Blue Cross and Blue Shield of Texas stops ER coverage on visits deemed “unnecessary” for certain policies

It has been reported that Blue Cross and Blue Shield of Texas has a new policy, which went into effect on August 6, 2018, that will stop paying for emergency room claims that they don’t consider a necessary visit. This is said to impact approximately 500,000 Texans.

KHOU reports that James Campbell, Sr. Manager Communications for Blue Cross and Blue Shield of Texas says that the new “process” is only for HMO members that do not have an out-of-network emergency room benefit unless “the required care is emergent.”

A statement by the company says, “Over the last two months, Blue Cross and Blue Shield of Texas (BCBSTX) has diligently worked with the Texas Department of Insurance, providing all requested information regarding a process- being implemented today- to review emergency room charges of our retail and group HMO members. Combined with continued education and information, we believe this thoughtful, multi-step review process will provide protection for our members from inappropriate billing, egregious charges, and fraud, waste and abuse by out-of-network emergency departments.”

Campbell says that BCBSTX will review medical records of each individual to be sure they are “taking into account the symptoms that caused the need for the visit while ensuring that the services our members receive are being accurately billed to eliminate inappropriate charges and that the services provided are medically necessary.”

The Houston Chronicle reported earlier this year that Dr. Robert Morrow, President of BCBSTX’s Houston and Southeast Texas office, previously said its patient penalty policy program grew “out of a need for increased review of emergency room claims to help weed out people using expensive emergency room care as a ‘convenience’ for non-emergency treatments rather than going to an urgent care clinic or waiting to see their primary care physician during office hours.”

It was added that claims will not be denied without being reviewed by a licensed physician. The patient can also appeal if the claim is denied.

According to an infographic on the Blue Cross and Blue Shield of Texas website, an ER visit should happen if patients are having life-threatening symptoms such as heart problems, breathing problems, heavy bleeding, broken bones, and severe pain.

The infographic says that the ER should not be visited when experiencing colds, sore throats, flu symptoms, ear or sinus pain, rashes, cuts that don’t need stitches, constipation, and tolerable pain.

The website also has resources for a 24/7 nurse-line, video doctor visits, other tools for finding non-emergency urgent care clinics, and a treatment cost estimator.

Please call Blue Cross and Blue Shield of Texas if you have any questions regarding this new policy. BCBSTX can be contacted at 972-766-6900.