Blue Cross Blue Shield of Texas is following in the footsteps of other insurers by clamping down on emergency room visits it deems non-emergency. In a memo that made the media rounds this week, BCBSTX says HMO members could be on the hook for their entire medical bills if they go to out-of-network emergency rooms “as a convenience for a condition they don’t think is serious or life-threatening.”
Members who’ve made such claims to date will get letters laying out their care options on May 1, and the new review process will kick in on June 4, the memo says.
When I got him on the phone, Paul Hain, BCBSTX’s North Texas market president, said that the new requirements will take into account the symptoms rather than the resulting diagnosis.
“If it’s obvious to a prudent layperson that this is not an emergency, than that becomes not a covered benefit and the member will be responsible for it,” Hain says.
The “prudent layperson” language is well-established bureaucratic speak for evaluating what exactly constitutes an emergency. (This super thrilling fact sheet has the term’s history, which evidently dates to 1994.)
BCBSTX’s memo points to things like head lice and sprained ankles as examples of ailments that shouldn’t require an ER trip.
It’s not the first insurer to make a change in the way it views ER visits. Anthem put a similar policy into place in some states last year, to plenty of backlash. The insurer has a list of “always pay” exemptions for things like IV fluids and meds, surgery, MRIs, and CT scans.
UnitedHealth Group has gone about it another way, as reported here by Modern Healthcare. The insurer is keeping a closer eye on the way hospitals code their emergency visits, which impacts reimbursement.