BCBS of Georgia to stop covering ED visits it deems unnecessary


http://www.beckershospitalreview.com/payer-issues/bcbs-of-georgia-to-stop-covering-ed-visits-it-deems-unnecessary.html

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Starting next month, Anthem Blue Cross Blue Shield of Georgia will no longer cover emergency department services it determines are unnecessary for members with individual plans.

The insurer said the policy aims to steer patients with nonemergent symptoms to see a primary care physician, urgent care provider or use its LiveHealth telehealth app to limit costly ED visits. If a BCBS of Georgia policyholder receives care for nonemergent symptoms, a medical director will use the prudent layperson standard to deem whether the service is necessary.

Jeff Fusile, president of BCBS of Georgia, told WABE, “The cost of care’s been going up so much faster than people’s earnings. We have got to find a better way to do some of this stuff, taking some of that unnecessary spending out of the system.”

The policy does not include referrals from a physician to the ED for nonemergent services, nonemergent services provided to children under age 14, instances when an urgent care clinic is more than 15 miles away and when care is administered on Sundays and major holidays.

“We’re not trying to steer people away from the emergency room if they have a serious condition,” Debbie Diamond, director of publications for BCBS of Georgia, told Becker’s Hospital Review. “If a member is having chest pain that they think is a heart attack, they should still go to the emergency department.”

Ms. Diamond said similar policies have been enacted at Anthem-affiliated plans in Missouri, Kentucky and Virginia. Missouri said it would reinforce the program June 1 and Kentucky enacted the policy in 2015.

Donald Palmisano, president of the Medical Association of Georgia, told WABE the policy disproportionately affects the elderly, rural residents and children over the age of 14. He added physicians are concerned the policy places “the patient, who doesn’t have the clinical background, to determine whether their condition is of an emergency nature.”

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