For individuals managing chronic illnesses or disabilities, emergency room visits can be crucial, particularly when symptoms escalate unexpectedly or during late-night hours. However, defining what constitutes an emergency and who has the authority to make that determination has become increasingly complex.
Starting July 1, Anthem Blue Cross/Blue Shield will implement a policy impacting members in Georgia, Missouri, and Kentucky. Under this new guideline, individuals will be held financially responsible for emergency room visits deemed non-emergency. A letter sent to members in Georgia states, “Save the ER for emergencies — or cover the cost. Starting July 1, 2017, you’ll be responsible for ER costs when it’s NOT an emergency. That way, we can all help make sure the ER’s available for people who really are having emergencies.”
Anthem outlines an emergency as a medical or behavioral health condition of recent onset that could, in a prudent layperson’s view, threaten their health or that of others if immediate care isn’t received. Examples include severe pain, chest pain, stroke, or other conditions that may necessitate urgent attention.
A spokesperson for Anthem emphasized that the aim of this policy is to encourage patients to consult their regular healthcare providers first. However, the ultimate decision on whether a visit qualifies as an emergency will be made by the insurance company, which raises concerns about potentially being left with unexpected bills.
Notably, this policy does not apply to children under 14 years old, visits on holidays or Sundays, and individuals without access to a nearby urgent care center. The provider hopes to redirect patients to telemedicine and urgent care facilities instead of emergency rooms.
The American College of Emergency Physicians (ACEP) has criticized this policy, asserting it violates the ‘prudent layperson’ standard established in federal law, including the Affordable Care Act. They argue that expecting patients to self-diagnose undermines the very purpose of emergency care. “Patients should seek emergency care if they suspect they are experiencing a medical emergency,” stated Dr. Emily Roberts, president of ACEP.
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In summary, Anthem Blue Cross/Blue Shield’s new policy regarding emergency room visits has sparked significant debate, particularly regarding its implications for those with chronic conditions. As the insurance company navigates changes, it remains essential for patients to be informed about their rights and options.