Blue Cross HMO Emergency Payment Review Policy Begins
By Steve Levine

1.25 surprise billing photo

Beginning today, Blue Cross Blue and Shield of Texas (BCBSTX) will require some members to pay 100 percent of their medical bills if they go to an out-of-network emergency room for certain non-life-threatening conditions, company officials have confirmed.

BCBSTX announced the policy for its fully insured group and retail HMO members in April, drawing criticism from numerous medical organizations, including the Texas Medical Association, as well as the Texas Department of Insurance (TDI). 

“We are disappointed that Blue Cross is moving ahead with this policy,” said TMA President Douglas Curran, MD. “Unfortunately, even the announcement of this plan has already planted a seed in patients’ minds that they’ll be left with a big bill if they go to the emergency room for the ‘wrong reason.’ We encourage TDI to join us in monitoring this closely to make sure no patients are denied necessary care.”

Dr. Curran asks TMA member physicians to report any specific cases to the TMA Hassle Factor Log.

Robert Morrow, MD, BCBSTX Southeast Texas market president, told Texas Medicine Today the new policy is a response to “a continual escalation of emergency room costs due to multiple factors including billing for services that were not performed or not medically necessary, inaccurate billings, inappropriate ER use, excessive and unconscionable charges for routine services, and the proliferation of out-of-network freestanding emergency rooms.”

Therefore, Dr. Morrow said, the company feels “a need to verify the accuracy and legitimacy of the services that our members receive and are potentially billed for by emergency facilities.” 

In a mid-May letter, TMA and 18 state specialty societies asked Insurance Commissioner Kent Sullivan whether the BCBSTX policy runs afoul of the state’s “prudent layperson standard,” which shields patients from having to self-diagnose emergencies.

Dr. Morrow said BCBSTX will “review each medical record so that we’re taking into account the symptoms that caused the need for the visit.” He said the company will “pend — not deny” a claim while it is under review.

BCBSTX’s decision coincides with a related lawsuit the Texas Association of Health Plans (TAHP) filed against TDI. The suit challenges TDI rules that require HMOs and EPOs to hold their enrollees harmless for out-of-network emergency care and require insurers to pay, at a minimum, the “usual or customary charge” for emergency care to physicians and providers who are out of network in a patient’s PPO health plan.

"This lawsuit is another health plan tactic to avoid paying for the out-of-network emergency coverage that our patients bought" with their policies, Dr. Curran said. "Rather than filing a suit that seeks to undermine critical TDI patient protection rules, we encourage all of the plans to develop adequate emergency care networks and to pay for non-emergent after-hours care, including via telemedicine, from patients’ primary care physicians.”

BCBSTX originally planned to implement the HMO policy June 4, but delayed the start to today to answer questions posed by state insurance regulators “while continuing to educate our members on the importance of appropriately using emergency services.”

In late May, TDI Associate Commissioner for Consumer Protection Melissa Hield asked for answers to six questions about the new policy, why it was proposed, how it will work, and patients’, physicians’, and providers’ appeal rights. 

According to BCBSTX’s response to TDI and Dr. Morrow, emergency room claims reviews will be done by a licensed physician. In addition:  

  • Any claims denials would come only after a review of medical records by a BCBSTX medical director;
  • When the medical director is contemplating a denial, the physician or provider will be offered a peer-to-peer conversation; 
  • Consumers will be able to appeal if the claim is denied as not medically necessary. This would include an appeal to an independent review organization.   

TMA leaders and staff will continue discussions about this and other issues with TDI, BCBSTX, and TAHP.

Texas Medicine Today will monitor the rollout and will provide updates as they happen.

 Additional reporting by Dave Doolittle

Last Updated On

August 10, 2018

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Steve Levine

VP, Communication

(512) 370-1380
Steve Levine

A former statehouse reporter, political press secretary, and state agency spokesman, Steve Levine has directed the Communication Division at TMA since 1997. He oversees Texas Medicine, Texas Medicine Today, TMA's media and public relations activities, and the TMA Knowledge Center, website, and social media activities.

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