A major insurer will institute a new policy for emergency room care beginning July 1.
Anthem Blue Cross/ Blue Shield of Georgia announced earlier this month in letters to some policyholders that it will no longer cover the cost of emergency room care if a “prudent layperson” would not consider the treatment an emergency.
“This is not to discourage somebody with an emergency condition who needs to go to an ER to go there,” spokeswoman Debbie Diamond told the Atlanta Journal-Constitution. “Health care is becoming more and more expensive. It’s a way to make sure that people are getting quality and affordable care.”
The new policy will not apply to children 13 and younger, members who do not have an urgent care clinic within 15 miles, or ER visits on Sundays and major holidays, when the emergency room is often the only medical establishment open.
The move is not without its critics. The American College of Emergency Physicians condemned the policy change and said that it “violated federal law.”
“This new policy will mean that patients experiencing emergencies will not go to the ER because of fear of a bill, and could die as a result,” said Rebecca Parker, MD, president of ACEP in a news release. “Health plans have a long history of not paying for emergency care. Now, they are trying to roll over federal law that emergency physicians fought for to protect patients from this ‘profits first, people last’ behavior by insurers.”
“This policy threatens the safety of all Georgians,” added Matt Lyon, MD, president of Georgia’s ACEP Chapter. “We treat patients every day with identical symptoms – some get to go home and some go to surgery. There is no way for patients to know which symptoms are life-threatening and which ones are not. Only a full medical work-up can determine that.”
The Blue Cross/ Blue Shield website has a page listing alternatives to emergency room care, saying that emergency room treatments for non-emergency conditions “contribute to the rising cost of our healthcare.”
Here’s how Blue Cross/ Blue Shield defines a legitimate emergency:
“Emergency” or “Emergency Medical Condition” means a medical or behavioral health condition of recent onset and sufficient severity, including but not limited to, severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness or injury is of such a nature that not getting immediate medical care could result in:
(a) placing the patient’s health or the health of another person in serious danger or, for a pregnant woman, placing the woman’s health or the health of her unborn child in serious danger;
(b) serious impairment to bodily functions; or
(c) serious dysfunction of any bodily organ or part.
Such conditions include but are not limited to, chest pain, stroke, poisoning, serious breathing problems, unconsciousness, severe burns or cuts, uncontrolled bleeding, or seizures and such other acute conditions as may be determined to be Emergencies by us.”
Date:June 29, 2017