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Doctors Sue Anthem Over 'Dangerous' ER Coverage Policy

Analysis  |  By Steven Porter  
   July 17, 2018

The insurer implemented its policy in six states over the past year, leaving patients on the hook for bills Anthem determined after-the-fact to be non-emergent, plaintiffs claim.

A long-running disagreement over Anthem's policy of denying payment for emergency department visits that are later deemed non-emergent escalated Tuesday, with a lawsuit filed in federal court.

Two groups, the American College of Emergency Physicians (ACEP) and the Medical Association of Georgia (MAG), sued Anthem's Blue Cross Blue Shield of Georgia, alleging that the ER policy violates the "prudent layperson" standard in the Affordable Care Act—which, the plaintiffs say, requires Anthem and other insurers to cover emergency care based on a patient's symptoms rather than their final diagnosis.

"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," ACEP President Paul Kivela, MD, FACEP, said in a statement calling the policy "dangerous."

The plaintiff organizations have tried repeatedly to work with Anthem to reverse the controversial policy, to no avail, Kivela said.

"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," he added.

A spokesperson for Anthem declined HealthLeaders Media's request for comment.

  • Longstanding claim of illegality: More than a year ago, ACEP joined with its Missouri chapter to publicly accuse Anthem of violating the law. In addition to Georgia and Missouri, the controversial policy affects beneficiaries in Indiana, Kentucky, New Hampshire, and Ohio, according to the plaintiffs.
  • Fatal consequences? "They're not going to change [this Anthem policy] until somebody dies and they get sued. That is going to happen at some point," Ryan Stanton, MD, an emergency medicine physician and CEO of Everyday Medicine in Lexington, Kentucky, told HealthLeaders Media in January.
  • Senators take notice: Anthem's policy caught the attention of some on Capitol Hill, including two Democratic senators who wrote a letter in March to Health and Human Services Secretary Alex Azar: "While we appreciate Anthem on their effort to encourage patients to seek medical care in lower-cost settings, we remain concerned that Anthem's ED policy still forces patients to determine, before they even leave their home, if their symptoms are serious enough to go to the emergency room," the senators wrote.
  • Not the first lawsuit: Tuesday's lawsuit follows one filed in February by Piedmont Hospital and five sibling facilities that accused Anthem of cutting costs at the expense of patient safety, as The Atlanta Journal-Constitution reported.
  • Physicians oppose the policy: More than 70% of physicians polled in Georgia said the average patient isn't sufficiently knowledgeable to determine whether a given medical situation is an emergency, MAG President Frank McDonald, MD, MBA, said in the plaintiffs' statement. "Even stopping to consider if it's an emergency could mean the difference between life and death," McDonald said.

The lawsuit asks the judge to block Anthem's policy under the ACA's prudent layperson standard and declare the policy to be in violation of the Civil Rights Act. It also seeks payment "for the services [ACEP] members legitimately provided" to Anthem's beneficiaries.

Doctors Sue Anthem Over 'Dangerous' ER Coverage Policy by HLMedit on Scribd

Steven Porter is an associate content manager and Strategy editor for HealthLeaders, a Simplify Compliance brand.


This escalates a long-simmering dispute over what insurers can do to reduce costs.

The suit seeks payment for services ACEP members provided to Anthem beneficiaries.

The controversial policy has already caught the attention of some on Capitol Hill.

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