Georgia hospital group sues Anthem over new ER and imaging policies

Atlanta-based Piedmont Hospital and five sister facilities have sued Blue Cross Blue Shield of Georgia and its parent company, Anthem, according to The Atlanta Journal-Constitution.

Anthem stopped covering hospital-based MRIs and CT scans without prior approval in Georgia last fall. The policy, which Anthem has rolled out in other states, is aimed at pushing patients to receive MRIs and CT scans at less-costly outpatient centers. Anthem also implemented a new ER policy in Georgia in 2017. Under the policy, Anthem reviews diagnoses after members' emergency room visits. If the condition is determined to be nonemergent, Anthem may not cover the ER visit.

"These two policies are motivated solely by Anthem's desire to reduce its costs, regardless of the policies' harmful consequences on access to medically necessary services, clinical integration, patient safety, and quality of care," Piedmont's complaint states.

Anthem said it will cover claims that meet the so-called layperson standard, which requires health insurers to define emergencies as any situation where a "prudent layperson" would think immediate medical attention is needed.

However, a Piedmont spokesperson told The Atlanta Journal-Constitution that standard is not being followed. The plaintiff hospitals have provided their lawyers with 75 examples of cases where Anthem incorrectly denied coverage.

Anthem has not filed a response in the case and told The Atlanta Journal-Constitution it would not comment on the lawsuit.

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