Last week the American College of Emergency Physicians (ACEP) and the Medical Association of Georgia (MAG) filed suit against Blue Cross Blue Shield (BCBS) of Georgia and its parent company Anthem over recent changes to their emergency care policy. Starting last year, Anthem implemented a policy across a number of states that patients who sought emergency care would be responsible for the cost if the insurance company later determined that their diagnoses were not truly emergencies.
In a press release last year when BCBS announced the change, ACEP warned the policy would violate the “prudent layperson” standard, which is currently federal law. The “prudent layperson” standard requires insurance coverage to be based on a person’s symptoms, rather than their final diagnosis. The lawsuit looks to compel Anthem to rescind the policy.
“This new policy will mean that patients experiencing emergencies will not go to the ER because of fear of a bill, and could die as a result,” said Rebecca Parker, MD, then-president of ACEP. “Health plans have a long history of not paying for emergency care. Now, they are trying to roll over federal law that emergency physicians fought for to protect patients from this ‘profits first, people last’ behavior by insurers.”
The president of the Georgia chapter of ACEP, Matt Lyon, MD, also warned of what the policy might mean. “This policy threatens the safety of all Georgians,” said Lyon. “We treat patients every day with identical symptoms – some get to go home and some go to surgery. There is no way for patients to know which symptoms are life-threatening and which ones are not. Only a full medical work-up can determine that.”
A year in, and the opinion from ACEP and MAG hasn’t changed. “ACEP and MAG have tried multiple times to work with Anthem to express these concerns and urge them to reverse this policy, and they have refused. We felt we had no choice but to take action to protect our patients, and therefore are asking the federal court to force Anthem’s BCBS of Georgia to abide by the law and fulfill their obligation to their policyholders,” said Paul Kivela, M.D., FACEP, president of ACEP.
“We can’t possibly expect people with no medical expertise to know the difference between something minor or something life-threatening, such as an ovarian cyst versus a burst appendix.”
MAG reported that more than 70% of physicians it polled in Georgia did not believe the average patient is knowledgeable enough to determine what qualifies as a medical emergency. Frank McDonald, president of MAG, warned of the danger of delay in the case of emergencies. “In an emergency, seconds count,” said McDonald. “Even stopping to consider if it’s an emergency could mean the difference between life and death. Patients should never hesitate to seek emergency care out of fear of getting a large bill.”
ACEP is encouraging patients who have had coverage denied to go to www.FairCoverage.org to share their stories.
Blue Cross Blue Shield of Georgia has not yet responded to inquiries regarding the lawsuit, this story will be updated when they do.
