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BCMS LEGISLATIVE
NEWS

Blue Cross HMO Emergency Payment

Review Policy Begins

By Steve Levine, TMA Vice President – Communications

Blue Cross Blue and Shield of Texas (BCBSTX) will require some while it is under review.
members to pay 100 percent of their medical bills if they go to an BCBSTX’s decision coincides with a related lawsuit the Texas As-
out-of-network emergency room for certain non-life-threatening sociation of Health Plans (TAHP) filed against TDI. The suit chal-
conditions, company officials have confirmed. lenges TDI rules that require HMOs and EPOs to hold their
BCBSTX announced the policy for its fully insured group and enrollees harmless for out-of-network emergency care and require
retail HMO members in April, drawing criticism from numerous insurers to pay, at a minimum, the “usual or customary charge” for
medical organizations, including the Texas Medical Association emergency care to physicians and providers who are out of network
(TMA), as well as the Texas Department of Insurance (TDI). in a patient’s PPO health plan.
“We are disappointed that Blue Cross is moving ahead with this "This lawsuit is another health plan tactic to avoid paying for the
policy,” said TMA President Douglas Curran, MD. “Unfortunately, out-of-network emergency coverage that our patients bought" with
even the announcement of this plan has already planted a seed in their policies, Dr. Curran said. "Rather than filing a suit that seeks
patients’ minds that they’ll be left with a big bill if they go to the to undermine critical TDI patient protection rules, we encourage
emergency room for the ‘wrong reason.’ We encourage TDI to join all of the plans to develop adequate emergency care networks and
us in monitoring this closely to make sure no patients are denied to pay for non-emergent after-hours care, including via telemedicine,
necessary care.” from patients’ primary care physicians.”
Dr. Curran asks TMA member physicians to report any specific BCBSTX originally planned to implement the HMO policy June
cases to the TMA Hassle Factor Log. 4, but delayed the start to today to answer questions posed by state
Robert Morrow, MD, BCBSTX Southeast Texas market presi- insurance regulators “while continuing to educate our members on
dent, told Texas Medicine Today the new policy is a response to “a the importance of appropriately using emergency services.”
continual escalation of emergency room costs due to multiple fac- In late May, TDI Associate Commissioner for Consumer Protec-
tors including billing for services that were not performed or not tion Melissa Hield asked for answers to six questions about the new
medically necessary, inaccurate billings, inappropriate ER use, ex- policy, why it was proposed, how it will work, and patients’, physi-
cessive and unconscionable charges for routine services, and the cians’, and providers’ appeal rights.
proliferation of out-of-network freestanding emergency rooms.” According to BCBSTX’s response to TDI and Dr. Morrow, emer-
Therefore, Dr. Morrow said, the company feels “a need to verify gency room claims reviews will be done by a licensed physician.
the accuracy and legitimacy of the services that our members re- In addition:
ceive and are potentially billed for by emergency facilities.” • Any claims denials would come only after a review of medical
In a mid-May letter, TMA and 18 state specialty societies asked records by a BCBSTX medical director;
Insurance Commissioner Kent Sullivan whether the BCBSTX pol- • When the medical director is contemplating a denial, the physi-
icy runs afoul of the state’s “prudent layperson standard,” which cian or provider will be offered a peer-to-peer conversation;
shields patients from having to self-diagnose emergencies. • Consumers will be able to appeal if the claim is denied as not
Dr. Morrow said BCBSTX will “review each medical record so medically necessary. This would include an appeal to an inde-
that we’re taking into account the symptoms that caused the need pendent review organization.
for the visit.” He said the company will “pend — not deny” a claim

For local discussion on this and other legislative advocacy topics, consider joining the BCMS Legislative
and Socioeconomics Committee by contacting Mary Nava, chief government affairs officer at
mary.nava@bcms.org.

10 San Antonio Medicine • September 2018