Anthem Blue Cross Blue Shield has announced it will not pay for emergency visits in six states: Georgia, Kentucky, Indiana, 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.
Yes, I agree that state and federal lawmakers must uphold the prudent layperson standard* and require health insurance companies to provide fair coverage for emergency services.
Anthem’s policy is unlawful — it violates the prudent layperson standard, which is part of federal law, including the Affordable Care Act; nearly all the states also have state prudent layperson laws.
"A migraine headache may be a headache, but it also may be a brain aneurysm. How can we possibly expect patients to know the difference?” said Paul Kivela, MD, FACEP.
*The Prudent Layperson Standard requires health insurance companies to cover visits based on the patient’s symptoms, not the final diagnosis. This means if a patient has chest pain, but turns out to have a non-urgent medical condition, such as a hiatal hernia, the insurance company must still cover the visit. It also eliminates requirements for prior authorization before seeking emergency care.
ACEP fought hard for many years at both the national and state levels to secure passage of legislation aimed at protecting emergency patients from retroactive denials of insurance coverage for emergency department visits for conditions that turned out not to be emergencies.
Health insurance companies have a long history of denying coverage and using scare tactics to prevent people from seeking emergency care.