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Clinical Laboratories and Pathology Groups

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Clinical Laboratories and Pathology Groups

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Experts concerned people will be unable to judge a true emergency from a minor health concern; patients could be left with a big ER bill if they are wrong

Here’s a groundbreaking way payers are keeping healthcare costs down: Anthem Blue Cross and Blue Shield (BCBS) of Georgia sent letters to its members in May informing them that they will no longer be reimbursed by the insurer for “non-emergency” related services obtained in emergency rooms (ERs).

Pathology groups and medical laboratory leaders, will want to monitor and potentially respond to this important emergency coverage development. Hospital-based medical laboratories receive high volumes of test orders from the ER. Any decline in ER visits from a payer policy like this will have staffing and budget implications for hospital labs.

Medical Groups Warn of Dire Consequences

The new policy garnered national media coverage in addition to local exposure in Georgia, where it went into effect on July 1. BCBS affiliates in New York, Missouri, and Kentucky are considering similar policies as well, noted an article in The Fiscal Times.

“Anthem believes that primary care doctors are in the best position to have a comprehensive view of their patient’s health status and should be the first medical professionals patients see with any non-emergency medical concerns,” Anthem stated in the Fiscal Times article.

In its letter, BCBS of Georgia defines an emergency as a “medical or behavioral health condition of recent onset” that a “prudent layperson” deems health-threatening. However, many symptoms, such as chest pain, can lead to sudden death. How is the average person to know if what they are experiencing will turn out to be angina, a painful but often non-fatal condition, and not a life-threatening embolism?

“The prudent layperson standard requires that insurance coverage is based on a patient’s symptoms, not their final diagnosis,” the American College of Emergency Physicians (ACEP) in Georgia explained in its own statement.

“Anyone who seeks emergency care suffering from symptoms that appear to be an emergency, such as chest pain, should not be denied coverage if the final diagnosis does not turn out to be an emergency,” the ACEP concluded.

Are Patients Able to Judge Where They Should Go?

Some experts warn that many people might be unable to judge the true nature of their conditions when under stress.

The ACEP and its Missouri Chapter said in a statement that Anthem BCBS lists almost 2,000 diagnoses it considers to be “non-urgent” and not covered in the ER. The professional organization contends, however, that some of the diagnoses on the insurer’s list have the propensity to be medical emergency symptoms as well.

Two examples ACEP noted are:

However, cold symptoms, sore throat, physical exams, and minor injuries are among the complaints best addressed by walk-in clinics or urgent care centers, BCBS explained in a blog article.

Nevertheless, Debbie Diamond, Public Relations Director for BCBS of Georgia, told The Fiscal Times that a person who mistakes indigestion for chest pain is likely to be covered for ER care (in keeping with prudent layperson guidance).

Distinguishing Between Necessary and Unnecessary ER Visits

It’s not always simple to recognize an emergency from a non-emergency. Even emergency medicine professionals often have difficulty doing so.

In a Los Angeles Times article, Renee Hsia, MD, Professor and Director of Health Policy Studies, Department of Emergency Medicine at the University of California San Francisco School of Medicine, noted that, “People don’t come with a sticker on their forehead saying what the diagnosis is. We as physicians can’t always distinguish necessary from unnecessary visits.”


Renee Hsia, MD

Renee Hsia, MD (above), is Professor and Director of Health Policy Studies, Department of Emergency Medicine at the University of California School of Medicine, San Francisco (UCSF). She told the Los Angeles Times that the Blue Cross Blue Shield of Georgia emergency coverage policy is a “well-intentioned policy with dangerous consequences.” (Photo copyright: Angie’s List/Adm Golub.)

According to the Centers for Disease Control and Prevention, there are 130.4 million emergency department visits each year in the US. A study published in the Journal of the American Medical Association (JAMA) Journal of Internal Medicine found that six of the 10 top symptoms that send people to non-emergency care settings match those driving decisions to head to emergency departments as well. They include:

  1. Back symptoms;
  2. Abdominal pain;
  3. Sore throat;
  4. Headache;
  5. Chest pain; and
  6. Low back pain.

“Our findings indicate that either patients or healthcare professionals do entertain a degree of uncertainty that requires further evaluation before diagnosis,” the authors wrote in JAMA.

Where Next? Who’s Next?

Despite the discord over the reduction in non-emergency coverage, more BCBS affiliates may soon adopt the same policy. And what of other large insurers? Might they be watching and considering whether to alter their emergency coverage, as well, to save money?

Thus, clinical laboratories in Georgia hospitals will want to closely monitor their institution’s ER test volume. It could take a while for Blue Cross patients in Georgia to realize that some ER visits (and the clinical laboratory tests associated with them) might not be covered by their insurance. This will happen in instances where their insurer denies claims for services that, in Anthem’s opinion, were better suited for primary care doctors and urgent care centers rather than ERs.

—Donna Marie Pocius


Related Information:

Got Chess Pain? This Insurer May Not Cover Your Emergency Room Visit

Blue Cross in Georgia to Limit Emergency Room Coverage

Choosing Between ER and Urgent Care

Blue Cross Blue Shield of Georgia Launch Emergency Room Policy

Emergency Physicians: Anthem Blue Cross Blue Shield Policy Violates Federal Law

Emergency Physicians: Georgia Blue Cross Blue Shield Policy Violates Federal Law

A Big Health Insurer is Planning to Punish Patients for Unnecessary ER Visits

Urgent Care Needs Among Non-Urgent Visits to the Emergency Department