In the wake of Anthem Blue Cross/Blue Shield notifying Missouri plan participants that non-urgent emergency room visits would no longer be covered, the Post-Dispatch published an article (June 23) asserting that St. Louis residents use the ER too often for unnecessary care. Unfortunately, there were serious methodological flaws in their study. This policy from Blue Cross/Blue Shield may violate federal law regarding the national "prudent layperson" standard.
This standard requires insurance coverage be based on a patient’s symptoms, not final diagnosis. Anyone seeking emergency care suffering from symptoms that appear to be an emergency should not be denied coverage.
Burning in the chest may be heartburn; however as emergency physicians, we know not infrequently it actually ends up being a heart attack.
If you have an Anthem Blue Cross/Blue Shield health insurance plan in Missouri, be aware that nearly 2,000 diagnoses — which the company consider to be “non-urgent” — would not be covered in the emergency room. Heart disease, cancer, asthma, stroke, diabetes, influenza and pneumonia are among the top eight causes of death in the United States. All of these illnesses can cause life-threatening conditions that require emergency care.
Missouri participants need to fight for their right to have access to emergency care as protected by the "prudent layperson" standard.
Patients should be able to seek emergency care immediately without wondering if insurance will cover the ER visit. The vast majority of patients who come to the emergency department seek care appropriately.
Dr. Kristen Mueller • St. Louis
Member, Missouri College of Emergency Physicians