Emergency physicians sue Anthem over ER policy change

The American College of Emergency Physicians (ACEP) is asking a federal court to prevent Anthem from implementing a new policy that restricts coverage for emergency room visits.

Since the policy was announced last year, Anthem’s Blue Cross Blue Shield of Georgia has been retrospectively denying payments for emergency department encounters it deems “non-emergent,” according to a complaint (PDF) filed by ACEP and the Medical Association of Georgia (MAG) in a U.S. District Court in Atlanta.

“As a result, providers and patients alike are operating in fear of denial of payment by Defendants when patients seek emergency department care,” the lawsuit states.

After instituting a hard-line approach in which it said it would deny claims in six states for minor injuries, Anthem scaled back the policy in February amid pressure from lawmakers by expanding the exceptions to its “always pay” list. But the insurer argued that inappropriate ER visits need to be contained.

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ACEP and MAG claim the policy still violates the “prudent layperson standard” found in the Affordable Care Act, which defines an emergency medical condition as acute systems identified by a “prudent layperson, who possesses an average knowledge of health and medicine.”

In arguing for an injunction, the groups said Anthem’s “dangerous” policy denies coverage “based, in part, on ‘secret lists’ of diagnosis codes.”

“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,” ACEP President Paul Kivela, M.D., said in a statement. “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.”

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ACEP spokesperson Laura Gore said the litigation is limited to BCBS of Georgia for the time being, although Anthem implemented the policy in five other states, including Kentucky, Missouri, Ohio, Indiana and New Hampshire.

BCBS of Georgia did not immediately return a request for comment. An Anthem spokesperson declined to comment.