- A national payer’s policy of screening ER visits to promote telehealth and mHealth options is being challenged in court.
The American College of Emergency Physicians (ACEP) and Medical Association of Georgia (MAG) have filed a lawsuit charging Anthem’s Blue Cross Blue Shield of Georgia plan with creating a dangerous situation in which patients might avoid seeking care that they need, quite possibly putting their lives in peril.
Anthem, which manages Blues plans in 14 states, launched its new policy one year ago, beginning with Georgia and extending since then to Indiana, Kentucky, Missouri, New Hampshire and Ohio. Under the policy, the insurer can review all ER visits and decide not to reimburse for certain visits deemed unnecessary, and which could have been handled through the plan’s mHealth app, a telehealth visit or at a much less expensive retail clinic.
Anthem officials have said the policy isn’t hard and fast, and that officials would review each claim to make sure the ER visit based on an urgent or emergency healthcare issue, rather than the assumption that the ER is the easiest and quickest path to care.
“This is not to discourage somebody with an emergency condition who needs to go to an ER to go there,” BCBSGa spokeswoman Debbie Diamond told the Atlanta Journal Constitution last June, when the policy was announced. “Healthcare is becoming more and more expensive. It’s a way to make sure that people are getting quality and affordable care.”
In their suit, ACEP – which has argued strongly against the policy since it was launched - and MAG argue that the policy itself might give patients cause to think twice about going to the ER, even if they have a legitimate health concern.
“We can't possibly expect people with no medical expertise to know the difference between something minor or something life-threatening, such as an ovarian cyst versus a burst appendix,” ACEP President Paul Kivela, MD, FACEP, said in a press release.
“ACEP and MAG have tried multiple times to work with Anthem to express these concerns and urge them to reverse this policy, and they have refused,” he added. “We felt we had no choice but to take action to protect our patients, and therefore are asking the federal court to force Anthem's BCBS of Georgia to abide by the law and fulfill their obligation to their policyholders.”
“In an emergency, seconds count,” added MAG President Frank McDonald, MD, MBA. “Even stopping to consider if it's an emergency could mean the difference between life and death. Patients should never hesitate to seek emergency care out of fear of getting a large bill.”
Anthem officials said their policy is based on reports of ER overcrowding and misuse, which combine to increase costs.
“The cost of care's been going up so much faster than people's earnings,” BCBSGa President Jeff Fusile told Atlanta’s WABE public radio station in July 2017. “We have got to find a better way to do some of this stuff, taking some of that unnecessary spending out of the system.”
According to Anthem, an ER visit costs about $1,200 on average, compared to $190 for a visit to an urgent care center, $125 for a trip to the doctor’s office and $85 for an appointment at a walk-in clinic at a pharmacy. Consumer-facing telehealth programs, meanwhile, generally charge between $50 and $80 for an online visit.
In Georgia, BCBSGa officials emphasized that all ER visits would be carefully screened to determine if they meet the definition of a non-emergency. They also pointed out the rule doesn’t apply to children under 13, Sunday or holiday visits or instances in which the member is more than 15 miles from the nearest urgent care clinic.
Anthem says its efforts are guided by national surveys that estimate some 75 percent of ER visits aren’t emergencies when all is said and done – Indiana-based Truven Health Analytics put that figure at 71 percent in a 2013 study. Other groups, including ACEP, have argued that that figure is much lower.
According to the lawsuit, Anthem policy violates the prudent layperson standard, which requires insurers to cover the costs of emergency care based on a patient's symptoms rather than the final diagnosis. The suit also argues that Anthem is violating the 1964 Civil Rights Act because the denials disproportionally affect members of protected classes' access to emergency care.