As of June 6^th, Blue Cross and Blue Shield of Texas implemented a controversial new program in which it will not pay any expenses for an out-of-network emergency room visit if they determine that a patient should have gone elsewhere for treatment. Under the new policy, which was announced in April, a medical director hired by the insurer, will review and approve or reject claims after the ER visit. They will determine the reason a patient opted for the ER and if they should have or could have received treatment at a less expensive clinic.

According to the Houston Chronical, “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.” Posing the potential of deterring patients to skip potentially life-threatening treatments out of fear that their medical bills will not be paid. The insurance provider has issued informative campaigns to help patients make informed decisions on choosing the correct medical care in order to avoid denials.

MEREM Healthcare Solutions and physicians around the country all wonder, could this become a national trend for insurers?

Luckily, we don’t have any clients in Texas at this time, so this policy hasn’t yet impacted our client’s reimbursements or their patients, but it is a serious policy that health care providers and consumers must consider.

Imagine your all-star high school athlete gets injured in an away game playing football. Instead of waiting hours in pain traveling home, you head straight to the local ER to address the shoulder injury and possible concussion. After MRIs, hours of waiting in pain, and a few evaluations, your insurance finds that your visit was unnecessary because there was a local Orthopedic Urgent Care, like OrthoExpress, nearby that offered Friday night Concussion clinics, or simply because the closest Emergency Room was out-of-network.

For more information, about this policy and the effects, check out this Houston Chronical update.