Physician Groups Sue Anthem in Georgia Over ED Policy

In an effort to compel Anthem’s Blue Cross Blue Shield of Georgia to rescind its “controversial and dangerous emergency care policy” that retroactively denies coverage for emergency patients, the American College of Emergency Physicians (ACEP) and Medical Association of Georgia (MAG) have filed suit in the U.S. District Court for the Northern District of Georgia. The policy, implemented by Anthem in Georgia and five other states over the past year, leaves patients who sought emergency care responsible for paying their entire bills if Anthem determines, after retrospective review, that their diagnoses were not truly emergencies. Along with Georgia, the other states include Indiana, Kentucky, Missouri, New Hampshire and Ohio.

According to the complaint, Aetna’s policy:

1. Violates the prudent layperson standard requiring insurance companies to cover the costs of emergency care based on a patient’s symptoms, not their final diagnosis;
2. Violates the Civil Rights Act of 1964 because the denials disproportionally affect members of protected classes;
3. Violates the Emergency Medical Treatment and Active Labor Act (EMTALA) by forcing providers to question the ultimate diagnosis, in spite of their presenting symptoms, as the ultimate indicator of whether payment will be made and;
4. Violates the Employee Retirement Income Security Act (ERISA) by failing to pay beneficiaries according to the terms of their plans.

“ACEP and MAG have tried multiple times to work with Anthem to express these concerns and urge them to reverse this policy, and they have refused. We felt we had no choice but to take action to protect our patients, and therefore are asking the federal court to force Anthem’s BCBS of Georgia to abide by the law and fulfill their obligation to their policyholders,” said Paul Kivela, MD, FACEP, president of ACEP.