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Anthem Sued by Doctors in Dispute Over Emergency-Room Coverage

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The health insurer Anthem Inc. was sued by doctors in Georgia for declining to pay for some emergency-room care, escalating a long-running battle over how far insurance plans can go to push patients to seek lower-cost treatment.

The American College of Emergency Physicians and the Medical Association of Georgia filed suit on Tuesday in U.S. District Court in Atlanta against Anthem’s Blue Cross and Blue Shield of Georgia unit over the denied payments. The doctors asked the court to require Anthem to halt its policy and cover the claims.

“Providers and patients alike are operating in fear of denial of payment by defendants when patients seek emergency department care,” the groups said in the filing.

(Related: Evergreen State Imposes ER Benefits Penalty)

It’s the latest legal challenge over a change in policy that Anthem says was designed to cut down on patients going to an emergency room in situations that don’t require it. Emergency-room care usually costs significantly more than treatment at a doctor’s office or an urgent-care clinic. Georgia’s Piedmont Hospital and five related facilities also have sued Anthem over the policy, the Atlanta Journal-Constitution reported in February.

Before putting the policy in place, Anthem sent letters to customers explaining the policy and urging them to use other sites for care. The insurer also held meetings with physicians, according to the suit.

Anthem didn’t immediately respond to a request for comment on the suit.

Medical Records

Anthem’s strategy went beyond what’s legally allowed, the doctors say in their lawsuit. The insurer reviewed the cases of patients who went to an emergency room, and decided whether to pay for their care based on billing information or medical records related to the incident. The suit says Anthem violated legal requirements that insurers cover care in a situation where a “prudent layperson” would believe he or she was experiencing an emergency.

According to the suit, Anthem began reviewing emergency-room visits in Georgia, Kentucky and Missouri, and has also brought the policy to Ohio, New Hampshire and Indiana. Based in Indianapolis, Anthem operates under the Blue Cross and Blue Shield brand in 14 states. The company has almost 40 million health-insurance members.

Lawmakers, including Sen. Claire McCaskill, D-Mo., have criticized Anthem’s policy. McCaskill and a fellow Democrat, Sen. Ben Cardin of Maryland, sent a letter in March to the Health and Human Services Department and Labor Department, asking them to investigate the payment denials.

“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,” the senators wrote.

— Read Prudent Layperson Standard Advances In New Jerseyon ThinkAdvisor.

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