Two Democratic senators penned a letter to HHS Secretary Alex Azar and Labor Secretary Alexander Acosta requesting they review whether Anthem's emergency department policy violates law.
The four-page letter, jointly written by Sens. Ben Cardin, D-Md., and Claire McCaskill, D-Mo., raises concerns Anthem may be violating federal law by denying ED claims allowed under the prudent layperson standard. The prudent layperson standard refers to a person who has an average understanding of healthcare presenting to the ED with conditions he or she would deem emergent.
Under Anthem's ED policy, which is in effect across several states, Anthem will review diagnoses after members' emergency room visits. If the condition is determined to be nonemergent, Anthem may not cover the ED visit. The policy is designed to discourage patients from using costly ED facilities for nonemergent medical treatment.
"While we appreciate Anthem's effort to encourage patients to seek medical care in lower-cost settings, we remain concerned that Anthem's ED policy still forces patients to determine, before they even leave their home, if their symptoms are serious enough to go to the emergency room," the senators wrote. "The Prudent Layperson Standard was specifically drafted to allow patients to get the services they need, when they need them. Patients should not be forced to act as their own doctors and second guess themselves when they truly believe that they are having a medical emergency."
In their letter, Sens. Cardin and McCaskill request documents and answers to eight questions by March 30 from the secretaries. The senators follow several other lawmakers who've spoken out against Anthem's policy. In early March, Democratic lawmakers introduced a bill in Ohio's General Assembly that would bar insurers like Anthem who cover ED visits on a discretionary basis from state contracts and tax incentives.
There are several exceptions to Anthem's ED policy. Click here to learn more.