Texas Blues insurer delays new ER payment policy

Blue Cross and Blue Shield of Texas agreed to delay a new payment policy aimed at reducing its emergency department claims costs while Texas insurance regulators review the policy.

The Richardson, Texas-based insurer, a subsidiary of Health Care Service Corp., will hold off on implementing the policy for 60 days at the request of Texas Insurance Commissioner Kent Sullivan. It was slated to go into effect on June 4.

Under the policy, the health plan's retail and HMO plan members who visit an out-of-network emergency department for conditions that are not serious or life-threatening would potentially be required to foot the entire bill. The policy would apply to about 500,000 of the insurers' members.

A spokeswoman for Health Care Service Corp. in April told Modern Healthcare that the Texas health plan would review medical records and the patient's itemized bill, and consider symptoms that led the patient to visit the ED when scrutinizing out-of-network claims. A physician would also review each claim. Members who are denied coverage would be able to appeal the decision, she said.

The Texas insurance department is seeking more information from the insurer about its claim denial process, patient appeal rights, and how it will communicate the new policy to members.

Blue Cross and Blue Shield of Texas created the policy in response to an uptick in the number of its members going to the ED as a convenience for things like head lice, immunizations and school physicals. Visits for conditions that are not serious drive up costs for all members and Texans, the Health Care Service Corp. spokeswoman explained.

"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," Blue Cross said in a statement.

Health Care Service Corp.'s other plans in Illinois, Montana, New Mexico and Oklahoma are not planning similar ED policies, the company said, but the Texas plan isn't the only insurer cracking down on ED spending. Anthem and UnitedHealth Group have also implemented polices aimed at reducing such costs. All have faced pushback from hospitals, physicians and patients.