Emergency room rule in limbo as insurance department asks questions about customer appeals

Emergency room rule in limbo as insurance department asks questions about customer appeals

LUBBOCK, TX (KCBD) - The Texas Department of Insurance is asking questions regarding a billing rule change that insurance company Blue Cross and Blue Shield of Texas almost implemented at the beginning of June.

The delay was caused after Kent Sullivan, Texas Insurance Commissioner, met with representatives of BCBSTX to discuss the proposed change and get insight into implementation procedures. The new rule would have scrutinized customer's emergency room visits and would not have covered out-of-network emergency room usage unless the issue was deemed serious or life-threatening.

That decision would have been left up to BCBSTX in whether the specific emergency room issue was worth a trip to the emergency room or not. This left a lot of questions about how this would affect customers and if it would open the option for any customer appeals to be heard, which was one of the main concerns of the insurance department.

"We had some additional questions, the department did, about how the policy would be applied and how emergency room claims would be handled and practiced," Ben Gonzalez, media relations officer for TDI, said. "So, we wanted to get those all straightened out in what the appeals process would be for consumers when they do have a claim denied at the emergency room."

It was after the meeting with Sullivan BCBSTX delayed the rule implementation for two months, according to an emailed statement from the company. The new anticipated implementation date has since been set for Aug. 6.

"We anticipate this thoughtful, multi-step review process will be implemented on August 6, 2018 to provide protection for our members from inappropriate billing, egregious charges and fraud, waste and abuse by out-of-network emergency departments," the company's statement read.

In the meantime, the company was also sent a letter with a list of specific questions from TDI. Those questions outlined most of TDI's concerns, mainly in how to communicate an appeals process, review processes and outreach, and education information.

Policies like this have been implemented in other states, even with outcry from insurance company customers, which was also a reason TDI asked questions, Gonzalez said. In sending the letter TDI officials are hoping to help in making sure its customers are fully aware of what the changes would mean.

"We will look to see what they are doing is compliant with Texas law and if there's any part of that that's not, then we would have further communications with the company," Gonzalez said.

Currently, the Texas Insurance Code includes a statute called the prudent layperson standard that requires insurance companies to pay emergency facilities at the customer's in-network cost, Dr. Ryan Lewis, physician and Chief Financial Officer with Star ER Lubbock, said. That means if a person presents symptoms which he or she believes warrants an ER visit, they are entitled to make a visit and pay an in-network rate.

If BCBSTX's rule would go into effect it would challenge that standard.

However, the company initially wanted to put this into effect to create a way of ensuring customers are using emergency rooms for emergencies. The scrutinizing of emergency room visits would also make sure its customers are not using ER doctors for his or her convenience; as opposed to visiting an urgent care center or going to one's own regular physician.

"That (potential mandate) does not affect anybody when it comes to Star ER, because we're in-network," Lewis said. "That said, as emergency physicians, we strongly oppose that way of doing business because it puts patient's lives at risk."

Many emergency care advocates have also voiced concerns recently, saying the rule could discourage customers from visiting an emergency room, he said. Because, if an insurance company goes back into a specific visit and determines it was not an emergency, customers would be left to pay more than what they initially thought.

This would make people a bit more apprehensive about an emergency room visit, which could potentially save one's life.

Lewis himself, who is on the board of directors for the Texas Association of Freestanding Emergency Centers, has also been lobbying to make sure this mandate does not go into effect.

"So, essentially, you're flipping a coin to decide if it's non-emergent or if it's emergent, and what are the ramifications of making the wrong choice," Lewis said. "Well, if you make the wrong choice you're putting your life, or serious disability, or prolonged hospital stays – which result in much higher healthcare costs – all of that is your risk."

There is always a potential for people to overuse emergency rooms, Gonzalez said, which was one of the reasons cited for wanting to put this rule in place. But one of the bigger concerns now is not deterring people from utilizing ERs when it is needed.

TDI's responsibility in this situation is to make sure the consumer's rights are protected if a rule like this is put into place.

"We don't want to set up a situation where people hesitate in a true emergency," Gonzalez said. "But I think this company, other companies (and) the department itself has been engaged in education about urgent care, things like telemedicine, using the nurses line to call if you have a medical concern that's not necessarily an emergency, so those kinds of things are ways that can control costs and control your own costs. Because it's not cheap to go to the emergency room."

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