August 2017 Newsletter

MAG calls for Blue Cross to disclose data it used as basis for retrospective ER policy

The president of the Medical Association of Georgia (MAG) is calling for Blue Cross Blue Shield of Georgia to disclose the data it used as the basis for its new policy to reject claims for care that patients who obtained their insurance through a federal ‘HealthCare’ exchange plan receive in an emergency room if the company retrospectively determines it was not an emergency.

“Every Georgian should be concerned about the effects of the new Blue Cross ER policy,” says Steven M. Walsh, M.D. “Patients shouldn’t have to worry about conducting a self-diagnosis while wondering whether their insurer will cover the care they have paid for in the form of their premiums when they are in the middle of what they fear could be life-or-death medical emergency.”

Dr. Walsh adds that a lot of his fellow physicians share his concern, pointing out that, “More than 70 percent of the physicians who completed a recent survey that MAG conducted said that they do not believe their average patient is knowledgeable enough to make judgments about what qualifies as a medical emergency.”

The Roswell anesthesiologist also explains that Blue Cross – the state’s largest health insurer – has failed to respond in writing to MAG’s requests for the data it used as the basis for its new ER policy.

“Plus,” he says, “the company has failed to release the diagnostic codes that are used to identify the diseases, disorders, and symptoms for billing and claims purposes that will no longer be covered under its new policy.”

According to Dr. Walsh, it’s not clear whether Blue Cross, which is reportedly seeking a 40 percent premium increase for individuals who are covered by one of the aforementioned exchange plans in 2018, will expand this policy to other health insurance plans in the state.

The American Medical Association (AMA) has called for Anthem, Blue Cross’ parent company, to “rescind this policy in states where it has taken effect, and halt implementation in all other states.” AMA Executive Vice President and CEO James L. Madara, M.D., cautions that, “The impact of this policy is that very ill and vulnerable patients will not seek needed emergency medical care while, bluntly, their conditions worsen or they die…[the policy] also reduces the value of health insurance policies on which patients have spent thousands of dollars to have access to care, including emergency care.”

And the American College of Emergency Physicians (ACEP) and its Georgia chapter believe that the Blue Cross ER policy violates the federal “prudent layperson” standard, which requires insurance policies be based on a patient’s symptoms – not their final diagnosis. ACEP says that, “Anyone who seeks emergency care suffering from symptoms that appear to be an emergency, such as chest pain, cannot be denied coverage even if the final diagnosis does not turn out to be an emergency. It also prohibits insurance companies from requiring patients to get prior authorization before seeking emergency care.”