Doctors: Blue Cross denied hundreds in Georgia coverage for ER bills

(PHOTO by KEN HERMAN / American-Statesman)

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(PHOTO by KEN HERMAN / American-Statesman)

Hundreds of Blue Cross policyholders in Georgia have been stuck with emergency room bills after the company decided they shouldn’t have gone to the emergency room and denied them coverage, according to doctors who testified Thursday at a state hearing.

Blue Cross Blue Shield of Georgia instituted the policy for individual policyholders just over a year ago to control unwarranted costs, and it's currently being challenged in federal court.

The patients whose ER bills were denied included:

  • A woman with a history of lung blood clots who developed calf pain and shortness of breath a few weeks after having surgery, but it turned out not to be a new blood clot.
  • A woman with chest pain who checked her blood pressure and called her doctor and was told to go to the ER.
  • A 59-year-old man who fell and got a large laceration in the scalp.
  • A woman who came in for abdominal pain and was found to have a serious liver abnormality.
  • A man who dropped a knife on his foot and required immediate wound cleaning and stitches.

“No prudent person who has in mind the best interest of the patient reviewed any of these charts or they would not have denied a single one of them,” said Dr. Chip Pettigrew, a member of the Georgia College of Emergency Physicians, who read the list.

He was speaking to a committee that the state House of Representatives formed to study the issue of surprise billing in emergency rooms.

“We’ve got families paying $1,600 for premiums,” said the committee’s chairman, state Rep. David Knight, R-Griffin. “They’re seeing higher deductibles and a higher co-pay. My concern with this policy is we’re seeing on the back end, sort of in hindsight, the delay or denial of a benefit that the insured paid for and believed that they were entitled to.”

Blue Cross’ parent company, Anthem, said in a statement that its goal was “to ensure access to high quality, affordable health care,” and that as part of that patients needed to get care in the most appropriate setting.

"Anthem's Emergency Department Review aims to reduce the trend in recent years of inappropriate use of EDs (emergency rooms) for non-emergencies," it said. "If a consumer reasonably believes that he or she is experiencing an emergency medical condition, then they should always call 911 or go to the ED. But for non-emergency health care needs, EDs are often a time-consuming place to receive care and in many instances 10 times higher in cost than urgent care."

Knight said he had tried to get a copy of the exact policy — what services are denied or approved and who makes that decision and how — from the state Department of Insurance. Instead, he said, the state sent him an affidavit from Blue Cross saying the documents were proprietary trade secrets.

The company on its website posts a long list of conditions and symptoms, and checks the best place for a patient to go for each of them. Knight displayed the list on the committee screen, but the doctors noted that many conditions produce symptoms that could mean different problems.

Pettigrew suggested that the hundreds of Georgia emergency room visits a day by Blue Cross policyholders were not being given careful review by an analyst, but spit out by a computer.

“This is no human that can do that,” he said. “If a human is actually doing that, I need to talk to this human because they have no understanding about what is and is not an emergency.”

Anthem said that when it denies an ER claim, it’s done by a medical director who has requested additional information from the hospital and patient and reviewed it.

The doctors who testified, representatives of doctors’ groups, were united in fearing that people who needed to go to the ER would be deterred.

“This puts patients in a terrible position where they’re asked to diagnose themselves before they go,” said Dr. Frank McDonald, the president of the Medical Association of Georgia. “Someone is going to make the wrong choice and someone is going to die.”

Dr. John Rogers, the president-elect of the American College of Emergency Physicians, said the policy was a tactic “based on fear and intimidation and requiring patients to balance the risks to their health versus their financial health.”

“Patients now are fearful; specifically, poor patients are fearful,” Rogers said. “They’re delaying care and sometimes overwaiting care, and we believe this is putting their health at risk.”

Anthem has said it makes its decisions based on the standard of what a prudent layperson should think is worth an emergency visit. It also added in its statement that every patient has the right to appeal a denial.

“Anthem has made, and will continue to make, enhancements to ED Review to help consumers receive the right care at the right place and time,” it added.

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