State agency to monitor Blue Cross rule on ER use

The state insurance department says it will monitor the new emergency room policy of Blue Cross and Blue Shield of Georgia “to make sure that it is not abused to the disadvantage of Georgia policyholders.”

Blue Cross recently told policyholders that starting in July, it will stop covering ER visits it considers to have been unnecessary. The health insurer, Georgia’s largest, said it’s pursuing the move, involving its coverage of individual policies, due to the costs of routine primary care being administered in an ER setting. Physician groups, meanwhile, have been critical of the policy.

Jay Florence, deputy state insurance commissioner, said in a statement that the agency supports insurers’ attempts to reduce “unnecessarily high premiums.”

But Florence added, “You buy health insurance to make sure you are protected when something bad happens. We are tracking our phone calls and have created a specific code for complaints related to Blue Cross Blue Shield’s new policy. . . . We will closely monitor this new policy to make sure that it is not abused to the disadvantage of Georgia policyholders.”

Routine care is far less expensive than emergency room care, and experts agree that unnecessary use of ERs is a financial drain on the nation’s health care system. But what constitutes unnecessary ER use can depend on many factors — such as patients’ symptoms, their perception of their medical condition, their location and other issues.

Blue Cross has cited the high cost of care in formulating its policy.

“We’re hoping that patients go to the most appropriate setting’’ for care, said Blue Cross spokeswoman Debbie Diamond. The company “has a 24/7 nurse line and online tools that are always available to help members find the right care option for their neighborhood,’’ she added. Urgent care and retail health clinics are other alternatives for patients, Diamond told GHN.

“We are not trying to keep people from the ER,’’ she said.

Blue Cross said its parent company, Anthem, worked with four board-certified emergency medicine doctors to develop a list of non-emergency conditions that would be better treated by a primary care doctor than in an ER. The list includes conditions such as suture removals, athlete’s foot, common cold symptoms and seasonal allergies including itchy eyes, the insurer said.

The insurer said it would cover ER visits that turn out not to be emergencies if the member was directed to the emergency room by another medical provider, if the services were provided to a child under age 14, if there was no urgent care or retail clinic within 15 miles of the member, or if the visit occurred on a Sunday or a major holiday.

If a member chooses to go to an ER to receive care for the common ailments listed when a more appropriate setting is available, the claim will be reviewed by a Blue Cross medical director using the “prudent layperson standard” before a determination is made, Blue Cross said.

In reviewing the claim, the medical director will consider whether the member had symptoms that appeared to indicate an emergency even if the diagnosis turned out to be a non-emergency ailment, the insurer added.

Still, the American College of Emergency Physicians (ACEP) said the policy violates the prudent layperson standard, which requires that insurance coverage be based on a patient’s symptoms, not the final diagnosis.

Anyone who seeks emergency care suffering from apparent emergency symptoms, such as chest pain, cannot be denied coverage even if the final diagnosis does not turn out to be an emergency condition, ACEP said.


“This policy threatens the safety of all Georgians,” Dr. Matt Lyon, president of  Georgia’s ACEP chapter, said in a statement. “We treat patients every day with identical symptoms – some get to go home and some go to surgery. There is no way for patients to know which symptoms are life-threatening and which ones are not. Only a full medical work-up can determine that.”

Lyon added that this action will be especially bad for Georgia’s rural population, who are often limited in their options for medical care.

Donald Palmisano, executive director of the Medical Association of Georgia, told WABE that the Blue Cross policy also might disproportionately affect the elderly, those living in rural areas and adolescents over the age of 14.

“I have four children, and if there’s an injury and it’s hard to determine the pain they’re experiencing, it’s hard to determine whether to go to the emergency room or not,” he said.


Jeff Fusile, president of Blue Cross and Blue Shield of Georgia, told WABE that “the cost of care’s been going up so much faster than people’s earnings. We have got to find a better way to do some of this stuff, taking some of that unnecessary spending out of the system.”

He also acknowledged, “There are lots of gray areas where the diagnosis wasn’t so bad after all, but you have to look at the situation the person was in at the time they were in it.”

Separately, Blue Cross and Anthem also have to decide whether to remain in the state’s health insurance exchange. (Here’s a recent GHN article on that decision.)