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Anthem Blue Cross Blue Shield Policy in Indiana — Violates Federal Law, Puts Patients At Risk
Dec 5, 2017

WASHINGTON — The American College of Emergency Physicians (ACEP) and its Indiana Chapter today said a policy that Anthem Blue Cross Blue Shield (BCBS) plans to implement early next year in the state, making their customers pay for an entire emergency department visit if it turns out not to be an emergency, violates federal law and puts patients at risk.

“This policy threatens the citizens of Indiana,” said Gina Huhnke, MD, FACEP, president of Indiana ACEP.  “We treat patients every day with identical symptoms – some get to go home, and some go to surgery.  Only a full medical work-up can determine that.  This policy could scare people away from the ER who really need our care. Health insurance companies can’t expect patients to know which symptoms are life-threatening and which ones are not.”

The federal “prudent layperson” standard requires that insurance coverage is based on a patient’s symptoms, not their final diagnosis.  Anyone who seeks emergency care suffering from symptoms that appear to be an emergency, such as chest pain or severe abdominal and head pain, should not be denied coverage if the final diagnosis does not turn out to be an emergency.  It also requires insurance companies from requiring patients to seek prior authorization before seeking emergency care.   Anthem BCBS has already implemented this policy in several states including, Missouri, Georgia and Kentucky.  More states are scheduled to be under the Anthem policy by early next year.

The company is using a secret list of pre-determined diagnoses — which Anthem BCBS considers to be “non-urgent” — and may not be covered if the patient goes to the emergency department.  Some of these diagnoses such as, “chest pain on breathing,” and “blood in the urine” are symptoms of medical emergencies.

According to a recent ACEP poll, more than 4 in 10 Americans reported that they delayed or avoided seeking emergency care in the past 2 years out of concerns about the cost of co-pays, co-insurance and deductibles.  Nearly half said their medical condition worsened as a result.

“Health plans have a long history of not paying for emergency care,” said Paul Kivela, MD, MBA, FACEP, president of ACEP.  “For years, they have denied claims based on final diagnosis instead of symptoms.  Emergency physicians successfully fought back against these outrageous policies.  Now, as the future of health care is debated again, insurance companies are trying to reintroduce the practice.”

Dr. Kivela added that that there is nearly a 90 percent overlap in symptoms between emergencies and non-emergencies, according to a 2013 study in the Journal of the American Medical Association.

Along with the federal law, 47 states have also adopted some form of the prudent layperson rule. New Hampshire, Mississippi and Wyoming are the only states that have not.  

ACEP is the national medical specialty society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies. 

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For further information: Mike Baldyga | 202-370-9288 | mbaldyga@acep.org | www.faircoverage.org