Private Payers News

BCBS Ohio Plans for Upping Patient ED Visit Costs Raise Concerns

BCBS of Ohio plans to charge beneficiaries the total cost of non-emergency ED visits, which has raised concerns from emergency physician experts.

BCBS of Ohio ED visit costs raise provider concerns

Source: Thinkstock

By Thomas Beaton

- BCBS of Ohio plans to charge beneficiaries the total cost of their emergency department visits  if a diagnosis suggests the visit wasn’t emergency-based, a policy which has been met with extensive concern from The American College of Emergency Physicians (ACEP) and its Ohio chapter (Ohio ACEP).

The policy is expected to come into effect on January 1st, 2018, and could create potentially serious outcomes for beneficiaries, according to Purva Grover, MD, ACEP fellow and president of Ohio ACEP.

BCBS Ohio wouldn’t cover ED costs if a patient goes in for a condition like a rash, according to the policy’s details. Rashes can be an indicator of lyme disease or endocarditis from an opioid injection, but patients may be discouraged from getting care because of high costs, Grover said.

BCBS Ohio’s policy may not be in alignment with current healthcare laws that require coverage to be based on current symptoms rather than a diagnosed medical condition.

The policy may not meet “layperson” standards that require payers to pay for emergency care based on a patient’s symptoms. Under layperson standards, if a beneficiary is having heart attack symptoms, but they don’t experience a heart attack, then a payer is still required by law to cover the cost.

"This policy is dangerous, because Ohioans who really need emergency care may be too afraid to seek care," said Grover. “Health insurance companies can't expect patients to know which symptoms are life-threatening and which ones are not, and they shouldn't be punished financially because of it.”

"Emergency physicians treat patients every day with identical symptoms – some go home, some need a medical procedure, and some need to be admitted. Only a full medical review can determine that."

ACEP conducted a poll that found 4-in-10 Americans reported avoiding emergency care in the past two years following concerns about copay, coinsurance, and deductible amounts. Half of these individuals said their medical condition worsened as a result.

This is not the first time that a BCBS branch has implemented policies that would fully charge beneficiaries for the total costs of emergency care.

ACEP previously criticized BCBS Georgia for a nearly identical policy that would force commercial beneficiaries to pay for emergency services out-of-pocket. ACEP accused the payer of violating layperson standards as well as endangering patient health by financially influencing beneficiaries to avoid ED utilization.

Leaders at ACEP accused BCBS Ohio, as well as branches in Missouri, Kentucky, and New York, of continuing to favor profitability over patient outcomes. Emergency physicians expect to advocate against these policies which are popular among payers.

"Health plans have a long history of not paying for emergency care," said Paul Kivela, MD, MBA, FACEP, president of ACEP.

"For years, they have denied claims based on final diagnosis instead of symptoms. Emergency physicians successfully fought back against these outrageous policies.  Now, as the future of healthcare is debated against, insurance companies are trying to reintroduce the practice."