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ACEP, Anthem Squabble Over 'Secret' Diagnoses List

By John Commins  
   October 11, 2017

Anthem says its list is an in-house screening tool to identify non-emergent care in the ER, but emergency physicians say it's a violation of the prudent layperson standard and could harm patients.

Emergency physicians say Anthem Blue Cross Blue Shield has created a "secret list" that contains about 2,000 emergency department diagnoses that the insurer will not pay for.

"There are things on there like 'chest pain with deep breaths' which we know as clinicians could be pleurisy but it could be a pulmonary embolism or a collapsed lung or influenza," says American College of Emergency Physicians President Rebecca Parker, MD.

"Thousands of people die from influenza every year," she says. "It’s like looking for a needle in a haystack and patients shouldn’t have to figure out whether or not they have an emergency."

Parker says ACEP learned about Anthem’s list from its state chapters in Kentucky, Georgia and Missouri.

"Anthem has to abandon this policy. It is bad patient care. It is not the way to look at appropriate use of acute care services," Parker says, adding that Anthem’s diagnoses list violates the prudent layperson standard — which is in the Affordable Care Act and in many state laws.

Instead of denying ED claims, Parker says Anthem should improve its provider network and expanding access points for care beyond the emergency department.

"Patients need to know that their insurance will cover them when they have emergency symptoms. We don’t want patients trying to make that decision at home," she says. "I don’t want someone clutching their chest wondering if they are going to be covered by their insurance company. People will die."

John Commins is a senior editor at HealthLeaders.

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