a hospital or doctor, the only thing we worry
about is our health.

Potential for improvement aside, health insurance is a solved problem in
countless countries and the US is refusing to learn from others in this
matter. It's painful to watch, even from afar.

------
sizzzzlerz
I'm unclear on what the woman should have done if not go to the ER? Had she
tried contacting her doctor first or did they immediately go to the ER? What
did the insurance company claim she should have done when experiencing severe
abdominal pain, take two aspirin? If it had been appendicitis, would that have
warranted an ER visit? Did they expect she would be able to distinguish
between the two? And as others have asked, how did this visit cost 12 grand?

~~~
falcolas
In my experience, when I went to a clinic complaining of gut pain, they turned
me right back around and send me to the ER. And this was for a relatively mild
pain. I'm not sure if that makes a difference to the insurance, but...

------
pxeboot
This is an extremely common tactic for insurance companies. Deny claims first,
then reverse that decision for the small number of customers who dispute the
denial.

------
athenot
One of the problems is poor primary care and a gap in urgent care. In many
cases, patients have no way of getting triage advice over an issue that occurs
at 3 AM, leaving with a choice of waiting till morning then going to a doctor
(after waiting or scheduling), or going to the ED.

This article is the perfect storm of all these dysfunctions combined:

\- no triage available, so went to ED (a sane choice in the absence of medical
advice).

\- the ED is required to make sure the Patient doesn't have some critical
condition, so they will be zealous with tests. It's usually not a motivation
for profit, it's a desire to make sure they don't miss some condition that may
be less common but could cost the life of the patient. That risk assessment is
usually different from what many patients are willing to accept.

\- the insurer is trying to curb on unnecessary ED visits which, unfortunately
is a problem many EDs face. Having a team of critical care workers tend to
benign issues is terribly inefficient for both the patient and the hospital.
The hospital passes the bill to the insurer who is then scratching their heads
when they see so many resources used to treat something so benign.

Now of course there's the issue of very critical issues that present with very
generic symptoms: your head ache could be a simple dehydration or some busted
blood vessel in the brain; the ED will have to rule out the latter before
declaring it to be a non-consequential headache. This is why traditionally
insurers have paid up without much of a fuss. But we need to fix all these
problems.

If 24h urgent care were more readily available (via tele-health AND in-
person), a lot of this could be avoided.

------
wehadfun
Whats going on the hospital is charging $12K for maybe 1 hour of actual time
spent with the patient. Unless most of that $12K is used to cover the non-
paying customers I don't understand how it could cost the hospital that kind
of money to provide the care.

I bet over half that money went to people who probably never steeped foot in
the hospital much less actually provide care.

~~~
jws
_Unless most of that $12K is used to cover the non-paying customers…_

The industry term is _uncompensated care_. It is currently at its lowest
levels in decades, about 4.2%.†

I suspect the ACA has something to do with that, so we might expect to see the
uncompensated care rise in the coming years as enrollment in insurance
shrinks.

␄

† [http://www.healthcarefinancenews.com/news/uncompensated-
care...](http://www.healthcarefinancenews.com/news/uncompensated-care-costs-
lowest-level-26-years-roughly-36-billion)

------
jcadam
Yep, I got stuck with a $1000 ER bill because the insurance company decided I
wasn't experiencing an emergency and covered me at a reduced rate of 80% or
some such.

Despite the fact that I was admonished by both the doctor and the nurses for
not calling 911 (I was basically unable to stand/walk and somebody else drove
me). This was the one time I had zero wait time when walking into the ER. The
staff took one look at me when I staggered in (holding a spent epi-pen),
shoved me into a weelchair and wheeled me into the back.

It was apparently coded as allergic reaction, non-emergency. No amount of
arguing with either the insurance company or the hospital rectified it, so I
ended up paying.

In the end turns out it wasn't an allergic reaction at all, I had undiagnosed
asthma (finally figured that out about a year after this incident - had to go
through _many_ different doctors until I found someone competent), fun!

------
mnm1
Yup, and this is nothing new. In 2008 they tried to decline paying for my
emergency treatment and ambulance. I was unconscious, but the ambulance was
out of network and therefore I should have chosen one that was in network
while unconscious. Then they wanted to not pay for the actual emergency room
trip despite the fact that I spent the night there. Only numerous appeals over
half a year and the patience of the staff at the hospital helped me to finally
resolve this without hitting collections for a few thousand dollars. There
will come a point when people are simply fed up with companies like this and
they will literally demand blood. I hope scummy companies like this remember
that.

------
tastyfreeze
Seeing some of the reasons that people go to the emergency room and the cost
of going to the emergency room I can understand the reasoning behind the
policy. Emergency rooms are often crowded with non-emergent ailments. The
problem is there isn't any triage before being admitted to the ER. A kid with
a fever and a somebody that cut off their finger get treated the same when
walking into the ER. The kid with a fever might get put at low priority but
the hospital is still going to charge for the visit and every doctor that
stopped in to say hi.

~~~
FilterSweep
That's a triage problem, not a "user" problem.

They're fun and costly ambulance rides up until that hidden blood clot goes
unnoticed.

------
beisner
My question is, why is the system designed such that she would be admitted to
the ER in the first place? Why aren't hospitals redirecting patients to urgent
care facilities, or better yet, why don't hospitals have urgent care
facilities attached?? If costs in emergency rooms are extremely high - and I
can understand why they would be higher to a certain extent - why aren't
hospitals employing some sort of dispatch mechanism?

~~~
FireBeyond
The thing is, for acute, severe, lower abdominal pain, the ER -is- the place
to go, speaking as a health professional.

While the minor issues (constipation, and the like) are indeed resolvable in
urgent care, any serious issue is likely to require some form of surgical
intervention.

Additionally, the diagnosis of such issues is likely to require sophisticated
imaging. While Urgent Care can use US (ultrasound), CT, possibly with
contrasts, and such, are still best handled at an ER.

Most likely this patient would have presented at Urgent Care and be
transferred, likely by ambulance, to ER anyway.

Now, do I think there is massive reform required to the healthcare _model_ in
the US? Absolutely, including the use of more urgent care models.

I work in the system as a paramedic, and I definitely agree with that, and I
realize that your question was more broad, but in this instance, ER was the
right place to go, even if the final diagnosis was benign.

------
Chardok
I am so fed up with the healthcare situation here. It is absolutely terrifying
how this is remotely legal or even acceptable.

The game theory is plainly there: people are going to question or refuse to
seek emergency treatment simply because they will be afraid of the cost. Now
you get to add the stress of which type of care you should be getting, in the
middle of a fucking scary medical emergency!

------
ransom1538
Whatever do you save with your blood, sweat and tears will be burned on
medical expenses in the end.

------
Dayshine
>We cannot approve benefits for your recent visit to the emergency room (ER)
for pelvic pain,

Pelvic pain could be an indication of an ectopic pregnancy, that's absolutely
a ER indicator!

