MAG & ACEP file lawsuit against Anthem/Blue Cross Blue Shield of Georgia

The American College of Emergency Physicians (ACEP) and the Medical Association of Georgia (MAG) today filed suit against Anthem’s Blue Cross Blue Shield of Georgia in federal court in an effort to compel the insurance giant to rescind its controversial and dangerous emergency care policy that retroactively denies coverage for emergency patientsClick to read lawsuit

Over the past year, Anthem implemented its policy in Georgia and five other states, leaving patients who sought emergency care responsible for paying their entire bills if the insurance company determined after retrospective reviews that their diagnoses were not truly emergencies. Along with Georgia, the other states include Indiana, Kentucky, Missouri, New Hampshire and Ohio.     

According to the lawsuit, Anthem BCBS of Georgia’s policy violates the prudent layperson standard, which is a federal law requiring insurance companies to cover the costs of emergency care based on a patient’s symptoms – not their final diagnosis. The company uses a pre-determined list of undisclosed diagnoses to make its decisions. Additionally, the lawsuit contends that the company is also violating the 1964 Civil Rights Act because the denials disproportionally affect members of protected classes’ access to emergency care.

“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,” said Paul Kivela, M.D., FACEP, president of ACEP. “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. 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.”

MAG President Frank McDonald, M.D., M.B.A., reports that more than 70 percent of the physicians it polled in Georgia do not believe the average patient is knowledgeable enough to make judgments about what qualifies as a medical emergency. 

“In an emergency, seconds count,” said Dr. McDonald. “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.”

According to a 2016 ACEP survey, one in four Americans said they had medical conditions that got worse after they delayed emergency care. 

The prudent layperson standard not only safeguards patients by requiring health insurers to base claims payments on a patient’s symptoms – and not their final diagnosis – it also prohibits those insurers from requiring patients to seek prior authorization before they seek emergency care. 

ACEP is encouraging patients who have had their health insurance coverage denied for an emergency to go to www.FairCoverage.org to share their stories. Georgians can also submit their concerns or complaints related to the Blue Cross Blue Shield ER policy to MAG at anthemerpolicy@mag.org.

ACEP is the national medical specialty society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies.  

With nearly 8,000 members, MAG is the leading voice for physicians in Georgia. MAG represents physicians in every specialty and practice setting. Go to www.mag.org for additional information on MAG. 

MAG encouraging Georgians to act on BCBS ER policy

The Medical Association of Georgia (MAG) is encouraging Georgians who have a Blue Cross Blue Shield of Georgia (BCBS) policy that they purchased through the federal ‘HealthCare’ exchange to research how the insurer’s policy not to cover non-emergency care that a patient elects to receive in an emergency room (ER) following a retrospective review will affect them and their family members.  

BCBS has failed to provide written answers to MAG’s questions about the data that it used as the basis for its new ER policy, which will go into effect on July 1 and which will leave affected Georgians facing significantly higher bills. BCBS has also refused to release the diagnostic codes (i.e., which are used to identify diseases, disorders, symptoms, etc. for billing and claims purposes) that will no longer be covered under its new policy. It is also unclear whether BCBS will expand this policy to other health insurance plans in the state. 

MAG is encouraging affected Georgians to… 

– Contact BCBS at the ‘member services’ telephone number that is located on their ID card or log into their BCBS member account at bcbsga.com to confirm what services will or will not be covered under their policy and how much money they will owe if BCBS determines that the care they receive is not deemed an emergency.

– Schedule an annual wellness visit with a primary care physician to minimize the chance that they will need non-emergency care in an ER.

– Contact Georgia Insurance Commissioner Ralph Hudgens’ office at 404.656.2070 or 800.656.2298 or click here to share their concerns or to file a complaint that is related to the new BCBS ER policy. (Note that an online account must be created to submit an email).   

– Email their concerns and complaints related to the BCBS ER policy to MAG at workercomp@mag.org