A change by the state’s largest medical insurer to the claims review process for emergency-room visits is drawing criticism from the Texas Medical Association and emergency-room physicians.

Citing rising emergency-room costs, Blue Cross Blue Shield of Texas on Monday instituted a process to retroactively decide whether an out-of-network emergency room visit warrants reimbursement based on a patient’s final diagnosis rather than his or her symptoms. The change affects 500,000 Blue Cross Blue Shield group and retail HMO members.

If the ailment is later determined not to have been be serious enough to warrant emergency care, the patient could be on the hook for 100 percent of the bill.

The insurer said that the decision was made in response to members using the emergency room “for convenience rather than for serious or life-threatening issues,” noting that sprained ankles and head lice are not emergency concerns.

“The Blue Cross Blue Shield Policy that went into effect yesterday ultimately is going to deter patients from seeking emergency care when they need emergency care,” said Dr. Gerad Troutman, president of the Texas College of Emergency Physicians. “People will end up dying because of this policy.”

A letter from the Texas Medical Association and 18 other Texas medical societies on May 8 asked Texas Department of Insurance Commissioner Kent Sullivan to evaluate the policy and the effect it may have on patient care.

The controversial policy, first announced in April, was set to go into effect on June 4, but Blue Cross Blue Shield of Texas delayed implementation by 60 days after state insurance regulators said they wanted more information about how the review and appeals processes will work.

Although the new policy is already in effect, medical societies are asking the Texas Department of Insurance to continue its probe into the policy.

“We think that keeping patients out of the emergency room when they should be in the emergency room is a predatory practice,” Troutman said.

Blue Cross Blue Shield of Texas spokesman James Campbell told the Rivard Report on Tuesday that the policy was enacted because of rising emergency room costs across the state. He said those costs include “billing for services that were not performed or were not medically necessary, inaccurate billings, excessive and unconscionable charges for routine services, and the proliferation of out-of-network freestanding emergency rooms.”

Troutman, an emergency room physician who is co-founder and chairman of a freestanding emergency room in Wichita Falls, said that the vast majority of patients seeking care in an emergency room need to be there, and that physicians are trained to use medical history and an initial physical examination to inform and rule out diagnoses before seeking further testing.

“Not every single patient that ends up in the emergency room ends up with a plethora of labs and multiple consultations,” he said.

The concern for medical providers, Troutman said, is that often what appears to be a minor illness is one symptom of a much larger illness. For example, a person may arrive at the emergency room complaining of chest pain that emergency room personnel may be determine to be indigestion, while another person may come in with the same symptom and could be having a heart attack.

“The health care profession believes that patients will die because of this policy,” Troutman said.

Blue Cross Blue Shield of Texas believes that the “thoughtful, multi-step review process will provide protection for [members] from inappropriate billing, egregious charges and fraud, waste and abuse by out-of-network emergency departments,” Campbell said.

Troutman pointed out that the parent company of Blue Cross Blue Shield of Texas reported $1.3 billion dollars in profits in 2017.

Blue Cross Blue Shield has rolled out the same policy in other states, including Georgia, Missouri, and Virginia, prompting similar backlash from local providers.

On July 17, the Medical Association of Georgia filed a federal suit in an effort to compel the insurance giant to rescind the policy, noting that more that 70 percent of doctors in Georgia do not believe the average patient is knowledgeable enough to make judgments about what qualifies as a medical emergency.

Additionally, the lawsuit claims that the policy violates the prudent layperson standard, a federal insurance law that requires insurance companies to cover the cost of emergency care for those who believe they need it, and prohibits insurers from asking that patients to seek prior authorization before seeking emergency care.

The Blue Cross Blue Shield of Texas policy states that no emergency room claim will be denied without completion of a multi-step review process by a licensed physician. If a claim is denied, members may appeal.

Dr. Douglas Curran, president of the Texas Medical Association, said that insurance companies need to offer more after-hours care options that would reduce the frequency of emergency-room visits.

Curran said that if insurance companies allowed more reimbursement for telehealth services done over the phone or via video conferencing for patients in need of immediate services, patient care would improve and insurers would see lower costs.

“There need to be adequate networks in place for patients to go after-hours, with better payment models and better models of care,” Curran said. “All of those things can be accomplished if insurance companies weren’t restricting” care options.

Roseanna Garza

Roseanna Garza reports on health and bioscience for the San Antonio Report.