On behalf of the members of the Mississippi Chapter of the American College of Emergency Physicians

(MS-ACEP), we are writing to express concerns regarding plans by Blue Cross & Blue Shield of
Mississippi (BCBS-MS) to deviate from industry standard CMS coding for emergency care. The
projected result of deviating from this standard would be to provide for payment based on a retrospective
review of post-discharge patient diagnosis. Such an altered process is inconsistent with CMS, various
standard payment policies, and sound medical practice. It is not in the best interest of patients visiting
the emergency department with a reasonable belief that they are experiencing a medical emergency.
In 1997, the federal government, along with the legislatures of 47 states, established the Prudent
Layperson Standard as a means to guarantee that insurers – whether private or governmental – provide
insured patients with coverage for visits related to the patient’s symptoms, not the final diagnosis. Thus,
a patient experiencing chest pain who fears that he or she may be experiencing a heart attack should be
covered for his or her visit, even if the condition turns out to be a non-urgent medical condition, such as a
hiatal hernia. The Prudent Layperson Standard recognizes that a patient should not be expected to
possess the expertise of a medical professional and to self-diagnose when deciding whether or not to go
to the emergency room. Patients with a prudent layperson’s belief that they are experiencing a medical
emergency should not delay care out of a fear that their visit will not be covered. The policies of insurers
should not be such that they lead to potentially unsafe delays in patients accessing potentially lifesaving
medical care.
In Emergency Medicine, patients routinely present with symptoms that can be identical for both a critical
life-threatening condition and for a less serious condition. For example, a patient can have “crushing
chest pain” associated with a heart attack, or “crushing chest pain” from severe acid reflux. The
expectation of the patient, and the national standard of care, is for Emergency Physicians to use their
medical expertise and the tools at their disposal to “rule out” the life-threatening condition. The proposed
coding policy changes by BCBS-MS to provide the payment level based on a final diagnosis completely
ignores the time, resources, and medical expertise required in meeting the standard of care. Further,
these proposed changes fail to meet patient expectations of ensuring that emergent conditions are
appropriately treated, or that less serious conditions are adequately explained so that discharge is
without risk to life or without risk of permanent disability.
People rely on emergency departments for a number of reasons. Those who believe that they may be
experiencing a life-threatening condition should have confidence that their health plan will properly cover
the emergency. Patients who fear that their visits will not be properly covered may delay seeking care
and thus put at risk their heath – and worse: their lives. As such, we request that BCBS not proceed with
these deviations that are out of line with industry standards. MS-ACEP members share concerns about
health plans and the cost of medical care, and they stand ready to work with BCBS-MS on appropriate
ways to address health care costs.
Sincerely,
The Mississippi Chapter of ACEP’s Board of Directors

Phillip Levin, MD, President Lawrence Leake, MD, Councillor

Utsav Nandi, MD, President-Elect Fred E. Kency, MD, Alternate Councillor
Sarah A. Sterling, MD, Immediate Past President William E. Walker, MD, Alternate Councillor
Allison C. Barrett, MD, Secretary-Treasurer Tara C. Lewis, MD, Residency Representative
Jonathan S. Jones, MD, Councillor Drew Trump, DO, Residency Representative