When an insurance company decides your health emergency

What happens when an insurance company decides your health emergency wasn’t one?

It’s called downcoding. And it’s a trend that has started to reemerge with the advent of AI

San Francisco Chronicle

By Maria Raven,

June 14, 2026

At the UCSF Emergency Department, doctors are seeing a dangerous trend: insurers refusing to pay for care after the fact based on whether a patient’s final diagnosis appears “serious enough.”

Imagine this: You’re out for a walk and feel an agonizing pain in your chest. You sit on a nearby bench and wait for the pain to subside. But it doesn’t.

The pain gets worse and you start to panic — could this be a heart attack? The pain feels serious enough that you need to get to a hospital emergency department to find out.

Once there, doctors aren’t sure what’s wrong, either. It could be a heart attack, or it could be something less serious. They can’t know for sure. So they run tests — electrocardiogram, blood work, imaging — to rule out life-threatening causes. Thankfully, those tests turned out normal. Having ruled out the potentially life-threatening causes of your pain, you’re discharged with a diagnosis like “chest wall pain.”

You’re shaken but relieved. Better safe than sorry. This is why you have health insurance.

At the UCSF Emergency Department, where I work, we’re starting to notice a dangerous trend: insurers refusing to pay for emergency care after the fact based on whether a patient’s final diagnosis appears “serious enough.”

For emergency physicians like me, this is a familiar and troubling pattern. Years ago, insurers attempted to deny coverage for visits deemed “non-emergent” based on discharge diagnoses. But emergency care doesn’t work that way. Patients don’t arrive with diagnoses — they arrive with symptoms, often indistinguishable from life-threatening conditions.

While insurers might have you believe that many emergency department visits are unnecessary and avoidable and contribute to high health care costs, this is a myth.

The U.S. health system is over capacity, and often the emergency department is the only open door.

Most patients are in the emergency department these days not because they want to be, but because they need to be. The hallways where I work — and those of many emergency departments across the country — are crowded with patients in stretchers and chairs. Our waiting rooms are full of additional sick patients who are frustrated that they have not yet been seen. We are a one-stop shop for heart attacks, strokes and trauma, and for people in acute mental health crises, who have severe substance use disorders and who are at the end of life from metastatic cancer.

The patients we see have become more seriously ill, with recent research showing that from 2012 to 2022, nonurgent emergency department visits decreased by over 50% while severe visits increased by nearly 35% and critical visits by over 75%.

Despite this, health insurance companies appear to be making another attempt to refuse to pay for emergency care.  

I have been an emergency physician for over two decades and also a researcher. Earlier in my career, insurers attempted to deny coverage for emergency department visits if the discharge diagnosis — the diagnoses we give a patient after we have ruled out all the possible emergency conditions they might have during their visit — was deemed to be “non-emergent.”

That might sound reasonable until you understand how diagnoses in our department actually work.

The insurers did not want to pay for the visit if they deemed chest wall pain not to be an emergency. But the only way we could arrive at that diagnosis was by doing high-intensity tests to rule out a heart attack and other serious medical problems. This seemed absurd: were they trying to discourage people with heart attack signs from coming to the emergency department?

In 2013, colleagues and I published a study in the Journal of the American Medical Association that used administrative data to analyze emergency department visits from start to finish. We found that among visits with the same presenting complaint as those ultimately given a “non-emergency” diagnosis based on discharge diagnosis, a substantial proportion required immediate emergency care or hospital admission. In other words, what insurers were proposing was not safe.

For a time after that report, it seemed as if insurers had backed down.

But now, in many instances across the healthcare spectrum, it appears insurers are beginning to use AI to resuscitate and automate this same flawed logic. Algorithms scan discharge diagnoses and automatically downcode visits — even when physicians performed extensive testing to rule out life-threatening illness.

Why does this matter?

Emergency departments are one of the last places in the American health system where anyone can seek care at any time, regardless of ability to pay. Physicians are legally and ethically obligated to evaluate every patient for life-threatening conditions — not to guess who is worthy of care after the fact.

Because the entire American health system is overstressed, emergency departments have no off valve. Patients are facing longer wait times, and we’re seeing increased violence toward staff. Refusing to pay for the care we provide can lead to hospital closures, cutting off a vital source of care for communities. Research has shown that emergency department closures lead to increased mortality at neighboring hospitals.

Denying payment based on hindsight doesn’t make care more efficient. It makes it more dangerous. If insurers succeed, patients will think twice before seeking care for symptoms like chest pain or shortness of breath — and some will arrive too late.