A group of emergency physicians is sounding alarms, but Blue Cross says there’s no fire.
The state and national chapters of the American College of Emergency Physicians are taking issue with Blue Cross & Blue Shield of Mississippi, saying a proposed policy will decide the severity of medical emergencies after the fact and leave hospitals, doctors and patients on the hook for uncovered expenses.
“Health insurance companies can’t expect patients to know which symptoms are life-threatening,” said Dr. Philip Levin, president of the Mississippi chapter of the American College of Emergency Physicians.
At issue is a bulletin sent in December by Blue Cross & Blue Shield of Mississippi to network providers. The Blue Cross update noted that in 2019, the insurer would be monitoring and evaluating how emergency visits were coded for severity and ensuring they were aligned with the severity of the diagnosis code submitted.
“If the office visit level is not in alignment with the diagnosis severity, the payment for the office visit level will be adjusted to align with the diagnosis severity,” the update says.
However, the Jackson-based insurance company said the emergency physicians group has misunderstood its intentions, and the group’s concerns that patients could end up shouldering the costs of treatment is incorrect.
“In emergency situations, our members should always seek care at the nearest healthcare facility and can trust their care will be covered,” said Blue Cross corporate communications director Meredith Bailess in written statements.
No new policy has been implemented, Blue Cross has a continuing focus on ensuring emergency care costs are managed appropriately, she said. The insurer is working to address provider questions.
“We think the Blue Cross & Blue Shield of Mississippi policy has been confused with emergency room policy that other commercial payors have implemented, which does not pay for any services in the emergency room if the payor determines the entire visit to be a non-emergency,” Bailess said.
Anthem Blue Cross Blue Shield implemented a policy in Georgia, Indiana, Kentucky, Missouri, New Hampshire and Ohio last year where it stopped paying for emergency visits for certain kinds of presenting symptoms, deeming them non-emergency. The policy is currently the subject of a federal lawsuit filed in Georgia by American College of Emergency Physicians and the Medical Association of Georgia. The prudent layperson standard is the general guideline for state and federal law in determining if an emergency visit is justified, according to the national emergency physicians group.
The Mississippi Insurance Department has received complaints from physicians, but there have been no reports of hospitals or doctors having emergency charges downcoded inappropriately by Blue Cross.
Dr. Jason Waller, Baptist Memorial Hospital-North Mississippi emergency department medical director, said he shares the concerns raised by the emergency physician group, but has not seen any reimbursement issues at the Oxford hospital.
“The (Blue Cross policy update) leaves a lot of room for interpretation,” said Waller, who also serves as the regional medical officer for Schumacher Clinical Partners. “I’m certainly not reassured.”
Source of concerns
The emergency physicians said they became concerned after the insurer sent out its December bulletin.
“We would like the chief complaint and the complexity of the work up to determine the severity,” said Jackson emergency physician Dr. Jonathan Jones.
Severe abdominal pain, headaches and chest pain can signal life-threatening conditions like appendicitis, stroke and heart attack. But they also could be a bad stomach ache, a sinus infection or heart burn. In some cases, it can require an in-depth exam, tests and medical imaging to tell life-threatening from uncomfortable, Jones said.
Based on Mississippi law against balance billing, it is likely hospitals and physicians would end up shouldering the cost if insurers downgrade severity based on final diagnosis. But that poses a long term problem for both patients and insurers, Waller said.
“If emergency departments aren’t adequately reimbursed, they aren’t going to be adequately staffed,” Waller said.
Blue Cross officials have told Insurance Department staff that the policy under development is not focused on rule-out testing and the insurer would not deny reimbursement for medically necessary work ups.
There have been well-publicized concerns raised about upcoding in the past year. In 2018, the Clarion Ledger reported about upcoding at Jackson area hospitals. Minor emergencies were classified with high severity levels, increasing the costs to insurers and patients.
The physicians group is opposed to upcoding and inappropriate use of medical testing, Jones said.
“Billing a level of care that is not needed is not justified,” Jones said. “We do not support upcoding.”