
Anthem’s emergency room coverage denials draw scrutiny - arkades
https://www.ajc.com/news/state--regional-govt--politics/anthem-emergency-room-coverage-denials-draw-scrutiny/sWT8ts3TYv6vNjrEN99kdO/
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arkades
Traditionally, policy states that ER utilization is covered by a prudent
layman's standard: if a reasonable person would think their condition is an
emergency, then the ER visit is covered.

Anthem/BCBS is now changing it to a retroactive review. If one of their
medical staff now thinks, retroactively, that a condition didn't merit an ER
visit - even if there's _no reasonable way_ a layman would know that - they're
denying coverage. They're basically arguing that their post-hoc review is a
reasonable interpretation of the prudent layperson standard, where "prudent
layperson" means "health insurance company algo."

It's a ridiculous policy stance, and one that is going to cost lives. There's
no reasonable way for a layman to know whether their chest pain is
musculoskeletal or ischemic in nature. Going to the ER with a suspected heart
attack is _appropriate_. Anthem now says, hey, if that doesn't turn out to
have been a heart attack - even if you had no way of knowing that - your ER
visit will not be covered. They're actively encouraging people with heart
attacks not to present to the emergency room.

This is the most repulsive move I've ever seen in the private insurance
industry, and I've seen some stuff in my career.

