Starting Aug. 6, Blue Cross and Blue Shield of Texas will no longer pay for out-of-network emergency room visits in which the insurer determines the patient should have sought treatment elsewhere, according to the Houston Chronicle.
Under the new policy, which was announced in April, a medical director hired by the insurer will review claims after the ER visit and determine the reason a patient opted for the ER and if they could have received treatment at a less expensive clinic. BCBS also will look for over-treatment. The policy is expected to affect roughly 500,000 BCBS of Texas members with health maintenance organization plans.
"We have, quite frankly, identified quite a bit of fraud, waste and abuse that happens within the context of some of these treatments at some of these facilities," Robert Morrow, MD, president of the Houston and southeast Texas office of BCBS of Texas, told the Houston Chronicle in a May interview.
The policy was slated to roll out June 4, but numerous complaints from the public and physicians forced it to undergo a 60-day review. However, the insurer and the Texas Department of Insurance OK'd the controversial measure late last week.
TDI said it decided to allow the policy because a physician would conduct the claims reviews and before a denial is issued, physicians could debate their patients' treatment plans with the insurer's physician. Consumers can also appeal the decision to an independent review organization, according to the Houston Chronicle.
Others disagree, calling the policy "intimidating" and "anti-patient." Rhonda Sandel, CEO of the freestanding ER chain Texas Emergency Care Center, told the publication the insurer's motive behind the policy is to "drive down the use of ER care [regardless of need] and to increase the profits of Texas' largest insurance provider at the expense of everyday Texans and their medical providers."
Anthem launched a similar policy in multiple states and has faced harsh criticism as well as numerous lawsuits. A recent report from Sen. Claire McCaskill, D-Mo., found the insurer denied 12,200 claims from members in three states during the second half of 2017 on the grounds the ER visits were "avoidable." However, when patients challenged the denials, Anthem proceeded to reverse itself and pay the claims most of the time.