Emergency Physicians: Anthem Blue Cross Blue Shield Policy Violates Federal Law

By a News Reporter-Staff News Editor at Insurance Weekly News -- The American College of Emergency Physicians (ACEP) and its Missouri Chapter 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."

Keywords for this news article include: Legal Issues, American College of Emergency Physicians ACEP, American College of Emergency Physicians (ACEP).

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