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Anthem Blue Cross Blue Shield has announced it will not pay for emergency visits in Indiana, Georgia, Kentucky, Missouri, New Hampshire and Ohio, based on secret lists of diagnoses (nearly 2,000 in Missouri from a list that ACEP obtained). Unless stopped, this policy could be implemented in more states, with additional health insurance companies following with policies of their own.
This policy is unlawful, because it violates the prudent layperson standard, which is part of federal law, including the Affordable Care Act, and 47 state laws. Patients can’t be expected to self-diagnose their medical conditions. Two people may have identical symptoms but have different diagnoses — one life threatening, one non-urgent.
“Health insurance companies are scaring people away from emergency departments, saying they will decide after the fact what is a real emergency. If your insurer disagrees with your decision to visit the ER, they may now refuse to pay. These new actions violate federal law and are dangerous, because people with identical symptoms — such as abdominal or chest pains — may either have a deadly medical condition or a non-urgent issue. It is not fair for health insurers to expect patients to know the difference between a heart attack and something that is not life threatening.”
– Paul Kivela, MD, FACEP, president of ACEP