Insurer’s Limits on ER Coverage Slammed by Doctors Group

(CN) – Anthem Blue Cross Blue Shield’s policy limiting coverage of emergency room visits for patients in Georgia, Kentucky and Missouri could be putting lives at risk, the American College of Emergency Physicians warned.

The advocacy group for emergency health care providers and their patients said in a statement Tuesday that health insurance behemoth Anthem Blue Cross Blue Shield has developed a “secret list of diagnoses” that it will not cover, even if a patient thought their symptoms could have been signs of a medical emergency.

For the last few months, Anthem has been warning patients in letters to “save the ER for emergencies – or you’ll be responsible for the cost.”

Dr. Rebecca Parker, president of the American College of Emergency Physicians, said in an interview that people shouldn’t be afraid to come to the emergency department if they’re having severe pain or other symptoms that they believe require urgent medical attention.

“We don’t want people staying at home wondering whether or not they’re going to have coverage,” Parker said. “This is a very dangerous thing and a patient safety issue.”

For Parker, Anthem’s policy violates the “prudent layperson standard,” which requires health insurance companies to cover emergency care based on a patient’s symptoms rather than a final diagnosis. Many states have mandates requiring health plans to follow the standard, including Missouri, Georgia and Kentucky, according to Parker. The standard was also written in the federal health care law.

The American College of Emergency Physicians said it obtained a list from Missouri that had almost 2,000 diagnoses for which Anthem would deny emergency room coverage, including blood in urine and “chest pain on breathing.”

“If you’re having severe chest pain and you’re not sure, you shouldn’t be worried about your insurance company covering you,” Parker said. “I might see you and say you’re having a heart attack, or I might say you have pleurisy — which is one of the diagnoses on the list that we obtained from Missouri. But you don’t know that and I don’t know that until we see you.”

A 2013 study in the Journal of the American Medical Association found that there was about a 90 percent overlap in symptoms between emergencies and non-emergencies.

On Tuesday, the physician’s group released results of a survey which found that 49 percent of American adults strongly oppose the policy of denying coverage for emergency care when a diagnosis turns out to be non-urgent.

The national survey of 2,201 people, conducted by polling group Morning Consult, found that, compared to a year ago, 41 percent are more likely today to avoid emergency care out of concerns about health insurance co-pays, co-insurance or deductibles.

Scott Golden, a spokesman for Anthem Blue Cross Blue Shield in Missouri, said in an email that the goal of the policy is to promote “appropriate care settings for members when they have a non-emergency medical condition.”

“If a member feels he or she has an emergency they should always call 911 or go to the emergency room,” Golden said.

“There’s a misunderstanding that this is a denial program for all emergency department care,” he added. “If a member chooses to receive care for non-emergency ailments at the ER when a more appropriate setting is available, their claim will be reviewed using the prudent layperson standard and potentially denied.”

The review, conducted by an Anthem medical director, considers both the presenting symptoms that brought the patient to the emergency room, as well as the diagnosis, Golden said.

Anthem will cover non-emergency visits if a patient was directed to the emergency room by another medical provider, if services were provided to a child under the age of 14, if there isn’t an urgent care or retail clinic within 15 miles of the member’s home, or if the visit occurs from 8 p.m. Saturday through 8 a.m. Monday or on a major holiday.

“Anthem believes that primary care doctors are in the best position to have a comprehensive view of their patient’s health status and should be the first medical professional patients see with any non-emergency medical concerns,” Golden said.

Parker said that while emergency rooms have been seeing more patients in recent years, the majority of these patients are accessing care appropriately. The patients that emergency room doctors see today have more complicated health issues than in the past, she said, because many people are living longer and have survived or are living with serious conditions such as cancer.

“We’ve looked at studies that have urgent care and emergency room care,” Parker said. “There’s a small percentage that could have been treated in the urgent care office.”

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