Some of the state’s most influential doctors’ groups are pressing the insurance commissioner to investigate a change that Blue Cross and Blue Shield of Texas is making to its emergency room coverage.
Starting June 4, some policyholders with the state’s largest health insurer could face sticker shock after a visit to the emergency room.
In a letter made public last month, Blue Cross said it will no longer pay the bill if it’s determined later that the patient wasn’t facing a serious or life-threatening medical event.
The change will affect 500,000 Blue Cross members who purchased HMO plans. It’s intended to crack down on the overuse of costly emergency services, driven in part by the growth of freestanding emergency rooms in Texas.
But the doctors’ groups say that it could have unintended consequences.
That could mean “extremely ill patients will not seek needed emergency medical care while, bluntly, their conditions worsen or they die,” they wrote in a letter released Thursday.
They accused the insurer of using scare tactics and of “a heavy-handed approach that could be detrimental to good patient care.”
The letter, sent by the Texas Medical Association and the Texas College of Emergency Physicians, was signed by the leadership of more than a dozen other prominent state medical associations.
The Blue Cross plan already has drawn the ire of consumer watchdogs and emergency doctors, who have vocally opposed policies insurers from have been more frequently adopting.
With 50,000 members, the Texas Medical Association is the state’s largest group of physicians. It asked the Texas Department of Insurance for an update on its review, and reiterated others’ concerns.
The letter asked: “Are health maintenance organizations allowed to punish patients who seek care for what they legitimately believe is a medical emergency?”
The Texas Department of Insurance, which regulates the industry and licenses the products that get marketed, sent a letter to Blue Cross this week demanding details.
It asked for copies of consumer notices and training documents on the new process. It requested specifics on how the new review of patients’ claims will work. And because state law requires that HMO plans allow for medical screening exams to determine whether an emergency condition exists, it asked the health insurer to explain how the screenings will be handled.
Blue Cross has until May 30 to respond.
“We want to make sure that consumer protections are maintained, and that this change complies with state insurance law,” a spokesman for the agency said. “We want them to spell out what are the details.”
In a statement, Blue Cross of Texas said it encourages patients who have, or think they have, a medical emergency to get help by calling 911 or going to the nearest emergency center.
But it also said that emergency room costs in Texas continue to escalate due to multiple factors, including inaccurate bills, billing for services that were not necessary, inappropriate ER use, the proliferation of freestanding emergency rooms and “excessive and unconscionable charges. Learn about term life insurance in the article called Best 10 Year Term Life Insurance Rates (Buying Tips) .
“This approach will address these issues and limit fraud, waste and abuse in the emergency room setting,” the company said.
It added that the review of patients’ emergency room claims will focus on the symptoms that sent the individual to the hospital in the first place, and not their final diagnosis. But the state’s doctors still take issue with that approach.
“With this policy, BCBSTX is asking that patients act as highly trained diagnosticians, skills our members spent many years of their lives acquiring,” said the letter whose signees represented pediatricians, anesthesiologists, pathologists, family physicians and other specialists.
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Originally Published On: Dallas News
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