New policy on ER visits begins July 1 for some Georgia consumers

Beginning July 1, a major insurer in Georgia will institute a new policy regarding payments for emergency room care. The Georgia Insurance Commissioner’s office tells us that Anthem Blue Cross Blue Shield has informed them of the policy.

“So Georgia law recognizes the ‘prudent lay person standard’ which is what Blue Cross Blue Shield says they are trying to enforce,” says Jay Florence, the assistant insurance commissioner. “That’s what they referenced in their letter (to the policy holders) is the prudent lay person standard. As they explain it, if a normal, prudent person (not a doctor but a lay person) believes that they have an emergency situation and need to go to the emergency room, then they can go. But if a regular lay person, a prudent person, would not believe it was an emergency – then Blue Cross Blue Shield will not pay that claim.”

Consumers for Quality Care has sent a letter to the Georgia Insurance Commissioner along with commissioners in three other states where the policy is being implemented next week. The group says customers are being asked to “be their own doctors” and it’s raising concerns that some people have a true emergency and need immediate care may not seek out an ER out of fear the service won’t be paid for.

“People should not be required to have a medical degree to figure out whether they need to get some sort of symptom like a headache or a chest cough looked at in the emergency room.,” said Jim Manley from Consumers for Quality Care. “It’s not a position that the average person should be put into and it’s going to lead to people being hurt and or dying.”

The letter sites a 2013 study from JAMA (Journal of the American Medical Association) which says that more than 85 percent of the time, symptoms and complaints presented by patients can be similar and overlap during emergency and non-emergency situations.

Consumers for Quality Care is asking Georgia to stop the insurance company from implementing the new rule saying it violates the Affordable Care Act (or Obamacare.) Bur Florence told us he “does not believe (the rule) is illegal per se, it really depends on implementation and how they do it.”

Florence told us the insurance commissioner’s office will be “watching any complaints closely and will monitor the changes being implemented.”

“We also have a consumer services division which receives complaints from physicians and consumers and we’ve created special codes so that we can track all of these complaints to try to take action if we believe Blue Cross Blue Shield is incorrectly denying policy holders.” said Florence.

He suggests that Blue Cross Blue Shield customers contact the office at 1-800-656-2298 after July 1 if they experience issues with an emergency room visit not being paid for and the consumer believes it should have been.

Meanwhile, Manley says this policy which is apparently being tested in four states is “part of a larger trend that fits in part with the current problems facing the health care system in our country.”

Manley could not answer why Blue Cross Blue Shield is only implementing the policy in four states. It is know that three of the states (including Georgia) opposed the Affordable Care Act and even joined lawsuits against it.

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