Anthem Denials of Emergency Room CT Scans and MRIs; Patients Sent to Clinics

Washington, DCIn July 2018, the American College of Emergency Physicians filed an insurance lawsuit against Anthem Blue Cross Blue Shield over the insurer’s new policy of denying emergency room coverage after the fact. As a subpart of the strategy, Anthem refuses claims for in-hospital CT scans and MRIs ordered in the course of emergency diagnosis and treatment. The lawsuit focuses on the harm the policy does to patients. But it also shines a light on the damage that Anthem’s plan does to hospitals and the wider healthcare system.

Anthem facing lawsuit over insurance coverage for CT and MRI tests
Anthem expects to implement this rule (formally named the Imaging Clinical Site of Care program and administered by its AIM Specialty Health subsidiary) in most of the states where it does business. In California, Anthem currently insures roughly 15,000 people.

HARM TO PATIENTS

letter to Anthem from the American Medical Association expressed the organization’s deep concern that Anthem’s policy would negatively affect patient care: “We fear that the impact will be greatest on patients living in rural or inner city areas, where hospital outpatient departments may be the only nearby site of service for advanced imaging. These vulnerable patient populations already face significant care access care challenges, and the Anthem policy may exacerbate these existing problems.”

Other studies suggest that these coverage denials disproportionately affect women and minorities.

Meanwhile, as the insurer’s coverage policy pushes patients to clinics, the number of freestanding imaging centers has actually declined because of changes in the industry and shrinking Medicare and Medicaid reimbursements. The squeeze is coming from all sides.

Separate and apart from the issue of whether care is available, others ask whether the “least cost” metric produces the best care. Decisions based solely on cost undermine the relationships between referring physicians and radiologists. They ignore choices based on experience with the quality of care and skill of the radiologist who performs and interprets the imaging study, according to a statement from the American College of Radiology.

Stories abound about inadequate staffing, inadequate equipment, potentially life-threatening scheduling delays and case-specific complexities that are dismissed as irrelevant by Anthem’s third-party reviewers. “We object to this economically motivated steerage policy largely because it goes against our priority— upholding the quality of patient care—and forces people to weigh costs over the best options for their health,” says Texas radiologist Ezequiel Silva III, MD, chair of American College of Radiology’s economics commission.

HARM TO HOSPITALS

Hospitals operate in a unique and complicated economic environment but, as a basic principle, like every other business, they must generate revenue in order to provide community health care services. Some services will produce extra revenue; others will likely never be self-supporting. The mix must generally balance out or the hospital will be forced to shut its doors.

Since imaging services are among the most profitable services hospitals perform, Anthem’s new policy is likely to hit hospitals’ bottom lines hard, especially in areas where Anthem covers large segments of the population.

By law, hospitals must provide critical services regardless of a patient’s ability to pay. The population that cannot pay includes the uninsured, the grossly underinsured and those have insurance, but whose insurer denies emergency room coverage after the fact.

In 2016, the total tab for uncompensated care in U.S. hospitals was $38.3 billion. As large as that figure is, it does not include unfunded costs that result from Medicare and Medicaid underpayment. Nor does it include the shortfall generated by specialty areas of service, like genetic testing and counseling, which are typically not self-supporting.

The revenue generated by imaging services effectively subsidizes these costs. So, losing the income will inevitably put a strain on hospital’s ability to pay for them. The Anthem policy may also put pressure on hospitals to reduce their charges for MRIs and CT scans. This would put further pressure on the freestanding operations.

How will the complex economic equation work out? Will smaller community hospitals be forced to cut back services or close? Although no one disputes the benefit of reducing the cost of health care in the U.S., few seem to be ready to view the question in its larger context. Pending further shakeout, none of the extended consequences of Anthem’s aggressive insurance claim denial policy appear to benefit patients or the hospitals where they go when they are sick.

Source: Anthem Denials of Emergency Room CT Scans and MRIs; Patients Sent to Clinics

Texas ruling on $11,000 ER bill may have long-lasting effects, experts say

The health care industry is closely watching a recent decision by the Texas Supreme Court that some say could have broader implications on how hospitals and health insurers negotiate their rates.

The court sided with an uninsured woman who was billed $11,037 after an emergency room visit.

The justices said that in order to prove her bill was “reasonable” compared with what an insured patient would be billed, the medical center would need to share in court details about the discounted rates it had with health insurers, data that’s generally seen as proprietary and confidential.

The case outlines the complexities of health care billing that consumers often see as arbitrary, confusing and not transparent, whether they have insurance or not.

Read the Texas Supreme Court decision here

Texas Supreme Court Negotiated Rates Decision From April 27, 2018 by Sabriya Rice on Scribd

While few dispute that costs are out of control and transparency would help, the ruling is seen as unprecedented by some, who worry it could deal a big blow to free market competition in health care.

The hospital had fought to prevent the data on its charges from being admissible at trial, saying it wasn’t relevant since the woman was not insured. But in a ruling published Friday, the Texas Supreme Court disagreed.

“The reimbursement rates sought, taken together, reflect the amounts the hospital is willing to accept from the vast majority of its patients as payment in full for such services,” the ruling said.

The key benefit of a hospital negotiating to be in a health plan’s network is that it can offer lower rates for a potentially higher volume of patients, like the difference between going to Sam’s Club and a boutique, said Christian K. Puff, a Dallas-based healthcare attorney with Hall Render, a group that represents hospitals.

“They’re private companies that want to be free to set their own rates,” she said.

But the problem for the Texas justices is that uninsured patients like the one who brought the case can too easily be stuck with big bills they couldn’t avoid or afford.

Crystal Roberts was taken by ambulance to the North Cypress Medical Center emergency room in June 2015 after a car accident. She was sent home three hours later, after X-rays, a CT scan, lab tests and other services, and later got a bill for $11,037.35, the full “chargemaster” rate, because she was uninsured.

The chargemaster lists the costs for each procedure, service, drug or test a hospital will bill for. It’s key in the health care revenue cycle and considered the starting point for billing patients and negotiating with health insurers.

But patients don’t get to see it. And some say there is a big incentive to keep it that way.

“Can you imagine a better scenario than “I’m not going to tell you how much I’ll charge you until you’ve already received the service and you have to pay me exactly what I say,” said Timothy S. Jost, an emeritus professor of health care law at the Washington and Lee University School of Law in Virginia. “We’d all like to be in that situation,” he said.

That may be the case, but should it be for the courts or a jury to decide, Puff asked.

“We don’t want courts determining what is usual and customary. We prefer they stay out of pricing, as a general rule,” she said.

Six of the nine justices signed the opinion. The final three issued a dissenting opinion, siding with the hospital. The dissent argued that neither the court nor the plaintiff could state how confidential reimbursement rates could be used to show that charges to an uninsured, self-paying consumer are unreasonable.

The debate is one that’s drawing attention not just in Texas — where both traditional hospitals and freestanding emergency rooms have been in public wars over negotiated rates — but on a national scale.

Health care price transparency has emerged as a hot topic among state legislatures, consumer groups and the federal government as the nation scrambles to contain unwieldy health costs.

There are many approaches that have varying level of success. Since 2005, California has required hospitals to publicly list the average charges for common outpatient procedures.

A handful of major health insurance companies have partnered to voluntarily share data anonymously about what they pay, which has led to regional comparisons. But it’s mainly  a research tool, said Dr. David Blumenthal, president of the Commonwealth Fund, a private group based in New York that researches ways to make the health care system more efficient.

“It’s helpful from a policymaking standpoint, but not a consumer standpoint,” he said.

And getting hands on data can be tricky, even for policymakers.

For example, pharmaceutical giant Pfizer sued the state of Texas in 2016 because the Texas Health and Human Services Commission provided two state lawmakers — who were trying to draft budgets– details about Pfizer’s negotiated drug pricing rates in the Texas Medicaid program, the most expensive health care program administered by the state.

The courts have been where more of these cases have been bubbling up. However the movement toward health care price transparency got a  major boost last week, when the Centers for Medicare & Medicaid Services issued a more than 1,800 page proposal that, among other issues, expressed concern about surprise medical bills and other cost-related issues.

The agency proposed requiring hospitals to make available a list of their current standard charges via the internet or in a digital format annually, “or more often as appropriate” starting in January.

It is also considering requiring hospitals to issue consumer-friendly communications about their charges that help patients understand the potential for financial liability for seeking hospital services. The public will be able to weigh in with comments through June 25.

Source: Texas ruling on $11,000 ER bill may have long-lasting effects, experts say | Health Care | Dallas News

What the media gets wrong about opioids – Columbia Journalism Review

AFTER JILLIAN BAUER-REESE created an online collection of opioid recovery stories, she began to get calls for help from reporters. But she was dismayed by the narrowness of the requests, which sought only one type of interviewee.

“They were looking for people who had started on a prescription from a doctor or a dentist,” says Bauer-Reese, an assistant professor of journalism at Temple University in Philadelphia. “They had essentially identified a story that they wanted to tell and were looking for a character who could tell that story.”

Although this profile doesn’t fit most people who become addicted, it is typical in reporting on opioids. Often, stories focus exclusively on people whose use started with a prescription; take this, from CNN (“It all started with pain killers after a dentist appointment.”), and this, from New York’s NBC affiliate (“He started taking Oxycontin after a crash.”)

Alternatively, reporters downplay their subjects’ earlier drug misuse to emphasize the role of the medical system, as seen in thispiece from the Kansas City Star. The story, headlined “Prescription pills; addiction ‘hell,’” features a woman whose addiction supposedly started after surgery, but only later mentions that she’d previously used crystal meth for six months.

The “relatable” story journalists and editors tend to seek—of a good girl or guy (usually, in this crisis, white) gone bad because pharma greed led to overprescribing—does not accurately characterize the most common story of opioid addiction. Most opioid patients never get addicted and most people who do get addicted didn’t start their opioid addiction with a doctor’s prescription. The result of this skewed public conversation around opioids has been policies focused relentlessly on cutting prescriptions, without regard for providing alternative treatment for either pain or addiction.

While some people become addicted after getting an opioid prescription for reasons such as a sports injury or wisdom teeth removal, 80 percent start by using drugs not prescribed to them, typically obtained from a friend or family member, according to surveys conducted for the government’s National Household Survey on Drug Use and Health. Most of those who misuse opioids have also already gone far beyond experimentation with marijuana and alcohol when they begin: 70 percent have previously takendrugs such as cocaine or methamphetamine.

Conversely, a 2016 review published in the New England Journal of Medicine and co-authored by Dr. Nora Volkow, director of the National Institute on Drug Abuse, put the risk of new addiction at less than 8 percent for people prescribed opioids for chronic pain. Since 90 percent of all addictions begin in the teens or early 20s, the risk for the typical adult with chronic pain who is middle aged or older is actually even lower.

This does not in any way absolve the pharmaceutical industry. Companies like Purdue Pharma, the maker of Oxycontin, profited egregiously by minimizing the risks of prescribing in general medicine. Purdue also lied about how Oxycontin’s effects last (a factor that affects addiction risk) and literally gave salespeople quotas to push doctors to push opioids.

The industry flooded the country with opioids and excellent journalism has exposed this part of the problem. But journalists need to become more familiar with who is most at risk of addiction and why—and to understand the utter disconnect between science and policy—if we are to accurately inform our audience.

THE INNOCENT VICTIM NARRATIVE

The reporters who called Bauer-Reese were not ill-intentioned in seeking the most sympathetic addiction stories; it is genuinely altruistic to want to portray those who are suffering in a way that is most likely to move readers and viewers to act compassionately. But such cases can have an unintended side effect: highlighting “innocent” white people whose opioid addiction seems to have begun in a doctor’s office sets up a clear contrast with the “guilt” of people whose addiction starts on the streets.

This is a result of racist drug policies that began decades ago. The war on drugs declared by Richard Nixon in 1971 was part of the Republican “Southern strategy,” which used code words like “drugs” “crime,” and “urban” to signal racist white voters that the party was on their side. When Ronald Reagan doubled down harsh law enforcement during the crack years, he merely intensified that strategy.

Rather than skeptically investigating, however, members of the media enlisted themselves as happy drug warriors throughout the 1980s and ’90s. Sensational stories focused on crack and its users as the cause of the problem, frequently ignoring that addiction hits hardest in communities facing high unemployment, de-industrialization, cuts in benefits, and loss of hope. In 1986, for example, promoting his documentary 48 Hours on Crack Street, CBS anchor Dan Rather intoned, “Tonight, CBS News takes you to the streets, to the war zone for an unusual two hours of hands-on horror.”  Or here’s The New York Times in 1991, “Crack Hits Chicago, Along with a Wave of Killing,” and in 1994, “Crack Means Power, and Death, to Soldiers in Street Wars.”

Now that the problem is seen as “white,” however, socioeconomic factors and other reasons that people turn to drugs are more commonly discussed. The result is that today’s white drug users are portrayed as inherently less culpable than the black people who were caught up in the crack epidemic of the ’80s and ’90s.

Craig Reinarman, professor of sociology emeritus at the University of California, Santa Cruz, has documented biased coverage of addiction since before the crack era. “Now that the iconic user is white and middle class, the answer is no longer a jail cell for every addict, it’s a treatment bed,” he says. The biased coverage ends up perpetuating a public perception that some drug use, usually by African Americans, is criminal while other drug use, usually by white people, is not.

Criminalization still deeply affects our sympathy for people with opioid addiction. This headline recently appeared in the Times: “Injecting Drugs Can Ruin a Heart. How Many Second Chances Should a User Get?” Is that a question reporters would ask about people with diabetes who don’t follow their diet or those with heart disease who don’t exercise? In fact, the condition discussed in the Times article is not inherent to drug injecting, and the treatment of it doesn’t require limited resources like transplants do: it’s spread by unsterile syringes, which is a result of lack of access to clean ones, not addiction itself.

Often, stories focus exclusively on people whose use started with a prescription.

It’s important for journalists to understand that criminalization is not some sort of natural fact, and laws are not necessarily made for rational reasons. Our system does not reflect the relative risks of various drugs;legal ones are among the most harmful in terms of their pharmacological effects. With the exception of the legislation that resulted in the creation and maintenance of the FDA, our drug laws were actually born in a series of racist panics that had nothing to do with the relative harms of actual substances.

In order to do better, journalists must recognize that addiction is not simply a result of exposure to a drug, and that “innocence” isn’t at issue.  The critical risk factors for addiction are child trauma, mental illness, and economic factors like unemployment and poverty. The “innocent victim” narrative focuses on individual choice and ignores these factors, along with the dysfunctional nature of the entire system that determines a drug’s legal status.

THE DIFFERENCE BETWEEN DEPENDENCE AND ADDICTION

Widespread conflation of addiction and dependence further mars opioid coverage.

These days, experts from the National Institute on Drug Abuse and the authors of the Diagnostic and Statistical Manual, now DSM-5, agree that the core of addiction is compulsive drug use that continues regardless of bad outcomes. Unfortunately, from 1987 to 2013, the DSM termed its diagnosis “substance dependence.” This misnomer supported a widespread misconception of “real” addiction as the need for a substance in order to function and avoid getting physically ill, rather than a compulsion that drives behavior.

The critical difference between addiction and dependence becomes clear when you look at specific drugs. Crack cocaine, for example, doesn’t cause severe physical withdrawal symptoms, but it’s one of the most addictive drugs known. Antidepressants like Prozac, meanwhile, don’t produce compulsive craving the way cocaine can, but some have severe withdrawal syndromes.

Needing opioids for pain alone, then, doesn’t meet the criteria for addiction. If the consequences of drug use are positive and the benefits outweigh the harm from side effects, then that use is no different from taking any other daily medication. Dependence in and of itself isn’t a problem unless the drug isn’t working or is more harmful than it is helpful.

Unfortunately, while the scientific understanding has changed to reflect these facts, the press hasn’t caught up. The Washington Postconducted a poll of pain patients on opioids that labeled one third of them as addicted after they responded “yes” to a question that asked whether they were “addicted or dependent,” without defining either term. A CBS affiliate in Chicago talked about treating “opioid dependence” when they actually meant “addiction”; this CNN story has the same problem.

Needing opioids for pain alone doesn’t meet the criteria for addiction.

This would be a mere semantic issue if it didn’t have such awful effects on policy. Conflating addiction and dependence results in harm to pain patients, children exposed to opioids in utero, and people who take medication to treat addiction.

Any pain patient who takes opioids daily for long enough will develop physical dependence and suffer withdrawal if the medication isn’t tapered slowly. But if either the doctor or the patient sees this dependence as addiction, then the patient is at risk of being cut off from medication that is actually helpful.

In some instances, hundreds or even thousands of patients have been forcibly tapered from opioids in an attempt to comply with federal guidelines and law enforcement pressures, without regard for individual medical circumstances or needs. For instance, Oregon has proposed rules which prohibit Medicaid patients from receiving more than 90 days worth of opioids, period, unless they are dying, and that all who are currently on opioids must stop. But there is no evidence to support cutting off chronic pain patients who are doing well on these medications, and at least one preliminary study associated such a drastic measure with increased risk of suicide while not reducing overdose risk.

To make matters worse, mistaking dependence for addiction also harms people who take treatment medications like methadone or buprenorphine, which are the only two therapies proven to cut the death rate by 50 percent or more.  These medications don’t produce any intoxication once an appropriate and regular dosing schedule is instituted. They relieve the compulsion and the consequences that are the hallmark of addiction.  However, they only work for as long as people stay on the meds—in other words, patients remain dependent.

Sadly, even if patients have gone from being homeless and unemployable to being productive workers, the fact that they are still on medication means that they are often stigmatized as being “not really” in recovery—indeed, if dependence is the same as addiction, they aren’t. This misconception leads many to prematurely stop, often resulting in overdose death.

It’s important for journalists to explain these distinctions—to ensure that both pain patients and people with addiction have access to appropriate medication.

Plus, there’s no such thing as an addicted baby

Perhaps the most insidious product of the media’s failure to distinguish between addiction and dependence is the myth of “addicted babies,” which leads to headlines like “The Tiniest Addicts.” Such a stigma that can do lasting harm to a child:  research from the crack years showed that infants labeled as “crack babies” were seen as having less potential and normal toddler behavior was labeled as pathological.

Infants certainly can experience physical dependence and painful withdrawal as a result; what’s known as “neonatal abstinence syndrome” is the result of withdrawal symptoms following opioid exposure in the womb. However, babies can’t be “born with addiction.” An infant doesn’t know why it feels uncomfortable or what could fix the problem—it has dependence, not addiction

How can journalists do better?  First, be aware of the importance of your language, and explain the differences between key terms to your readers and viewers.

Last year, the AP decided to update its stylebook to address these issues, which provides a useful guide. Journalists are advised to use the phrase “person with addiction” rather than the noun “addict.” “Person first” language is already used routinely for people with other mental illnesses such as schizophrenia and depression; failing to follow best practices for people with addiction suggests it’s not really a legitimate health problem.

Similarly, just as we no longer use offensive terms like “maniac” to refer to people with bipolar disorder, words like “druggie” and “junkie” should be avoided. The AP urges its members not to conflate addiction and dependence for precisely the reasons listed above, and also warns against using the term “drug abuse”—which, like “dependence,” has been removed from the DSM. “Misuse” is more accurate and less moralistic.

Ask yourself if you are covering addiction the way you would any other medical disorder. Would you rely on police as sources to discuss patients’ behaviors or pharmacology? Would you accept claims about patients that frame them fundamentally dishonest by nature? Would you highlight only “innocent” victims of the disease?

 

Ask yourself if you are covering addiction the way you would any other medical disorder.

 

Don’t accept claims about what works in addiction treatment at face value. Ask for research supporting treatment outcomes. If it doesn’t exist, or if there is data on similar programs having poor outcomes, include these facts.

Be as skeptical of claims about work or spiritual cures as you would be for cancer care. The addiction treatment industry simply is not professionalized in the way other health care is. Many treatment providers have little training beyond their own experience with addiction and are not familiar with the research. Don’t give self-interested claims about treatment outcomes or the supposed superiority of self-help groups the same weight as peer-reviewed data—and make sure you include peer-reviewed research whenever you cover medication and behavioral treatment.

Ensure that your audience knows that our system of drug laws is not based on scientific information about drugs. Writing about drugs frequently contains implicit racism;stories framed around the idea that white people with addiction “are not typical” imply that people of color are.

Finally, if you think you know a fact about substance misuse, check it. Some of the best stories come from simply exploring the research that shows that most of what we think we know about drugs is completely wrong.

Source: What the media gets wrong about opioids – Columbia Journalism Review

‘Dear Doctor’ Letters Reduce Opioid Prescribing : NPR

For a doctor, learning that a patient has died is often an emotional moment. Emergency room physician Roneet Lev wondered if telling doctors when their patients die of an overdose might motivate them to rethink their prescribing behavior.

“I asked other physicians if they would want to know if a patient had died,” says Lev. “They said yes. I needed to help make that happen.”

Lev, the director of operations of the Scripps Mercy Emergency Department in San Diego, coauthored a study published Thursday in Science that tests this idea.

The study evaluated the effect of sending letters to San Diego area clinicians informing them of the deaths of patients to whom they had prescribed opioids. Half of a group of 861 doctors received such a letter from San Diego’s medical examiner, detailing the name, birth date and death date of the patient. The other half got no letter.

Among the letter recipients, opioid prescribing decreased between 6.2 to 13.2 percent compared to those who didn’t get a letter.

“What’s important about what we’ve found is that you can do very simple things to change prescribing and make prescribing safer,” says coauthor Jason Doctor, an associate professor of health policy and management at the University of Southern California.

Opioid overdoses went up 30 percent between 2016 and 2017. Despite policy efforts to limit prescribing, opioid prescribing rates are still far higher than they were in the late 1990s.

The letter-writing intervention targets the riskiest prescribers, Doctor says.

Physicians are aware of the opioid crisis, but they might see it as happening somewhere outside of their own practice, he says. Putting a face on overdose victims can give them a perspective about what’s going on in their own clinics, he says.

“Right now, doctors are getting biased information. They are only seeing patients that are coming back alive to their clinic, not those who die and never return,” Doctor says. “A lot of times, they never learn about a patient’s death.”

The letter provides some safer prescribing guidelines, such as avoiding co-prescribing opioids with benzodiazepines, a sedative which can raise the risk of overdose. Nearly 30 percent of overdoses involving opioids also involve benzodiazepines.

Jason Doctor hopes that other county or state medical examiners will consider the idea of sending overdose letters to physicians, nurses, dentists and other providers who prescribe opioids.

The study noted that the 170 patients in the study who had fatal overdoses had on average gotten opioid prescriptions from five and half prescribers.

This could reflect the problem of doctor shopping, says Amy Bohnert, an associate professor of psychiatry and mental health research at the University of Michigan. That is when a patient seeks several prescriptions for the same ailment to acquire more drugs.

Bohnert, who was not involved in the study, says that doctors don’t always know about all the other prescriptions a patient is receiving, so they may unintentionally prescribe an opiod that overlaps with another prescription.

Study coauthor Lev remembers learning of the death of a patient she had prescribed pain medications to. The young woman had come in to the emergency room with a traumatic injury. Lev wrote her a prescription for painkillers, not realizing that this woman was a chronic pain patient who had only one day before been prescribed a large dose of another opioid.

While the small prescription she wrote likely wouldn’t have been the turning point for this woman who died 15 months later, it still upset Lev since she hadn’t taken the chance to intervene then and there. “The fifteen pills I prescribed her didn’t kill her, but it was a missed opportunity,” Lev says.

Bohnert says that the approach of sending doctors letter was “clever.” It took advantage of existing systems, and could be done for a very low cost.

“It’s something that the health departments in each state could feasibly undertake with relatively little cost,” she says.

But Bohnert says that while implementation is doable, the effect might diminish over time if doctors keep getting these letters, shrinking the impact they may have on their choices.

Kelly Dineen, an assistant professor specializing in health law and bioethics at Creighton University School of Law, who was not involved in the study, says she is concerned that this intervention misses part of the picture of opioid addiction. She says that when opioid prescriptions are reduced, some patients could end up resorting to using risky illicit drugs instead, because they lack support in finding addiction treatment.

The outcome measure of this study is prescription amounts, but Dineen says she’s curious to see if mortality rates fall after doctors get these letters.

Jason Doctor of USC agrees there’s a risk that if you cut patients off of addictive painkillers suddenly they may turn to street drugs like heroin.

But he says, in this research, the doctors who got letters weren’t much more likely to abruptly drop their patients than the control group. And, in an optimistic result, he says, those who got letters showed a decrease in the number of new patients they introduced to opioids, therefore potentially preventing addiction from starting at all.

San Diego County will be sending out these letters regularly to doctors whose patients fatally overdose, according to Lev.

“The letters are just a small way to make a difference,” says Lev.

Source: ‘Dear Doctor’ Letters Reduce Opioid Prescribing : Shots – Health News : NPR

BCBS Controversial ER Claims Process Begins – Houston

The largest health insurer in Texas changed an ER claims review process Monday.

Blue Cross Blue Shield of Texas said its 500,000 HMO members may have to pay the entire cost of an out-of-network emergency room bill, if they go for something not serious or life-threatening.

The insurance carrier said the stricter review policy is designed to help make health care costs more affordable. In an April 18 memo, Blue Cross first explained the change by pointing to examples of people who use out-of-network ERs for things like head lice or sprained ankles.

In our recent News 88.7 In Depth, we reported backlash from physicians in Texas prompted the insurance company to delay rolling out the new change.

In a statement provided to Houston Public Media, the Texas Medical Association said it’s disappointed Blue Cross Blue Shield of Texas is moving ahead with the change.

“Unfortunately, even the announcement of this plan has already planted a seed in patients’ minds that they’ll be left with a big bill if they go to the emergency room for the ‘wrong reason,’” said TMA President Dr. Douglas Curran. “We encourage TDI to join us in monitoring this closely to make sure no patients are denied necessary care.”

Dr. Alison Haddock reviews a patient chart before her shift in the Ben Taub Hospital emergency room on May 28, 2018.

Dr. Alison Haddock, board member of the Texas College of Emergency Physicians, previously told Houston Public Media she feels this change requires patients to “self-diagnose.”

“I think it’s wrong to be putting that extra burden on patients in their times of greatest need,” said Haddock, in a May interview. “No one wants to go to ER. That’s no one’s idea of a great time. But when people look at their situation think, ‘I think I’m having a medical emergency,’ they have the right to come access our care…. But we also need you to have the right for the insurance company pay appropriately for care that you need. And that’s something that people get really nervous about and afraid of, and will potentially delay care and put themselves in great danger.”

Haddock believes the change is a violation of Texas’ prudent layperson law, which was passed in 1997. It protects patients’ rights to seek emergency care without preauthorization for coverage and doesn’t allow insurance companies to base that coverage on a final diagnosis; but rather the initial symptoms.

Blue Cross Blue Shield of Texas 

BCBSTX previously said it firmly does not believe the change is in violation of the prudent layperson standard.

Over the past two months when this change was pending, Blue Cross Blue Shield of Texas said it provided all requested information about the new review process to the Texas Department of Insurance.

“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,” Blue Cross Blue Shield of Texas spokesman James Campbell said, in an e-mail to Houston Public Media.

In a May interview, Dr. Robert Morrow, Southeast Texas Market President for Blue Cross Blue Shield of Texas, told Houston Public Media there is no change to benefits to HMO members: it’s a stricter claims review process.

“If you have or think you have an emergency condition, go to emergency room. And if that’s the case, it’s going to be covered,” said Morrow. “It doesn’t look at diagnosis that somebody leaves the emergency center with. The review looks at the reason the person sought emergency care…. We follow the law now. That is not going to change.”

Morrow said the emergency claims would not be denied without being reviewed by licensed physicians, which would then still open to the appeal process. Morrow added Blue Cross’ SmartER website helps inform members where to go for non-emergency care, and tries to direct non-emergencies away from the ERs.

Texas Department of Insurance 

The Texas Department of Insurance (TDI) is the state’s regulatory body that makes sure companies are in line Texas’ insurance laws and patients’ rights are maintained.  In an e-mail to Houston Public Media, a spokesman for TDI said the agency has worked with BCBSTX over the past couple of months, to make sure consumer protections were in place.

TDI stated those protections are:

  • Emergency room claim reviews will be done by a doctor.
  • Any claim denials would come only after a review of medical records by a BCBSTX medical director. When the medical director is contemplating a denial, the provider will be offered a peer-to-peer conversation.
  • Consumers will be able to appeal if the claim is denied as not medically necessary. This would include an appeal to an independent review organization.

Freestanding emergency rooms speak out

Texas became the first state to allow freestanding ER’s almost a decade ago, in 2009. Now, there are more than 200 such facilities across the state. Proponents of the BCBSTX review change say overuse of these centers with non-emergencies propels rising healthcare costs.

But in a statement, the Texas Association of Freestanding Emergency Centers (TAFEC) said, in part:

“While the reasons for issuing this intimidating, anti-patient, anti-ER policy were presented as positive (saying that non-essential ER use by members “drives up cost for our members” and taxes “limited ER resources”), in reality, what they were doing then and now served to accomplish just two things—and neither are to the benefit of Texans: drive down the use of ER care (regardless of need) and increase the profits of Texas’ largest insurance provider at the expense of everyday Texans and their medical providers.

An attack on state and federal law, this policy—which was originally scheduled to go into effect on June 4, 2018, created so many questions and concerns for the Texas Department of Insurance (TDI), that the Department decided this patient penalty policy could not go into effect at the time.”

Source: Blue Cross Blue Shield of Texas’ Controversial ER Claims Process Begins – Houston Public Media

Texas allows Blue Cross Blue Shield to deny payments for some out-of-network ER visits

Blue Cross and Blue Shield of Texas will begin a controversial new program Monday in which it will not pay any expenses for an out-of-network emergency room visit if it is later determined the patient should have gone elsewhere for treatment.

The measure was originally set to roll out June 4, but vigorous complaints from the public and physicians, as well as concerns from the Texas Department of Insurance, delayed it for 60 days of further review.

Blue Cross and Blue Shield of Texas officials and TDI confirmed late last week that the deeply contentious program will now launch and that any sticking points have been resolved.

The new measure is expected to affect about 500,000 Texans with Blue Cross and Blue Shield health maintenance organization (HMO) plans.

Claims will be scrutinized after the fact by a medical director hired by the insurer to determine the reason a patient chose going to the emergency room and whether treatment could have instead been handled at a less expensive clinic or by a family physician. The company also will look for over-treatment.

“We have, quite frankly, identified quite a bit of fraud, waste and abuse that happens within the context of some of these treatments at some of these facilities,” Dr. Robert Morrow, president of the Houston and Southeast Texas office of Blue Cross and Blue Shield of Texas, said in a May interview.

Doctors outside coverage networks can bill at much higher rates, sometimes two to three times higher than if they were in-network, according to health care policy experts. Then, any portion of a bill not paid by the insurer can be shifted onto the patient, who must make up the difference in a practice known as “balance billing.”

But critics continue to slam the program as harsh and punitive as it seeks to not only underpay providers but also forces patients to make untrained diagnoses and potentially skip treatment if they fear their medical bills will not be paid, doctors and their advocates have said.

Rhonda Sandel, CEO of Texas Emergency Care Center, a chain of four free-standing emergency rooms in Houston, Dallas and Lubbock, called the measure intentionally “intimidating” and “anti-patient.”

In an email Sunday, Sandel, a board member of the Texas Association of Freestanding Emergency Centers, said the true motive of the insurer was to “drive down the use of ER care (regardless of need) and to increase the profits of Texas’ largest insurance provider at the expense of everyday Texans and their medical providers.”

The rapidly growing industry, which got its start in Texas and operates walk-in emergency rooms, has frequently locked horns with insurers over reimbursement rates. The centers are staffed around-the-clock and provide much of the same testing and treatment options as traditional emergency rooms but are often out-of-network.

Insurance regulators initially questioned the program, announced in April, with worry of a chilling effect for sick or injured patients who might avoid care if they feared the bills. Twice state officials asked the insurer to clarify the guidelines ahead of the June launch and also to provide proof for the allegations that some emergency physicians and facilities were over-charging.

The company responded with 56 pages of documentation, including copies of submitted claims and itemized bills, obtained by the Chronicle through a state records request. Included was a billed charge totaling $8,719.10 for bronchitis. The patient underwent a CT scan for $4,155.95 as well as what appears to be 15 separate lab tests. The charges also included an emergency room facility fee of $2,226.40 which was coded at the highest severity level. Such fees are coded on a scale of 1 to 5 depending on the amount of time, number of tests and complexity of the treatment. This one was given a 5. The name of the patient and provider were redacted.

Another submitted claim totaled $45,000 for a 22-year-old patient with tonsillitis whose treatment included 18 hours of observation. Yet another showed a $7,000 claim for a first-degree sunburn.

Last week a TDI spokeswoman said in an email that the agency’s concerns had been satisfied.

Sandel on Sunday was critical of TDI’s capitulation to Blue Cross and Blue Shield.

“By permitting this harmful policy to go through, TDI is allowing for insurance consumers’ rights to be violated and potentially putting everyday Texans in clinical and financial distress,” she said in an email.

Morrow and other Blue Cross and Blue Shield officials bristle at the accusation they are putting anyone at risk. They say that they will not punish patients if they guess wrong, such as thinking they are having a heart attack that turns out to be indigestion.

And if it appears a patient made a reasonable decision in seeking care, even if it is out of network, their claim will likely be paid, Morrow has said, adding that denials only will happen if a patient’s treatment is found to be excessive or if they intentionally sought treatment in the wrong place.

“Over the last two months, Blue Cross and Blue Shield has diligently worked with the Texas Department of Insurance, providing all requested information regarding a process — being implemented (Monday) — to review emergency room charges of our retail and group HMO members” the insurer said in an emailed statement on Friday.

TDI said last week that its decision to let the measure stand came after assurances that any claims reviews would be done by a doctor, and that before a denial is issued a patient will have the right to have their doctor debate the treatment plan with the insurer’s doctor. Also, consumers will be able to appeal to an independent review organization.

In general, HMO plans already have tight restrictions on out-of-network care. The legal exception comes when a patient is having an emergency. In that case the insurer must cover out-of-network screenings, tests and treatments as if they were in-network, according to TDI.

Baked into the controversy is a piece of state insurance law called the “prudent layperson” standard which assesses whether a reasonable consumer without medical training would see a need for emergency care. Both sides in this fight say the standard is on their side.

Consumer groups in Texas are warily watching the drama unfold. They worry that patients rarely have any control over the tests or treatments that doctors order, especially in an emergency situation, yet they could be on the hook for hundreds if not thousands of dollars in bills if their insurer balks.

Similar restrictions on emergency room visits by insurance giant Anthem has faced harsh criticism across the country as patients found their claims denied more and more often. The company faces a lawsuit over the policy, and a recent report shows that many of the initial denials were ultimately overturned after the patients appealed.

Source: Texas allows Blue Cross Blue Shield to deny payments for some out-of-network ER visits – Houston Chronicle

9 unforgettable emergency room stories

The next time you have an embarrassing situation or accident, I want you to keep in mind that compared to what doctors see on a daily basis, it is likely no one will blink twice. Here are some of my favorite emergency room stories – all true – from my career in medicine to date.

1. Peanut butter balls

A 5-year-old girl came in with her sister, who was pregnant but unconscious, in an ambulance. We kept asking the little girl what had happened to her sister, and she kept saying, “She needs her peanut butter balls.” We were absolutely confounded and running every test we could think of and had neurology, psychology, OBGYN (me) critical care and even gastrointestinal looking at things.

Then, one of the little third-year medical students who was watching from the corner came up and said, “I think I know the problem.” Everyone gave an eye-roll or a skeptical look, but she went on bravely. “It isn’t peanut butter balls. It’s phenobarbital. Her seizure medicine. She had a seizure and needs her meds.” The young doctor-to-be got an ovation from the entire ER.

2. Hungry schizophrenic

A woman was brought down from the psychiatric unit with a distended belly and in a lot of pain. As gynecology chief, I was called in to see if I had anything to add. The CT scan showed a large mass in her abdomen, but it was unlike anything any of us had ever seen. As radiology and surgery were reviewing it, I went over to her and said hello and asked her how she was doing. She said that we had it all wrong, that it wasn’t a tumor.

What was it? No answer. Did you eat something? Maybe. What was it, maybe? It might have been my sheet. Your sheet? Yes. Why did you eat your sheet? I was bored. Why didn’t you tell anyone? No one asked. True story.

3. The homeless guy on MTV

In Seattle, a scraggly looking guy, presumably homeless, came in the ER with a laceration on his forehead. The attending told me, the fourth-year medical student, to go take care of it. As I was sewing him up, I was talking to him, and he turned out to be really intelligent and funny. He said he got jumped walking back to his car after a show. Who was the band? Were they any good? He laughed and said, “Pretty good, I hope. I’m in it.”

There are thousands of bands in Seattle, so I humored him some more. What’s your band called? “Soundgarden.” It turns out that I had just watched one of their videos on MTV in the break room. I recognized him now. He’s the drummer. So every time I have seen them on TV since then, I always look to see how his scar is looking.

4. Assaulted friend

I was called to the ER to evaluate a sexual assault. She was so beat up I didn’t recognize her as a nurse from Labor and Delivery that was a very good friend. I was so angry. She was so calm and just said, “Do you job and be thorough, so when they catch him they can convict. Don’t be mad. Don’t make any mistakes.” Cool as a cucumber with her face all covered with bruises and cuts.

I cooled down and I got the evidence, they caught the guy, I testified and they convicted and sentenced him for a long time. I’ll never stop admiring her for her calmness and bravery. Amazing woman.

5. Can’t go home

A young woman came in by ambulance, 16 weeks pregnant, and thought she might be leaking fluid. She had been home alone. I went down and evaluated her and diagnosed an infection that was easily treatable. I explained it all and said she was free to go.

“I can’t go.”

“You can go. You and your baby are fine. We have a ride waiting.”

“No, I can’t.”

“Are you unsafe at home? Are you scared?”

“No! I just can’t go!”

She then looks around and whispers, “I ain’t got no pants.” She lifted up the sheet and sure enough, no pants, no undies. Nothing.

“Um…Why, um…why?”

“I forgot.”

I am not sure what more you can even say about that one. I think the take-home lesson is that there is almost always time to grab some pants on your way out the door.

6. Exploding uterus

A patient of mine came into the obstetrics triage area with some pain at 32 weeks. In the process of evaluating her, I was looking at the baby with ultrasound and I literally saw the baby pop out the top of the uterus. This is a bad thing. Really bad. I grabbed the gurney, ran it to the elevator and down the ER, yelling for pediatrics and nurses.

In less than three minutes, we got the baby out, and somehow it did just fine and is a beautiful, feisty 17-year-old young woman today. There are still gouges in the floor of the unit where I took the corners as fast as I could. That took a few years off my life, I think.

7. Being at the right place at the right time

I was called by the ER that one of my patients was in the parking lot bleeding. It was a woman with twins, near term. I saw her in the parking lot, leaning on her car, with blood running down her legs. The ER staff got there about the same time and had an IV into her before we even got through the ER doors. I could see the people waiting in the ER with looks of horror as we ran by with blood running down onto the floor.

The OR staff was waiting when we got there. I didn’t even have time to change. I quickly scrubbed, and by the time I was gowned, she was asleep and draped and still actively bleeding. The babies were out within a minute, and amazingly, though premature by six weeks and stressed by the placental abruption, they did great and are two of the rowdiest set of twins you will ever see. That probably took a few more years off my life, too.

8. Cellphone hide-and-seek

I was called one night to evaluate a woman, still fairly inebriated, who had been asleep/passed out, and her also-inebriated partner had hidden her cellphone in a body cavity, but didn’t tell her which one.

After I figured out which one it was (in the lower colon), we gave her some sedation and I set out to retrieve it. The phone kept buzzing and ringing every minute or so. When I finally got it out she wanted to see who was calling and laughed. It turns out that her boyfriend, who was sitting in the waiting area, was the one calling. Actually, that was kind of funny.

9. Follow post-op instructions!

I got called one night to see one of my post-op hysterectomy patients in the ER. The ER attending sounded very worried so I got there ASAP. When I got arrived, her husband was pale and looked terrible as he sat in the corner. The patient, however, was laughing and talking on her cell phone. She hung up and said, “I did a no-no. I know you said no sex for at least six weeks but I felt so good I thought I’d give it a try (three weeks early).”

“Did you have bleeding?”

“Not exactly.”

The ER nurse then moved her sheet down, where some moist dressings were covering about 12 inches of small intestine that had herniated out (she had recently had a hysterectomy).

“Crazy, huh? Just popped out of nowhere. You can fix that, right?”

After taking one more selfie of it, we took her back to the OR and fixed her up. And I will say that the second time around, her husband would not touch her until they both came in and I absolutely guaranteed him that it wouldn’t happen again.

So, whatever happens to you and you need to be seen, don’t worry about it. It would take a lot to surprise the ER staff.

Source: From an exploding uterus to cellphone hide-and-seek: 9 unforgettable emergency room stories – St George News

Victoria freestanding ER closes amid battle with insurers 

Mercer ER, a slick, stand-alone 24-hour emergency center near Home Depot, closed its doors for good last week.

Patty Lutes, a 29-year-old executive assistant in Victoria, said she wasn’t surprised it closed, especially after her experience of receiving a surprise bill in the mail.

She remembers the facility had just opened in Victoria – its signs weren’t even up – when she woke up feeling terrible. There was no time to schedule an appointment with her family doctor before an important work event that night.

“I felt like death,” she remembered thinking. She thought she could have strep, a highly contagious infection, and could not risk getting anyone else sick.

She thought she would just run up to Mercer real quick and make sure it wasn’t strep. “I was the only person there. In-and-out in 20 minutes,” she said. She paid her $250 copay, got a prescription and went on her way.

Later she learned her insurance company paid more than $1,000 for the test and she was being charged the rest of the balance to the tune of more than $500.

She learned later “balance billing” is a national problem that Texas lawmakers have been working on.

Texas legislators passed two bills last year aimed to help protect consumers from surprise bills. The laws, passed in September, state that freestanding emergency rooms must post notice of whether they are part of any insurance networks or risk losing their license and updated a process so that patients can dispute the bill. Not all consumers know that since 2009, they can contact the Texas Insurance Department with complaints or help with mediation.

A former staff member of Mercer said Wednesday that the business closed because Blue Cross Blue Shield and a couple others are not paying their bills.

The next day, Chris Callahan, a spokesman with Blue Cross Blue Shield of Texas, confirmed that Mercer ER was out-of-network but didn’t have any other information about working with this specific center.

Accepting all insurances and being in-network are not the same thing, Callahan said. “It’s a difference that can cost our members, or a patient, thousands of dollars out of pocket.”

“We take very seriously the obligation to pay claims for our members’ covered services,” he said. “If a member or provider, whether in- or out-of-network, has questions about claims payments, we are here to help.”

Some say the problem is that people are confused about what kind of center they are walking into despite the clear “emergency” signs.

recent study from Rice University’s Baker Institute analyzed insurance claims from 2012-2015, finding a huge overlap – 75 percent of the 20 most common diagnoses at freestanding emergency departments – were the same as at less-expensive urgent care centers.

In 2015, the average price per visit of a hospital-based ER and freestanding ER were similar at $2,200. The price for urgent care centers was only $168.

In recent years, freestanding ER operators say insurance companies are denying coverage for emergency room visits that the companies say didn’t constitute a “true emergency.”

Brad Shields, executive director of the Texas Association of Freestanding Emergency Centers, said this isn’t good for patients and such policies could cause freestanding ERs to go out of business.

“We continue to grow into different parts of the state, but the challenge that does exist is the ability to be paid for our services,” he said.

Shields says insurance companies shouldn’t be able to penalize patients who believe they are having an emergency by outright denying or underpaying a claim after the fact.

“We believe this new policy by Blue Cross Blue Shield is against the law and puts people’s lives in danger,” he said. “Unless the Legislature addresses it, there’s a fear that patients are going to be put in a difficult spot.”

Last summer, Neighbors Emergency Center on Houston Highway closed before opening for business, citing a saturation of the market. A call to Victoria ER wasn’t returned, but the business is still in operation since it opened in 2015.

As for Lutes, next time she’d rather wait for her doctor’s office or go to an urgent care center. She said the convenience of a freestanding ER wasn’t worth the extra out-of-pocket cost.

“I told them I’m not paying that. That’s insane,” she said. “They’ve sent me like two bills since then.”

Source: Victoria freestanding ER closes amid battle with insurers | Local News | victoriaadvocate.com

If it’s not an emergency, Blue Cross Blue Shield won’t pay 

It’s the middle of the night and that nagging chest pressure seems to be getting worse. Could be a heart attack. Could be indigestion from the bad burrito at dinner.

Do you a) Go to the nearest emergency room; b) Find an open urgent care clinic; or c) Take a Tums and wait until morning to see your doctor during office hours?

Choose wisely, Texans, because the stakes are about to get a whole lot higher.

Starting June 4, Blue Cross and Blue Shield of Texas, the state’s largest insurer, will step up its scrutiny of all out-of-network emergency room claims for patients who have health maintenance organization, or HMO, plans. If, after treatment, a company review finds patients could have reasonably gone elsewhere for care, it will pay zero.

That means even insured patients could potentially be on the hook for thousands — if not tens of thousands — of dollars in medical bills if they make the wrong choice.

As word of the new initiative seeped out, doctors across the state were swift in their outrage and accused Blue Cross Blue Shield of forcing frightened patients to self-diagnose when they are at their most vulnerable. Guessing wrong, the doctors contend, could be deadly.

Blue Cross and Blue Shield flatly denies putting customers at risk.

“One thing I want to make very clear right off the start is if any of our members, or quite frankly, anybody in general, if you have or think you have a medical emergency you need to seek treatment at the closest place you can that can provide needed treatment or call 911,” said Dr. Robert Morrow, president of the Houston and Southeast Texas office of Blue Cross and Blue Shield of Texas.

Instead, the after-the-fact review and potential for denials can help weed out people inappropriately using expensive emergency rooms for non-emergencies. The insurer also seeks to push back against inaccurate billing, overtreatment and “excessive and unconscionable charges” from the physicians who treat emergency patients, Morrow said in an interview with the Houston Chronicle.

“We have, quite frankly, identified quite a bit of fraud, waste and abuse that happens within the context of some of these treatments at some of these facilities,” he said.

The Texas Association of Health Plans has previously said its internal claims data shows that nearly half of emergency physician claims in 2015 were outside the networks of the state’s three major insurers: Blue Cross and Blue Shield of Texas, Aetna and UnitedHealthcare. Doctors outside a network are free to bill two to three times more than those within network coverage, the health insurance lobby’s data showed.

In the example of chest pains, Morrow said his company would review the circumstances but most likely pay the claim even if it is out of network.

The ‘prudent layperson’

HMO plans already sharply restrict members seeking out-of-network services, typically not paying for care. The legal exception has always been if a patient truly believes they are having an emergency. In such cases the insurer must cover out-of-network screenings, tests and treatment, according to the Texas Department of Insurance.

A piece of legalese buried in most state insurance codes and in the federal Affordable Care Act is called the “prudent layperson” standard, and that is what’s at the heart of this fight, both in Texas and across the country where other insurers are trying similar measures. Does a patient think they are in crisis?

In Texas about a half-million people have Blue Cross Blue Shield HMO plans. It is not immediately known how many in Houston, the company said.

Morrow, who previously practiced family medicine, said his company will not penalize a patient if the ultimate diagnosis rules out an emergency — a stomach bug rather than appendicitis, for instance.

Instead the measure seeks to look at patient intent, of “what brought them in,” he said. Morrow calls it a “well thought-out” remedy to a stubborn problem.

Emergency room doctors call it something else entirely.

“This is a war going on,” said Dr. Cedric Dark, an emergency physician at Ben Taub Hospital and CHI St. Luke’s Health and a health scholar at Baylor College of Medicine Center for Medical Ethics and Health Policy.

Dark accuses Blue Cross and Blue Shield of circumventing the prudent layperson rule in an effort to underpay doctors and enrich the company. Doctors and the insurance industry have been locked in an escalating fight over reimbursement insurance for years. Dark says this is just the latest volley.

Morrow counters that his company’s policy adheres to the prudent layperson standard and in fact “embraces it.” He also points to Blue Cross and Blue Shield’s efforts to educate members on what constitutes an emergency.

Still, the Texas Department of Insurance was concerned enough to send a letter May 9 to the insurance company asking for clarification.

“The review is performed to determine if the claim accurately reflects the services rendered according to the medical records, and if the medical record supports the determination that an emergency existed in accordance with the prudent layperson standard in the Insurance Code,” Dr. Dan McCoy, Blue Cross and Blue Shield president, replied in a May 17 letter.

McCoy’s letter, obtained by the Chronicle through a records request, added that “HMO members will have their appeal rights if they disagree with the decision that their visit was not an emergency.”

Emergency room doctors argue it is wrong to try to divine patient intent in retrospect.

“Why do people come to an emergency room? Because they are afraid. They don’t know what to do. It’s the mom who brings in her child at 2 a.m. because a fever is spiking,” said Dr. Carrie de Moor, CEO of Code 3 Emergency Partners, a Frisco-based network of free-standing emergency rooms, urgent care clinics and a telemedicine program.

“They are Monday morning quarterbacking,” said de Moor. “The physicians who are reviewing records are not laypersons.”

A trained doctor might look at the circumstances of a case after the fact and see it differently than a patient or doctor in the heat of the moment, she said. In addition, a doctor might need to perform a battery of costly tests to arrive at the correct diagnosis or rule out more serious ones.

De Moor said what’s really at play is the insurer taking aim at the proliferation of free-standing emergency rooms. The retail centers, equipped and staffed like a hospital emergency room, are a Texas phenomenon that is starting to spread in a handful of states across the nation. De Moor is chair of the American College of Emergency Physicians’ section on Freestanding Emergency Centers.

Patients are often confused by free-standing emergency rooms and their less expensive cousin, urgent care clinics. Often the two care centers are close to each other and sometimes even in the same facility. One big difference between the two, however, is that free-standing emergency rooms typically are not included in patient insurance coverage.

‘Land mines’ for patients

Morrow of Blue Cross and Blue Shield of Texas acknowledges the bitter feud between his company and the free-standing emergency room industry but lays the blame at the provider’s doorstep. He pointed to a $45,000 bill to treat a patient who came into the emergency room with a sore throat, later diagnosed as tonsillitis.

Currently, about 80 percent of Blue Cross and Blue Shield out-of-network claims for emergency care come from free-standing emergency rooms, according to insurance claims data.

Stacey Pogue, a senior policy analyst for the Center for Public Policy Priorities in Austin, is wary of the new initiative.

“I can see why they are doing this,” she said of the unsustainable trajectory of health care costs. But the test will come in how it is implemented — and how well the appeal process works, she said.

Pogue and other health policy watchers worry most about how patients could get stuck in the crossfire. If their insurer decides to deny payment to the doctor or facility, the entire bill could then get passed on to the patient with a demand for payment. And unlike in other types of insurance plans, HMO coverage is not eligible for the state-sponsored mediation process.

“There are land mines all over this,” she said.

The Blue Cross and Blue Shield rollout is not happening in a vacuum. Elsewhere in the country, Anthem, the insurance giant, has initiated a similar program in six states — Kentucky, Missouri, Indiana, Ohio, New Hampshire and Connecticut. In the Anthem program, the final diagnosis can be part of the denial decision.

Anthem has faced harsh criticism from emergency room physicians and some health policy experts who worry about a chilling effect among patients trying to decide when and where to get emergency care.

The insurer denied thousands more emergency room claims last year over the previous year, according to an analysis of claims by the American College of Emergency Physicians. The spike corresponds with the implementation of Anthem’s program, said Laura Wooster, associate executive director of public affairs for the physicians organization.

While not identical to Anthem’s program, she said her organization is still concerned about what could happen in Texas.

“You can’t look at intention in a medical record. At best, you can look at presenting symptoms,” she said. Mostly she worries people may skip care and then something goes wrong. “Will you ever be able to forgive yourself?”

Source: If it’s not an emergency, Blue Cross Blue Shield won’t pay – HoustonChronicle.com

HCA helps fill gap in care left by Houston hospital closure

Nashville, Tenn.-based HCA Healthcare’s Gulf Coast Division will open a new freestanding emergency room in Houston July 17, according to the Houston Business Journal.

The new ER will help fill the medical gap left by the closure of HCA’s East Houston Regional Medical Center. The hospital closed Nov. 9 after suffering extensive water damage during Hurricane Harvey.

“The Gulf Coast Division is committed to providing emergency services in the east Houston area and has been for more than 40 years,” HCA Gulf Coast Division President Troy Villarreal said in a press release. “Unfortunately, Hurricane Harvey destroyed East Houston Regional Medical Center, leaving many people in the area without a nearby, easily accessible place to seek medical attention in case of an emergency.”

Demolition of East Houston Regional Medical Center is scheduled for late July. HCA is still considering several options for the property’s future, according to the Houston Business Journal.

Source: HCA helps fill gap in care left by Houston hospital closure

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