Emergency RoomAs a provider of emergency room medical billing services, we are focused on ensuring that physicians are adequately reimbursed for the services they provide. The news that Blue Cross and Blue Shield of Texas (BCBSTX) has postponed the rollout of the controversial emergency room (ER) claim review process for members holding HMO policies came as a relief for many of our clients. BCBSTX had planned to implement this change for claims incurred after June 4, but has announced that it will delay the process for 60 days.

A University of Maryland School of Medicine (UMSOM) published last year found that nearly half of all US medical care is delivered by emergency departments. Over the 14-year period of the study, there were more than 3.5 billion health care contacts including emergency department visits, outpatient visits, and hospital admissions. During that time, emergency care visits increased by nearly 44 percent.

Overuse of the emergency department has been long been considered a key factor driving health care costs. According to the Health Care Cost Institute, spending on an emergency room visit rose to $1,917, on average, in 2016, up more than 31% from four years earlier. The use of emergency care resources for non-emergency cases has been contentious, as patients who come in for emergency care often end up getting treated for non-emergency medical issues. To control costs, insurers use various methods such as imposing separate deductibles for ER care that does not result in hospital admission and charging lower copays to patients who go to an urgent care center or retail health clinic.

In an April 18 memo, BCBSTX had announced that its fully insured group and retail HMO members may have to pay their entire bill if they go to an out-of-network emergency department for things like sprained ankles, “or convenience rather than for serious or life-threatening issues.”

This announcement sent shock waves across the ER physician community which strongly protested the change. Physicians pointed out that this policy could lead patients to self-diagnose with disastrous consequences. For most people, the decision to go to the emergency room involves a lot of uncertainty. They don’t know if their condition is something that requires going to ER or is something mild that can be handled by their primary care physician.

The Texas Medical Association and 18 other Texas medical societies wrote to the Texas Department of Insurance (TDI), protesting this change. The letter stated: “BCBSTX is asking [patients] to diagnose their symptoms at a critical and emotional moment, when time can be of the essence. As a result, it is very likely that extremely ill patients will not seek emergency medical care while, bluntly, their conditions worsen or they die…. Scaring them into avoiding emergency care seems a heavy-handed approach that could be detrimental to good patient care.”

In a Houston Public Media report, Dr. Alison Haddock, board member of the Texas College of Emergency Physicians says: …patients cannot self-diagnose. I think it’s wrong to be putting that extra burden on patients in their times of greatest need. No one wants to go to ER”. Dr. Haddock notes that you need to have the right for the insurance company pay appropriately for care that you need. If people are uncertain about whether their insurance will pay, it will potentially delay care and put them in great danger.

Federal law and numerous other states’ laws are in agreement with the “prudent layperson” standard for emergency care coverage by HMOs as defined by Texas law, which is as follows:

“Emergency care” means health care services provided in a hospital emergency facility, freestanding emergency medical care facility, or comparable emergency facility to evaluate and stabilize medical conditions of a recent onset and severity, including severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that the individual’s condition, sickness, or injury is of such a nature that failure to get immediate medical care could:

  1. place the individual’s health in serious jeopardy;
  2. result in serious impairment to bodily functions;
  3. result in serious dysfunction of a bodily organ or part;
  4. result in serious disfigurement; or
  5. for a pregnant woman, result in serious jeopardy to the health of the fetus.

Citing the company’s example of sprained ankles, top Texas physicians pointed out that it is not reasonable for an HMO to expect that a “prudent layperson possessing an average knowledge of medicine and health,” in significant pain, can differentiate between a sprain, a fractured bone in the ankle, and a dislocated ankle.

The American College of Emergency Physicians (ACEP) noted that emergency physicians are committed to providing emergency care to all patients who present to the emergency department regardless of their ability to pay. The new BCBSTX rule, if implemented, could leave ER physicians unpaid if the insurer decides that the patient’s condition does not qualify as an emergency. ER bills are high and most patients would be left in the lurch without support from their health plan.

A Jackson LLP blog discusses other implications of the new Blue Cross rule on physicians:Emergency Room

  • Primary care physicians may see a potential increase in after-hours calls from patients who have “frightening symptoms”, and want their condition warrants a visit to the ER.
  • Physicians will be faced with the daunting task of considering costs of care when making a ER clinical judgment over the phone.
  • The consumption of health care services would increase during regular hours, with patients wanting rule out any unnecessary and costly visits to the ER.
  • if they happen to run up bills that they are unable to pay, patients may forgo emergency care in future, as this would leave them with less money to pay for other healthcare services they need.

The new Blue Cross process has been delayed for 60 days, according to the Texas Department of Insurance. Discussions are being with the health insurer about how consumers would be able to appeal denied claims. Blue Cross has written to HMO plan members saying that non-emergent medical conditions can be easily treated at retail clinics, urgent care clinics or 24/7 telehealth services. It has also reminded them about the SmartER website which is designed to help people make smart decisions about ER visits so that they are “not taken advantage of by out-of-network, usually freestanding emergency rooms, and their unconscionable charges.”

Emergency departments provide consistent round-the-clock access for patients to physicians, specialty medicine care, advanced diagnostic technology They also perform intrahospital and interhospital transfer of critically ill patients to appropriate centers of care. Emergency physicians need efficient tools to stay on top of coding, billing, and reimbursement changes. The support of an experienced medical billing and coding company can prove invaluable in these challenging circumstances.