Blue Cross & Blue Shield of Georgia Inc. plans to enforce a policy in July that requires customers to pay for visits to the emergency department if the diagnosis is later deemed not to be an emergency, a move opposed by a group of doctors who would treat such patients.
The Georgia Chapter of the American College of Emergency Physicians, or ACEP, said that the insurer's policy flouts the "prudent layperson" standard that is written in federal law and over 30 state laws. The standard requires insurance plans to base emergency-care coverage on symptoms that a prudent layperson would see as signs of an urgent need for care, rather than a diagnosis.
The insurance company worked with four board-certified emergency medicine doctors employed by Anthem Inc. to develop a list of non-emergency conditions deemed better treated by a primary care doctor, said Debbie Diamond, BCBS director of public relations. BCBS of Georgia will review claims by members who seek emergency care for conditions on the list using the prudent layperson standard.
"If the members presenting symptoms appeared to be an emergency, even if the diagnosis turned out to be a non-emergency ailment, it will be covered," Diamond said.
The Journal of the American Medical Association reported almost a 90% overlap in symptoms between emergencies and non-emergencies in a 2013 study. Rebecca Parker, president of the ACEP, said in the college's release that patients have no way of discerning life-threatening symptoms from those that are not, and the policy will discourage patients from seeking emergency treatment for fear of a bill.