WASHINGTON, D.C.—A new study in JAMA Network Open underscores the risk to patients if the Anthem Blue Cross Blue Shield policy to deny emergency coverage based largely on a patient’s diagnoses after a visit, is adopted nationwide. The study found that nearly one in six (15.7 percent) of emergency visits could qualify to be denied.    

“It is unreasonable and dangerous to force patients to self-diagnose before going to the emergency room, said Vidor Friedman, MD, FACEP, president of the American College of Emergency Physicians (ACEP). “Insurers cannot expect a patient to know in advance whether a headache is a migraine or an aneurysm, or if abdominal pain is indigestion or something far worse. In addition to sticking patients with large medical bills, this policy could deter people from going to the emergency department in a situation where they need immediate medical attention.”

The study, “Analysis of a Commercial Insurance Policy to Deny Coverage for Emergency Department Visits With Nonemergent Diagnoses,” also found that, consistent with other JAMA research, emergency symptoms overlapped with nonurgent symptoms 87.9 percent of the time.

More than 65 percent of patients that could be denied coverage received emergency-level services, such as imaging or multiple blood tests, according to the study.

“Our results demonstrate the inaccuracy of such a policy in identifying unnecessary emergency department visits. This policy could place many patients who reasonably seek emergency care at risk of coverage denial,” lead author Shih-Chuan (Andrew) Chou, MD, MPH, attending physician in the Department of Emergency Medicine at Brigham and Women’s Hospital and senior author Jeremiah D. Schuur, MD, MHS, emergency physician and health policy researcher at Brigham and Women’s Hospital, wrote.

Currently, Anthem’s policy is active in six states, Indiana, Kentucky, Missouri, New Hampshire and Ohio and Georgia. ACEP and the Medical Association of Georgia filed a federal lawsuit in July asserting that Anthem BCBS of Georgia is violating the prudent layperson standard, which is a federal law requiring insurance companies to cover the costs of emergency care based on a patient’s symptoms – not their final diagnosis.

Patient and consumer advocates, physician groups, elected officials and health experts continue to raise concerns about the insurer’s misguided initiative.