Anthem sued by doctors in dispute over emergency room coverage

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 Tuesday in the 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.

It’s the latest legal challenge over a change in policy that Indianapolis-based 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.

Last summer, Anthem told its members in Indiana that starting October 1, it would deny claims for hundreds of non-emergency diagnosis codes, such as bruises, rashes, minor burns, swimmer’s ear and athlete’s foot. It said those kind of medical problems should be treated in a doctor’s office or an urgent care-center for a fraction of the cost.

But some Indiana physicians said they worried that patients might start to second-guess whether their middle-of-the-night chest pains were a heart attack or indigestion. They said patients should get such serious issues evaluated in an emergency room.

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 expanded the policy to Ohio, New Hampshire and Indiana. Anthem operates under the Blue Cross and Blue Shield brand in 14 states. The company has almost 40 million health-insurance members.

Lawmakers including U.S. Sen. Claire McCaskill of Missouri 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.