A state-level suit against Anthem over its emergency services policy accused the health insurer of breach of contract and false advertising. (Photo: Diego M. Radzinschi/THE NATIONAL LAW JOURNAL.)

In 2017, insurance company Anthem, Inc. began implementing new medical coverage policies that affect emergency services and medical imaging. As to the former, Anthem’s new policy allows it to reduce coverage for emergency services provided if Anthem later determines that the situation giving rise to the services was not, after all, an emergency. As to the latter, Anthem is denying certain claims for medical imaging performed at hospitals rather than at clinics.

In March of this year, Senators Claire McCaskill (D-Mo.) and Ben Cardin (D-Md.) sent a letter to the Department of Health and Human Services and the Department of Labor asking that the departments investigate whether Anthem’s emergency services policy violates the Prudent Layperson Standard. That standard was introduced by the Senate in 1997 related to Medicare and Medicaid managed care plans. It has since been codified in the Affordable Care Act and in 47 state statutes. Sen. McCaskill also sent a letter directly to Anthem asking how it was complying with the standard and sought documents from Anthem related to how the new policies may represent a cost savings benefitting the insurer.

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