Are There Any Class Actiob Suits Agains Blue Cross for Not Contraxting With Er Soxtora?

Two physicians organizations filed a lawsuit Tuesday against Blue Cantankerous and Blue Shield of Georgia and its parent company over the insurer'southward emergency room payment policy,...

Two physicians organizations filed a lawsuit Tuesday against Bluish Cantankerous and Blue Shield of Georgia and its parent visitor over the insurer's emergency room payment policy, calling it "dangerous.''

The parent company, Indianapolis-based Anthem, has pursued a new policy over the past year in Georgia and v other states, reviewing customers' ER visits and limiting or denying payment for those it deems not to have been true emergencies.

The new lawsuit, from the Medical Association of Georgia (Magazine) and the American College of Emergency Physicians, seeks to force Blue Cross to finish its emergency care payment policy.

A similar lawsuit was filed past Piedmont Healthcare hospitals earlier this yr. That suit, though, ended when Piedmont and Blue Cross reached a new reimbursement contract in Apr.

The physicians groups say Blue Cross' policy violates the "prudent layperson'' standard, a federal law requiring insurers to embrace the costs of emergency care based on a patient'south symptoms, not on the final diagnosis.

The company uses a list of undisclosed diagnoses to make its decisions on whether the patient really had an emergency condition, the plaintiffs allege. Magazine said that nether the payment policy, when the claim is deemed invalid, the ER physician is not paid and the patient is stuck with a large beak.

"We tin can't peradventure expect people with no medical expertise to know the difference betwixt something minor or something life-threatening, such as an ovarian cyst versus a flare-up appendix,"  Dr. Paul Kivela, president of the American College of Emergency Physicians (ACEP), said in a argument Tuesday. He said his group and Magazine "have tried multiple times to work with Canticle to express these concerns and urge them to reverse this policy, and they have refused. We felt we had no choice simply to take action to protect our patients.''

A Blue Cantankerous spokesman declined comment Tuesday on the lawsuit, filed in federal court in Atlanta.

Blue Cantankerous has previously emphasized that emergency rooms are an expensive place to receive routine care. Anthem said it is seeking to make health care more affordable and to encourage patients to get intendance in the most appropriate setting.

Canticle offset began reviewing ER visits in Georgia, Kentucky and Missouri, and has also implemented the policy in Ohio, New Hampshire and Indiana.

"Anthem's avoidable ER program aims to reduce the tendency in contempo years of inappropriate use of ERs for non-emergencies as the costs of treating non-emergency ailments in the ER has an bear on on the cost of health treat consumers, employers and the health care system equally a whole," the company said in a May argument to NPR.

Critics of the Blueish Cantankerous policy agree that ERs are not the right places to treat routine medical complaints. But they say patients oftentimes cannot estimate how serious a sudden medical problem is.

The lawsuit alleges that doctors and patients "are operating in fright of denial of payment'' past Blueish Cross when its members seek care in emergency departments. The suit said Anthem is pursing "a dangerous policy'' in at to the lowest degree six states, which denies coverage to emergency patients based, in part, on "secret lists" of diagnosis codes.

Anthem before this yr made a list of exceptions to the policy, including if a person was directed to the ER by a provider or an ambulance, if care was received by a patient under age 15, and if the ER visit occurred over a weekend or on a major vacation (when facilities for ordinary care are oft closed).

McDonald

Magazine'due south president, Dr. Frank McDonald, said in a statement that more than 70 percent of the physicians polled in Georgia do not believe the average patient is knowledgeable enough to brand judgments virtually what qualifies as a medical emergency.

"In an emergency, seconds count," said McDonald. "Fifty-fifty stopping to consider if it's an emergency could mean the difference between life and expiry. Patients should never hesitate to seek emergency intendance out of fear of getting a big bill."

The prudent layperson standard not only safeguards patients by requiring wellness insurers to base claims payments on a patient's symptoms, just it also prohibits those insurers from requiring patients to seek prior authorization earlier they seek emergency care, the doctors groups say.

Georgia's department of insurance said Tuesday that it has received four inquiries since 2022 about ER claims denied by Bluish Cross. One deprival was reversed, leading to payment of the claim, 2 denials were upheld, and the 4th is yet in the appeal process, said Glenn Allen, a spokesman for the department.

Piedmont said earlier this yr that its hospitals gave 75 examples to their lawyers of cases where coverage had been denied when it should not have been.

ACEP represents more than 38,000 emergency physicians, emergency medicine residents and medical students.

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Source: http://www.georgiahealthnews.com/2018/07/physicians-groups-sue-blue-cross-denial-er-claims/

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