WASHINGTON, D.C.—The American College of Emergency Physicians (ACEP) and its Missouri Chapter today said the list of medical diagnoses developed by the health insurance giant, Anthem Blue Cross/Blue Shield (BCBS), is a clear violation of the national prudent layperson standard, which is codified in federal law including the Affordable Care Act. It's also law in more than 30 states.
The "prudent layperson" standard requires that insurance coverage is based on a patient's symptoms, not their final diagnosis. 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. It also prohibits insurance companies from requiring patients to seek prior authorization before seeking emergency care.
"Health plans have a long history of not paying for emergency care," said Rebecca Parker, MD, FACEP, president of ACEP. "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 health care reforms are being debated again, insurance companies are trying to reintroduce this practice."
Nearly 2,000 diagnoses on the list — which Anthem BCBS considers to be "non-urgent" — would not be covered if the patient goes to the emergency department. Some of these diagnoses are symptoms of medical emergencies. For example:
- "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.
Anthem BCBS plans to enforce this policy in Missouri this summer, followed by potential rollouts in Indiana and Ohio. The company has already put this practice into place in Virginia and Kentucky and may try to enforce it in other states.
"This policy threatens the citizens of Missouri," said Jonathan Heidt, MD, MHA, FACEP, president of Missouri's ACEP Chapter. "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."
Dr. Parker added that research shows patient perceptions of urgency are what contribute most to emergency department use (Center for Studying Health System Change 2013).
"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," said Dr. Parker. "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 (Morning Consult 2016)."
Patients cannot be expected to self-diagnose their medical conditions, which is why the "prudent layperson" standard must also be included in any replacement legislation of the Affordable Care Act.
"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," said Dr. Parker. "The vast majority of emergency patients seek care appropriately, according to the CDC and often times should have come to the ER sooner."