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BCBS 'Non-urgent' Diagnosis List Violates Law, ER Doctors Say

News  |  By Gregory A. Freeman  
   May 19, 2017

A group representing emergency room physicians says the list of approved medical diagnoses developed by Anthem Blue Cross Blue Shield violates the "prudent layperson" requirement of the Affordable Care Act.

The list of what diagnoses will be covered in emergency departments by Anthem Blue Cross Blue Shield (Anthem BCBS), is a clear violation of the national prudent layperson standard, according to The American College of Emergency Physicians (ACEP).

The prudent layperson standard is codified in federal law, including the Patient protection and Affordable Care Act, and it is also found in more than 30 states. It requires that insurance coverage be based on a patient's symptoms rather than the final diagnosis.

In a statement released jointly with its Missouri chapter, which is facing enforcement of the BCBS list soon, ACEP said anyone who seeks emergency care suffering from symptoms that appear to be an emergency, such as chest pain, should not be denied coverage if the final diagnosis does not turn out to be an emergency.

The standard also prohibits insurance companies from requiring patients to seek prior authorization before seeking emergency care, ACEP President Rebecca Parker, MD, FACEP, noted.

"Health plans have a long history of not paying for emergency care," she said.

"For years, they have denied claims based on final diagnoses instead of symptoms. Emergency physicians successfully fought back against these policies, which are now part of federal law. Now, as healthcare reforms are being debated again, insurance companies are trying to reintroduce this practice."

Nearly 2,000 diagnoses on the list are classified as non-urgent by BCBS and would not be covered if the patient goes to the emergency department. ACEP says some of these "non-urgent" and non-reimbursed diagnoses can be symptoms of medical emergencies, citing these examples:

  • "Chest pain on breathing" can be a life-threatening pulmonary embolism.
  • "Acute conjunctivitis," if caused by gonorrhea, can cause blindness.
  • "Influenza," which has killed hundreds of thousands of people over the past century, can be an emergency. Thousands of people die from the flu each year.

Missouri emergency physicians are particularly concerned because Anthem BCBS plans to enforce this policy there this summer, said Jonathan Heidt, MD, MHA, FACEP, president of Missouri's ACEP Chapter.

The company has already put this practice into place in Virginia and Kentucky and may try to enforce it in other states, most likely Indiana and Ohio, he said.

"This policy threatens the citizens of Missouri," Heidt said. "If this practice of denying emergency care can happen in our state, it can happen in any state and we must work both locally and nationally to fight for our patients'' rights to have access to emergency care as protected by the 'prudent layperson' standard."

Parker noted that research shows patient perceptions of urgency are what contribute most to emergency department use, and the Anthem BCBS list could discourage people from seeking lifesaving care.

Prudent Layperson Standard

"When privately insured people have an urgent medical problem and cannot access their usual physicians as quickly as they believe necessary, they frequently will go to hospital emergency departments," Parker said.

"At the same time, patients may minimize their symptoms. In fact, nearly one in four Americans responding to a poll reported that their medical conditions got worse after they delayed visiting an emergency department because they feared their health insurance companies would not cover the costs."

Patients cannot be expected to self-diagnose their medical conditions, which is why the "prudent layperson" standard was created and must also be included in any replacement legislation of the Affordable Care Act, ACEP said. The vast majority of emergency patients seek care appropriately, according to the CDC and often times should have come to the ER sooner, Parker noted.

"If patients think they have the symptoms of a medical emergency, they should seek emergency care immediately and have confidence that the visit will be covered by their insurance," Parker said.

Gregory A. Freeman is a contributing writer for HealthLeaders.

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