Doctors File Lawsuit over Anthem Blue Cross Emergency Room Coverage Denials

A group of doctors has filed a lawsuit against an insurance company because of denied Anthem Blue Cross emergency room coverage. A similar lawsuit by patients might not be far behind.

A Bloomberg report says that on July 17, the Medical Association of Georgia and the American College of Emergency Physicians filed a lawsuit asking the court to require Anthem subsidiary Blue Cross Blue Shield of Georgia to cover denied emergency room claims and to rescind a policy that resulted in the denied claims.

According to the lawsuit, Anthem began reviewing the diagnoses of insured members’ trips to the emergency room. If Anthem’s reviewers decided a diagnosis was not a true emergency, they would allegedly deny the claim. Bloomberg notes the lawsuit indicates this policy is in place in the states of Kentucky, Missouri, Ohio, Indiana and New Hampshire.

“Providers and patients alike are operating in fear of denial of payment by defendants when patients seek emergency department care,” say the doctors in their lawsuit regarding Anthem Blue Cross emergency room coverage.

The two plaintiffs are professional organizations for physicians. More than 38,000 emergency room physicians are members of the American College of Emergency Physicians (ACEP). The Medical Association of Georgia boasts more than 7,800 physicians.

Anthem has defended its new policy regarding Anthem Blue Cross emergency room coverage because the goal is to lower the costs incurred by insured members to visit the emergency room for nonemergent situations.

Issues with Anthem Blue Cross Emergency Room Coverage

The plaintiffs point out that when a patient visits an emergency room that is covered by his or her insurance, the patient believes that visit will be a covered expense. To later find out that an insurance representative has looked over the paperwork and decided your diagnosis is not worthy of an emergency room visit seems arbitrary.

The doctors’ lawsuit alleges the law states a “prudent layperson” who believes he or she is experiencing an emergency requires insurance to cover that emergency room treatment. According to the plaintiffs, the law clearly states a health insurer must cover the emergency room costs based on the patient’s symptoms and not on the ultimate diagnosis.

Sometimes, symptoms of life-threatening conditions are mimicked by those of relatively benign conditions. Someone with little or no medical background who is suffering disturbing symptoms is not equipped self-diagnose, said ACEP.

According to Bloomberg’s article, U.S. Senator Claire McCaskill of Missouri and Senator Ben Cardin of Maryland, both Democrats, asked the Health and Human Services Department and the Labor Department to investigate the Anthem Blue Cross emergency room coverage denials.

The letter written by the senators said in part, “By denying patient claims based on the patient’s final diagnosis and ignoring the patient’s symptoms present at the time of the emergency, we believe that Anthem likely violated federal law.”

Piedmont Hospital and five affiliated facilities also filed a lawsuit against Anthem and Blue Cross Blue Shield of Georgia in February regarding the Anthem Blue Cross emergency room coverage policy.

Individual insured patients who have been denied Anthem Blue Cross emergency coverage may have legal claims of their own. If you are a patient with Anthem Blue Cross and Blue Shield and you visited an emergency room that was later denied coverage because insurance representatives deemed your diagnosis was not an emergency, you could be eligible to participate in this lawsuit investigation.

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