BCBS of Texas: Some members may have to pay entire bill for nonemergent use of out-of-network ED

BlueCross BlueShield of Texas may begin requiring some members who access nonemergent care at out-of-network emergency departments to pay their bills in full.

Here are five things to know about BCBSTX's emergency benefit management process.

1. The process will affect BCBSTX's fully insured group and retail health maintenance organization members with out-of-network ED claims filed after June 4. Those members may be on the hook for the entire out-of-network ED bill if they use the facility for care the insurer deems not serious or life-threatening.  

2. BCBSTX said some of its members are "using the emergency room for things like head lice or sprained ankles, for convenience rather than for serious or life-threatening issues. Doing so not only drives up costs for our members, but uses limited ER resources," according to a document obtained and shared on Twitter by Ed Gaines, chief compliance officer at the emergency medicine division of Zotec Partners.*

3. In the document, BCBSTX said after June 4, it will begin reviewing out-of-network ED claims by requesting medical records and an itemized bill for the claim. The payer will consider members' medical record and presenting symptoms during the review to ensure the services rendered were accurately billed to eliminate inappropriate charges. While the review takes place, members' claims will be pending, and will not be denied without physician review. 

4. BCBSTX spokesperson Chris Callahan told Becker's in an emailed statement, "We also want to make sure that what the ERs are billing us for is in line with the testing, medications and level of service our members actually received. For example, during some recent reviews, we discovered that a facility billed our member for an MRI that the medical record didn't support."

He added, "Our focus has been how to put the member first in reviewing these out-of-network ER claims so that we can be good stewards of their money and manage the cost of premiums."

5. BCBSTX's emergency benefit management process is the latest in insurers' attempts to push members with nonemergent care needs toward cheaper urgent and primary care services. However, similar policies rolled out by Anthem have drawn considerable backlash from providers and lawmakers.

*Zotec Partners works with Becker's Hospital Review, but the firm did not contribute to this article.

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