Health Insurers Retroactively Deny ER Coverage

In 2017, Anthem Blue Cross Blue Shield announced it would refuse to cover visits to the ER that it thinks were not emergencies in six states: Georgia, Kentucky, Indiana, Missouri, New Hampshire and Ohio.

This policy violates the Prudent Layperson Standard, which is a federal and state law that provides an important patient protection and is one of emergency medicine’s bedrock principles alongside EMTALA.

EMTALA makes sure that anyone can receive emergency care regardless of insurance status or ability to pay. The Prudent Layperson Standard requires insurance companies to provide coverage for that care, based on your symptoms, not your final diagnosis. Anyone with little or no medical expertise (a “prudent layperson”) could think they are having a health emergency and should not hesitate to get evaluated by an emergency physician.

Nobody should expect a patient to self-diagnose a medical condition in advance of an ER visit. How could you possibly know whether your stomach pain is appendicitis, or your headache is an aneurysm?

The bottom line is that the Anthem policy puts a completely unreasonable, costly and dangerous burden on patients. Emergency physicians are concerned these unfair practices could force a patient experiencing any number of emergency symptoms to skip or delay going to the ER because they are afraid their insurer will abandon them and stick them with a huge bill.

To ensure patients continue to receive the emergency care they need, the American College of Emergency Physicians, along with the Medical Association of Georgia has sued Anthem in the State of Georgia. Visit www.faircoverage.org to see the ACEP’s video campaign, patient petition, media kit, fact sheet and more related to its advocacy efforts against these coverage denials.   

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