New ‘Top Docs’ show addresses MAG/ACEP’s lawsuit to rescind Anthem ER policy 

Frank McDonald, M.D., M.B.A., the president of the Medical Association of Georgia (MAG), and John Rogers, M.D., a former chair of the American College of Emergency Physicians’ (ACEP) Board of Directors, discuss why MAG and ACEP have filed a lawsuit in federal court to compel Anthem’s Blue Cross Blue Shield of Georgia to rescind its policy to review health insurance claims for emergency care on a retrospective basis on the latest edition of MAG’s ‘Top Docs Radio’ show.    

“Anthem’s ER policy is dangerous because it can result in patients having to self-diagnosis and either avoid emergency care or face the prospect of being responsible for a huge bill if the company decides the diagnosis was not a true emergency after the fact,” says Dr. McDonald, a neurologist at the Longstreet Street Clinic in Gainesville. “I just don’t believe that patients should be put in this difficult position when every second counts.” 

Dr. Rogers explains that the lawsuit contends that the Anthem policy violates the “prudent layperson” standard, a federal law that requires insurance companies to cover the costs of emergency care based on a patient’s symptoms – not their final diagnosis. The Macon-based emergency physician also maintains that the lawsuit contends that the Anthem/BCBS policy violates the 1964 Civil Rights Act because the denials disproportionally affect members of protected classes’ access to emergency care. 

ACEP President Paul Kivela, M.D., FACEP, emphasizes that, “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.”

He adds that, “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.”

And Dr. McDonald points out that, “Anthem/Blue Cross has failed to respond in writing to MAG’s requests for the data it uses as the basis for its new ER policy, and it has refused to release the diagnostic codes that it uses to identify diseases, disorders, symptoms, etc. for billing and claims purposes that are no longer covered as a result of this policy.”

More than 70 percent of the physicians who completed a MAG survey do not believe that the average patient is knowledgeable enough to make judgments about what qualifies as a medical emergency. 

In addition to Georgia, Anthem has implemented this policy in Indiana, Kentucky, Missouri, New Hampshire and Ohio. 

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 Anthem ER policy to MAG at anthemerpolicy@mag.org.

MAG sponsors at least two ‘Top Docs Radio’ episodes per month. Between downloads and live listeners, the program has reached more than 200,000 listeners – which includes people in all 50 states and more than 80 countries.  

MAG’s ‘Top Docs Radio’ show is supported with a grant from Health Care Research, a subsidiary of Alliant Health Solutions.   

Click for ACEP/MAG press release

Click for lawsuit