California Blue Cross Blue Shield Not Pay Emergency Level 5
Confused about Blue Cross Blue Shield's new ER policy? Here's what you need to know
The new Blue Cross and Blue Shield of Texas plan to more stringently review out-of-network emergency room claims has not only brought fiery criticism from the medical community, it has also left thousands of Texans confused.
Here is what you need to know about the measure rolled out Monday:
What it is: Blue Cross and Blue Shield of Texas, the largest insurer in Texas, announced in April it was implementing stepped-up scrutiny of all out-of-network emergency room claims for its HMO patients. If the after-the-fact review finds that a patient could have -- or should have-- sought care at a less costly clinic or their doctor's office, the insurer is now able to pay zero on the claim.
What it isn't: HMO patients who go to in-network emergency rooms will not be affected, the insurer said. Neither will those with preferred provider organization (PPO) plans.
Who's affected? About 500,000 Texans with Blue Cross and Blue Shield HMO plans.
HAVE AN EMERGENCY-ROOM BILLING STORY?Help us investigate medical billing in the Texas health care industry.
Why? The insurer has said it must crack down on unnecessary and expensive ER visits and treatments. It is also trying to curb what it calls abuse and fraud from doctors and facilities who overcharge with medically unneeded tests and treatments. Doctors have countered that the insurer is simply using that as an excuse to underpay them and deny patient claims.
Will patients get stuck? That remains to be seen. Blue Cross Blue Shield executives have said they will not deny claims based on final diagnosis but rather why a patient chose the facility for care. If someone thinks they are having a heart attack but it turns out to be indigestion, the insurer insists it will pay the claim once it is determined the patient reasonably believed they needed emergency care. Critics have contended this forces medically untrained patients to self-diagnose and could lead to people skipping care if they fear their bills won't be paid.
Is there more to the story? Probably. There is wide speculation that the insurer is really taking aim at the rapidly growing free-standing emergency industry which typically operates outside their network. Patients often confuse the much more expensive centers with their lower-priced cousin, the urgent-care clinic. They often look the same, operating as walk-ins, but the free-standing emergency rooms charge much higher facility fees and can perform more complex and expensive treatments. The industry has defended the higher costs as needed because they must be staffed around the clock and are equipped the same as a traditional hospital emergency room. They also say they are out-of-network because the insurer offers too low of a reimbursement rate.
Do consumers hav any recourse? Yes, but again it remains to be seen how well it will work. The Texas Department of Insurance initially balked and asked for clarification from the insurer. That led to a 60-day delay of the launch initially planned for June. TDI now says it is satisfied with the insurer agreement that all after-treatment reviews must be done by a doctor. And if a claim is denied, a patient has the right to have their doctor fight it out with the insurance doctor to prove why the visit was needed.
Read the full story on HoustonChronicle.com: Texas allows Blue Cross Blue Shield to deny payments for some out-of-network ER visits
Jenny Deam covers the business of health care for the Houston Chronicle. She'd love it if you follow her on Twitter.
Source: https://www.chron.com/business/medical/article/Confused-about-BCBS-ER-policy-Here-s-what-you-13137902.php
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