The American College of Emergency Physicians and its Missouri Chapter have declared that the list of medical diagnoses developed by health insurer Anthem Blue Cross Blue Shield is a clear violation of the national prudent layperson standard, which is codified in federal law, including the Affordable Care Act, and in over 30 states, including Connecticut.
The “prudent layperson” standard requires that insurance coverage be based on a patient”™s symptoms, not their final diagnosis. Anyone seeking emergency care who is 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.
Nearly 2,000 diagnoses on Anthem”™s list that the insurer considers to be “non-urgent” would not be covered if the patient goes to the emergency department. ACEP maintains that some of those diagnoses are symptoms of medical emergencies, including:
- “Chest pain on breathing,” which can be a life-threatening pulmonary embolism.
- “Acute conjunctivitis,” which if caused by gonorrhea can cause blindness.
- “Influenza,” which kills thousands of people each year.
Anthem has said it plans to enforce the policy in Missouri this summer, followed by potential rollouts in Indiana and Ohio. The company has already put the practice into place in Virginia and Kentucky and may try to enforce it in other states, including Connecticut.
“Health plans have a long history of not paying for emergency care,” said Rebecca Parker, 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.”
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, Parker added.
Anthem had no immediate comment.
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