Some Texans could be stuck with full cost of out-of-network ER visit

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WACO, Texas (KWTX) The Texas Medical Association and 18 other state medical societies are asking the Texas Department of Insurance to review a Blue Cross Blue Shield of Texas policy that means some HMO members will be forced to pay the full cost of out-of-network emergency medical bills.


The state insurance commissioner has given the company until May 30 to respond.

Blue Cross Blue Shield of Texas announced the new policy in a memo issued last month.

“Starting June 4, 2018, our fully insured group and retail HMO members may be required to pay for the entire emergency room bill if they go to an out-of-network ER as a convenience for a condition they don’t think is serious or life-threatening,” the company said in the memo.

“Some of our members are using the emergency room for things like head lice or sprained ankles for convenience rather than for serious or life-threatening issues. Doing so not only drives up costs for our members, but uses limited ER resources for conditions that are not serious or life threatening. We want to make health care affordable for our members, and to do so, we have to be good stewards of their money,” the company said.

The TMA says the policy is at odds with state law that sets HMO coverage requirements defines “emergency care” in a way that shields patients from having to “self-diagnose” emergency conditions.

“What this policy essentially does is put part of the decision-making diagnostic decision making on the patient, do they have something serious or not,” said Dr. Robert Wolf, the president of the McLennan County Medical society.

Wolf, an orthopedic surgeon at the Elite Sports Medicine Center in Waco, says people who fear they may have to pay the whole price may decide not to visit an ER, which could prove to be fatal.

"You have vague abdominal pain or vague chest pains. Do you want to sit at home and think this is something that's really an emergency to go to the emergency room and they tell you no it wasn't, or do you want to sit at home and then potentially die of a heart attack two, four or six hours later because you didn't go in,” he said.

Wolf agrees that some patients use emergency rooms for the wrong reasons.

"There is no question that there has been some overuse of emergency care, but again it's not for the patient to decide that."

But Wolf says patients have no experience in diagnosis,

"We spent years as physicians through medical school and training, learning the subtle clues, the subtle bits of medical history of what's important and what's not."

"So if I were sitting down with Blue Cross I'd say this: You cannot ask a patient to make a determination if they have a life-threatening or limb threatening injury, period.”

About 500,000 Texans have purchased HMO plans from the company.

The TMA and other organizations are recommending that Blue Cross Blue Shield educate those covered under its HMO plans about in-network options including urgent-care centers and emergency facilities.

The Texas Insurance Code, in setting the standard for coverage by HMO’s defines emergency care as “health care services provided in a hospital emergency facility, freestanding emergency medical care facility, or comparable emergency facility to evaluate and stabilize medical conditions of a recent onset and severity, including severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that the individual’s condition, sickness, or injury is of such a nature that failure to get immediate medical care could place the individual’s health in serious jeopardy, result in serious impairment to bodily functions, result in serious dysfunction of a bodily organ or part, result in serious disfigurement or for a pregnant woman, result in serious jeopardy to the health of the fetus.”