The health plan denies payment if a patient goes to an emergency department and the diagnosis is not a true emergency.
Patients' lives are at risk with Anthem's policy denying coverage for emergency department visits that turn out to be something other than a real emergency, and it is only a matter of time before someone dies as a result of the policy, a leading emergency department physician says.
Anthem BlueCross BlueShield is only likely to abolish the rule after the death of a patient who was afraid to go to the ER for fear of being saddled with paying the entire bill out of pocket, says Ryan Stanton, MD, an emergency medicine physician and CEO of Everyday Medicine in Lexington, Kentucky.
Stanton also works with the American College of Emergency Physicians (ACEP) to educate the public and the healthcare industry on emergency medicine.
Stanton says that death is inevitable.
"They're not going to change it until somebody dies and they get sued. That is going to happen at some point," Stanton says.
ACEP has opposed Anthem's policy since it was first introduced in some states in 2017, calling it a clear violation of the national prudent layperson standard, which requires that insurance coverage be based on a patient's symptoms rather than the final diagnosis.
It also prohibits insurance companies from requiring patients to seek prior authorization before seeking emergency care.
The prudent layperson standard is more than just a good idea. It is codified in the Patient Protection and Affordable Care Act and specific laws in in 30 states.
ACEP recently launched a new video explaining how Anthem's policy hurts patients. In a letter, Sen. Claire McCaskill (D-MO) has asked Anthem's CEO to provide answers and access to internal documents that would help consumers and healthcare providers better understand how the health plan applies the policy.
Anthem has declined to release its list of which diagnoses it will not pay for in the ER. There apparently has been no response to the senator's request, and Anthem declined to comment for this article.
"Patients are not physicians," said Sen. McCaskill in the letter. "I'm concerned that Anthem is requiring its patients to act as medical professionals when they are experiencing urgent medical events."
Gregory A. Freeman is a contributing writer for HealthLeaders.