BCBS of TX Delays Non-Emergency ED Claims Review Policy

June 12, 2018 - BlueCross BlueShield of Texas has delayed implementation of a claims review policy that would require HMO members to pay the total cost of an emergency department visit if the encounter is later deemed to be a non-emergency, according to a memo forwarded to The Houston Chronicle.

The payer and the Texas Department of Insurance (TDI) held a meeting at the end of May of 2018, during which BCBS of Texas President Dan McCoy, MD, and TDI Commissioner Dan Sullivan agreed to delay enactment of the policy.

A letter from RDI Associate Commissioner Melissa Held asked that BCBS of Texas should first explain the reasons for the new ED policy and support the plan with available data or insights. Held also asked BCBS of Texas if they communicated fraud, waste, or abuse concerns with ED visits to appropriate regulatory agencies such as the state’s Attorney General.

The letter also questioned BCBS of Texas on how the payer will effectively communicate the new policy, how members without email or digital services will receive claims denial updates, and how BCBS plans to ensure members are thoroughly educated about the new policy and what constitutes a claims denial.

These issues had not been fully explained in an April 2018  memo to HMO commercial members.

The memo explained that BCBS of Texas has noticed overutilization of ED care among commercial members in recent years.

“Some of our members are using the emergency room (ER) for things like head lice or sprained ankles, for convenience rather than life-threatening issues,” BCBS of Texas said.

“Doing so not only drives up the cost, but also uses limited ER resources for conditions that are not serious or life-threatening. We want to make healthcare affordable for our members, and to do so, we have to be good stewards of their money.”

The policy would have taken effect on June 4, 2018. Members of HMO commercial plans would have been required to pay the entirety of an ED bill if BCBS of Texas found that members visited the ED in a non-emergency situation. HMO members would be allowed to consult with providers for denial reviews and initiate appeals processes.

Eighteen provider societies, including the Texas Medical Association and the Texas College of Emergency Providers, argued that the policy is too restrictive and violates standard layperson laws for HMO coverage.

The layperson laws in Texas require payers to cover ED visits for HMO members when those members experience symptoms that could reasonably indicate a serious health event.

“For example, when a person wonders if his or her chest pain is indigestion or a heart attack, will HMOs now be allowed now to penalize that person if he or she seeks care only to learn the ailment is the lesser concern?” the provider societies said. “Or whether head trauma caused a concussion? Or whether abdominal pain is constipation or actually a dangerous appendicitis?”

The organizations argue that policies like the one proposed by BCBS of Texas would likely cause more individuals to make inaccurate self-diagnoses or avoid necessary care out of fear of being wrong.

BlueCross BlueShield organizations across the country have tried to implement similar policies that have been met with criticism from emergency care experts.

Both Anthem BCBS and BCBS of Georgia implemented similar ED policies, wherein patients could become liable retroactively for the total cost of non-emergency ED visits.

Leaders at the American College of Emergency Physicians (ACEP) responded that the policies are a dangerous way for BCBS companies to limit ED utilizations and costs.

Both organizations subsequently amended the policy by adding a number of “must pay” procedures, such as surgery.

The BlueCross BlueShield Association widely supports ED alternatives as part of its corporate mission to lower costs and utilization related to ED care.  For example, the payer uses a platform called SmartER Care Options that help members find more cost-effective alternatives to ED visits, including telemedicine and retail clinic options.