Sens. call for HHS/DoL to uphold prudent layperson standards for ER coverage

The offices of U.S. Sens. Ben Cardin and Claire McCaskill distributed the following press release on March 7…

U.S. Senators Ben Cardin (D-Md.) and Claire McCaskill (D-Mo.) are calling on Health and Human Secretary Alex Azar and Labor Secretary Alexander Acosta to review a pattern of actions by Anthem health care, a BlueCross BlueShield affiliate that may have violated consumers’ rights. In a joint letter, the senators outline how Anthem may have violated federal law by disapproving emergency room claims that should have been allowed under the Prudent Layperson standard, which is applicable in group health plans, plans offered on the individual and group markets, Medicare, and Medicaid managed care plans.

“Despite federal law, private insurers are once again using tactics to prevent people from seeking care in the emergency room. On January 24, 2018, the Los Angeles Times reported that Anthem, one of the nation’s largest health insurers, has over the last few months informed patients in six states that ‘if they show up at the emergency room with a problem that later is deemed to have not been an emergency, their ER claim won’t be paid,’”[1] the senators wrote.

“[W]e remain concerned that Anthem’s ED policy still forces patients to determine, before they even leave their home, if their symptoms are serious enough to go to the emergency room.… The Prudent Layperson Standard was specifically drafted to allow patients to get the services they need, when they need them. Patients should not be forced to act as their own doctors and second guess themselves when they truly believe that they are having a medical emergency. Anthem’s coverage denials are creating obstacles to emergency room care and are leaving patients responsible for thousands of dollars in medical bills.”

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