A major health insurance provider in Missouri is taking heat from a group of doctors.  American College of Emergency Physicians (ACEP) claims Anthem Blue Cross Blue Shield is warning members they may have to pay for trips to the emergency room (ER).

Photo courtesy of the Centers for Medicare and Medicaid Services

The organization says Anthem has developed a secret list of diagnoses it will not pay for, even if a patient thought the condition was a medical emergency.

ACEP contends the insurance company is violating the “prudent layperson” standard, which states that an insurer must offer coverage based on a member’s symptoms, not on the final diagnosis.

For example, if a member seeks emergency care for symptoms of a stroke, the insurance company is required by law to pay for the emergency room visit, even if the ailment turns out to be something else.   The standard also states that insurers cannot require a member to get prior medical authorization for coverage of emergency department services.

Dr. Jonathan Heidt, President of the Missouri Chapter of ACEP, says Anthem’s policy breaks with key provisions in the Affordable Care Act.

“As part of the Affordable Care Act, as part of the essential health benefits that the insurance carriers have to offer, emergency medical services is a component of that,” said Heidt.  “So every insurance package offered on the exchange, for example, has to meet that essential health benefit, which includes access to emergency medicine.”

Missouri was one of the first states where Anthem has implemented its practice to deny coverage of certain diagnoses.  Heidt claims ACEP obtained a copy of a list of 2,000 such diagnoses, including 350 the organization finds troubling, such as chest pains on breathing.

Dr. Jay Moore, Anthem’s Missouri Medical Director, denies that its doctors are violating the “prudent layperson” standard.

“The physicians who are reviewing, are reviewing based on the “prudent layperson” standard,” said Moore.  “They are doctors doing the review, but they’re instructed very carefully to use the “prudent layperson” standard, and not their own medical standard when approving these cases.”  Contrary to what ACEP has said, Moore insists that Anthem covers ER visits for chest pains.

Further, Moore contends Anthem’s policy is in compliance the Affordable Care Act’s essential health benefits requirement.

“If the condition is an emergency condition, then it’s paid.  But that is the whole point of the (new) program.  If the condition that the person goes in for is not an emergency, and we’re talking about the actual reason they go in in the first place, if that’s not an emergency, then that is not protected under the ACA.”

National ACEP President, Dr. Rebecca Parker, contends Anthem is wrongly placing the burden on patients to determine whether their conditions are serious or not.    “It is not fair for health insurers to expect patients to know the difference between a heart attack and something that is not life threatening,” said Parker.

Heidt says if patients have to cover emergency rooms costs once, they’re likely to put off subsequent visits which could compound their health problems.

“If they would have gotten to us a little bit quicker, a lot of times there’s the possibility we could have helped them when they weren’t quite as sick.  But if they come to us later in that disease process, it could lead to a hospitalization, or long-term health issues that we could have prevented.”

A new poll from Morning Consult, a nonpartisan research company, finds more than 4 in 10 (43 percent) Americans surveyed reported that they delayed or avoided seeking emergency care in the past 2 years out of concerns about the cost of co-pays, co-insurance and deductibles.  Nearly half said their medical conditions worsened as a result.

Eight in 10 poll respondents (79 percent), said once they understood the “prudent layperson” standard, they supported it. Six in 10 said that insurance companies are interfering with patient/doctor relationships.  The poll further finds more than two-thirds (67 percent) oppose the policy to deny coverage for emergency care that Anthem has implemented in Missouri.

The American Medical Association’s “AMA Wire” reported in August that the AMA had asked Anthem to immediately rescind the policy in states where it had been put into effect (Missouri, Georgia and Kentucky) and halt implementation in all other states.

Heidt of ACEP Missouri says a statewide medical alliance has been established to oppose the Anthem policy.  “We have formed a coalition that involves the state Medical Association, the Hospital Association and the Association of Osteopathic Physicians and Surgeons,” Heidt said.  “And we’re all in agreement that this policy is bad for patients, bad for Missouri.  And we need to fight against it.”

Anthem’s Moore claims the insurer is simply trying to address member concerns that they’re paying for other recipients who are driving up costs with unnecessary ER visits.

“We are trying to keep some fairness here, so that if someone goes to emergency room unnecessarily, the other employees of that group don’t have to pick up that cost.  It just seems to be the fair thing to do.”

Moore also says he met with the Missouri Hospital Association and ACEP before Anthem implemented its new policy, and says there was no resistance to it at the time.

“We told them about the program.  We asked for feedback.  The message that we got at that meeting was ‘It seems like a reasonable program’.  We did that specifically because we knew that it could be misunderstood, and we wanted to be transparent about this program.  We weren’t trying to bring it in under cover of night.”