BCBS says it won’t cover non-emergency ER visits starting 7/1

According to an article that appeared in The Atlanta Journal-Constitution (AJC) on May 31, Blue Cross Blue Shield of Georgia (BCBS) has sent a letter to its customers advising them that “starting July 1 it would no longer cover non-emergency visits to emergency rooms.”The AJC reported that, “[According to BCBS]: ‘Emergency’ or ‘Emergency Medical Condition’ means a medical or behavioral health condition of recent onset and sufficient severity, including but not limited to, severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness or injury is of such a nature that not getting immediate medical care could result in: (a) placing the patient’s health or the health of another person in serious danger or, for a pregnant woman, placing the woman’s health or the health of her unborn child in serious danger; (b) serious impairment to bodily functions; or (c) serious dysfunction of any bodily organ or part.”

The article also noted that, “Such conditions include but are not limited to, chest pain, stroke, poisoning, serious breathing problems, unconsciousness, severe burns or cuts, uncontrolled bleeding, or seizures and such other acute conditions as may be determined to be emergencies by [BCBS].”

The AJC story indicated that the rule will “not apply if the covered patient is 13 or younger; the member doesn’t have an urgent care clinic within 15 miles; [or] the visit happens on a Sunday or major holiday.”

The article said that BCBS defines an emergency as “what a ‘prudent layperson’ would think could pose a serious danger,” and it says “[it] will decide what makes that cut.” 

Georgia Rep. Terry England was quoted as saying that, “What I’m interpreting is it’s because they’re trying to change habits and get people to focus on going to their physician and not to the ER.”

BCBS is reportedly “steering those patients who don’t need emergency care to their personal physicians, urgent care clinics or to Blue Cross’ 24-hour online medical service, LiveHealth Online.”

Medical Association of Georgia (MAG) President Steven M. Walsh, M.D., promises that, “MAG will work with its allied stakeholders to oppose this new policy through every available channel.”

It is also worth noting that MAG Executive Director Donald J. Palmisano Jr. expressed MAG’s concerns over the new BCBS policy in a recent interview with WABE 90.1 FM Radio

Palmisano believes that, “Blue Cross Blue Shield is putting the onus on the patient to play medical expert to determine if the health problems they or their loved ones are experiencing are worth visiting the ER, which is a serious issue and a potentially life-or-death decision.”

Contact MAG Legal Analyst Kimberly Ramseur at 678.303.9274 or kramseur@mag.org with questions. 

Click for WABE report