Anthem’s emergency room coverage denials draw scrutiny

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.