ATLANTA/WASHINGTON, D.C.–The American College of Emergency Physicians (ACEP) and the Medical Association of Georgia (MAG) are applauding a U.S. Court of Appeals for the 11th Circuit decision that will revive a lawsuit the organizations filed to compel Anthem’s Blue Cross Blue Shield of Georgia to rescind a policy that allows it to deny claims for emergency care on a retroactive basis.  

“This is a great development for patients and physicians,” explains MAG President Lisa Perry-Gilkes, MD, FACS. “The average patient simply isn’t knowledgeable enough to make judgments about what qualifies as a medical emergency, and they shouldn’t have to worry about getting a large bill when they’re in the middle of a medical emergency.”

ACEP president Mark Rosenberg, DO, MBA, FACEP, says “ACEP is pleased that the 11th Circuit Court has recognized the validity of our cause to hold Anthem accountable to follow the law. We are emboldened by this ruling to continue our fight to ensure the millions of patients our members treat each year are not deterred from seeking emergency care when they need it.” 

The 11th Circuit determined that:

• Providers who receive a patient’s assignment of benefits have the right to seek equitable relief under ERISA.
• Anthem/Blue Cross Blue Shield’s emergency room claims review process is being conducted on a systemic versus individual basis – noting the company uses a pre-determined list of undisclosed diagnoses to make its decisions.   
• The Anthem/Blue Cross Blue Shield policy could subject ACEP and MAG physicians to past and ongoing harm.   

The 11th Circuit opinion said that, “The [emergency department] review is also conducted by a physician, not a layperson. The prudent layperson standards ask what someone with ‘average knowledge of health and medicine’ would think is an emergency based on the severity of ‘acute symptoms’…A physician’s professional assessment of symptoms is irrelevant. The regulations do not call upon a medical doctor to put aside her years of training to evaluate what someone without such training would view as a medical emergency.”

ACEP and MAG stress that the prudent layperson standard both safeguards patients by requiring health insurers to base claims payments on a patient’s symptoms—and not their final diagnosis—and prohibits those insurers from requiring patients to seek prior authorization before they seek emergency care. 

Anthem has implemented the policy in Georgia and five other states, including Indiana, Kentucky, Missouri, New Hampshire and Ohio. Under this policy, patients who seek emergency care in these states are responsible for paying their entire bills if Anthem determines that their diagnoses were not true emergencies after a retrospective review.  

ACEP and MAG originally filed the lawsuit in federal court in 2018, but the District Court for the Northern District of Georgia dismissed the suit in March of this year—after Anthem challenged the case. ACEP and MAG then appealed the case to the 11th Circuit.