Emergency room doctors in Georgia are suing health insurer Anthem Blue Cross Blue Shield for refusing to cover certain medical services that the company determined didn’t constitute an emergency.
The lawsuit was filed Tuesday in U.S. District Court in Atlanta by the Medical Association of Georgia and the American College of Emergency Physicians. It asks Anthem to rescind an emergency room policy retroactively denying medical coverage for patients who receive ER care, and to pay the claims it has denied.
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The groups say that patients shouldn’t have to hesitate to seek emergency treatment out of fear that they will be charged if an insurer determines their condition could have been treated elsewhere.
“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,” said Dr. Paul Kivela, ACEP president. “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.”
Anthem has said that its policy is intended to discourage patients from going to the emergency room when they could seek medical care elsewhere, such as at a doctor’s office or urgent care clinic. Medical care in an emergency department tends to be significantly more costly, and can increase costs for other customers on an insurance plan. The company declined to comment when asked to respond to the lawsuit.
Customers that were under Anthem in Georgia, Kentucky, and Missouri received letters from Anthem saying that they must save the ER “for emergencies — or you’ll be responsible for the cost.” The policy was later expanded to customers in Indiana, New Hampshire, and Ohio, but Anthem began retroactively denying to pay for medical services in the ER, according to the filing.
The plaintiffs say that Anthem hasn’t defined what constitutes an emergency situation and has confused its members, which they say is in “clear violation of the national prudent layperson standard.” This standard is set by federal law and requires health insurers to cover the costs of emergency room care based on a patient’s symptoms rather than on what their final diagnosis is.
Hospitals in Georgia filed similar lawsuits in February, saying the policies harmed patients.
ACEP has said that patients who are facing difficult symptoms, and are not medically certified themselves, are not in a position to determine whether their condition is serious or not.
“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,” Kivela said.
