Blue Cross Blue Shield of Georgia's discretionary emergency room policy is landing hundreds of patients with denied claims after the insurer decided their care could be performed outside the ER, according to physicians who testified during a Sept. 27 hearing.
BCBS' policy, which was instituted about a year ago in an effort to curb unwarranted costs for individual policyholders, is being challenged in federal court, according to The Atlanta Journal-Constitution. Physicians said some of the claims denied included care for a woman with a history of lung blood clots who experienced calf pain and a shortness of breath a few weeks after undergoing surgery. Ultimately, physicians found she did not have a blood clot. In addition, a 59-year-old man who fell and had a large laceration in his scalp did not receive coverage for his visit.
"This puts patients in a terrible position where they're asked to diagnose themselves before they go," said Frank McDonald, MD, the president of the Medical Association of Georgia. "Someone is going to make the wrong choice and someone is going to die."
John Rogers, MD, the president-elect of the American College of Emergency Physicians, described the policy as "based on fear and intimidation and requiring patients to balance the risks to their health versus their financial health."
In a statement to The Atlanta Journal-Constitution, Anthem said it decides which ER visits to cover based on the standard of what a prudent layperson would think is an emergency visit. Patients can appeal any denials, and there are several exceptions to the policy. "Anthem has made, and will continue to make, enhancements to ED Review to help consumers receive the right care at the right place and time," the insurer told the publication.
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