Simply put, Anthem’s retrospective denial of emergency care coverage is unethical and illegal. In 2010, the Affordable Care Act renewed this standard for emergency care coverage as one of the 10 essential health benefits. Other states followed, and it became federal law in 1997 as part of the Balanced Budget Act. Maryland passed the first prudent layperson standard in 1992.
This standard defines emergency medical conditions as “acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in. In response, states and the federal government passed laws requiring insurers to cover emergency care based on the prudent layperson standard. Patients sometimes deferred lifesaving care for fear that their insurance would not cover it. And insurers tried to discourage patients from going to the emergency department by requiring pre-authorization for such visits. In the 1990s, managed care companies commonly denied coverage for emergency care. This tactic of reviewing emergency department visits after the fact isn’t new. The reason? Those patients had the same spectrum of symptoms that brought nearly 90 percent of patients to the emergency department. A 2013 report in the Journal of the American Medical Association showed that, at the start of emergency visits, they identified as non-urgent only 13 percent of patients who ultimately had diagnoses that didn’t qualify as emergencies. What’s more, this expenditure would not count towards your deductible or out-of-pocket limit.Įven the most experienced emergency triage nurses frequently get it wrong. The company then covers only a fraction of the cost, if any, and you are responsible for most of the bill. Say you went to an emergency department for severe abdominal pain and nausea that sounded like your cousin’s appendicitis, only to find out the cause was a nasty stomach virus.Īfter the dust has settled, Anthem reviews the bill and decides that your visit was inappropriate and could have been treated in your doctor’s office or at an urgent care center. But if you have health insurance through Anthem, a health insurance company that covers an astounding 1 in 8 Americans, watch out: You may be on your own in an emergency.Īnthem has introduced a restriction on emergency care coverage, effectively denying most if not all coverage if they decide after your ED visit that you didn’t have an emergency condition. Most people buy insurance to protect financially against potentially catastrophic events and emergencies. “In this case, our examination team concluded with a significant degree of confidence that the cyber attacker was acting on behalf of a foreign government,” said Jones in a statement.Exclusive analysis of biotech, pharma, and the life sciences Learn More
And the incident is likely to have been an intentional international attack. The investigators concluded that the hack actually began all that way back in February 2014, when just one user at an Anthem subsidiary opened a phishing email that then gave the hacker access to Anthem’s data warehouse. Information security firm Mandiant was also hired by Anthem to conduct its own internal investigation into the cyber attack.Ĭlick here to subscribe to Brainstorm Health Daily, our brand new newsletter about health innovations. A team of investigators led by seven state insurance commissioners across the country, including California’s Dave Jones, were tasked with conducting a nationwide examination of the breach.
The Anthem hack was first discovered in January 2015 and left an estimated 78.8 million consumer records exposed.
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