Should Blue Cross Deny Claims for out of Network Emergency Room Visits?

Blue Cross Blue Shield is catching heat for its controversial decision to not cover out-of-network ER visits...

Should Blue Cross Deny Claims for out of Network Emergency Room Visits?

Blue Cross Blue Shield is catching heat for its controversial decision to not cover out-of-network ER visits that are not an emergency. There are several sides to this one. First, there are the abusive costs associated with these free standing emergency rooms and the outrageous claims that get created. Then, there are the Doctors groups who are up in arms about the decision. They claim that people will not go to out-of-network ERs with true emergencies because of fear that it will not be covered. It would be "life threatening." Is that the case or are these standing room ERs, a goldmine of health insurance and patient cost abuse afraid that their money machines will lose money? After all, they advertise to go in for non-emergency type cases. One billboard in Dallas said 'does little Tommy have a stomach ache? Let us take care of him'. Then, there are the patients who go to ER's with non-emergency related issues.

If someone is having a true life threatening issue, they are not going to think about the costs. They are going to the ER. Besides, people walk away from medical debt all of the time.

My own personal experience with freestanding emergency rooms was a good example. My son dislocated his shoulder in basketball. Being July 3rd, I was concerned to wait 2 days to get him into a doctor. I took him to a free standing ER. 20 minutes (total visit time from car door back to car door) and one x-ray later, they charged me $1,900 for the experience.

This article points to the abuses found in this study:

According to a study of more than 16 million Blue Cross Blue Shield of Texas insurance claims between 2012 to 2015, the use of the state’s freestanding emergency rooms shot up 236 percent, as opposed to a 24 percent increase for urgent care clinics and a 10 percent growth rate for hospital-based ERs. Texas became one of the first states to allow freestanding emergency rooms. Now, there are over 200 of these statewide. The stories are rampant of patients getting ripped off. This study also found that in 2015, a freestanding ER bill averaged $2,199, as opposed to $168 at an urgent care clinic. Blue Cross shows that over 80% of their out-of-network claims come from free standing emergency rooms.

Should patients with real emergencies be covered? Absolutely they should be covered. Do people have a good idea of what an emergency is and what it is not? I think that common sense should tell you that for example a case of head lice is not an emergency. If you truly think that you have an emergency then you should have a case against the insurance company for coverage. If it is a life or death call and a true emergency, costs are not going to be the consideration.

Insurance is by far from a perfect world. However, if the health insurance industry is ever going to be reformed, we have to cut out the insurance abuses brought on by free standing emergency rooms and non-emergency related emergency room visits. Maybe we need to fire the politicians who are responsible for their existence in the first place. The Texas Freestanding Emergency Medical Care Facility (FEC) Licensing Act was first enacted in 2009 by the 81st Legislature.

Uhmmmmm....it always comes full circles back to the politicians.

Bob Brooks is host of the Prudent Money Radio Show. He writes daily at www.prudentmoney.com. If you have a question for him. go to www.askbobbrooks.com. If you want to inquire about his financial advisement services, email him at bob@prudentmoney.com or call 972-386-0384 and ask for Judy.

Comments
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BobBrooks
BobBrooks

Editor

@JosephC - yes at best it is a messed up situation!

JosephC
JosephC

I agree, insurance for most is nothing more than catastrophic insurance now and doesn't cover much of what routinely happens in most peoples life. It is just an expense with little benefit. That said, sometimes they are just wrong and should pay and even sometimes do with a little pressure. A claim I had at an ER was denied because while I went to a hospital that was in network the ER Dr. was not. Went in with a head wound and explained had I been unconscious how was I supposed to interview the attending Dr.s to determine who I could see or if there was one on duty. You usually have to escalate a claim past those initially making the denial to apply any common sense to the situation.

atkinsww1
atkinsww1

There seem to be several issues. First, if I'm having a true medical emergency(possible heart attack, back accident) I'm not going to a free standing ER. Second, the few times we've gone to regular ER's(kid with a broken wrist, appendicitis, etc) I've felt like the prices there were crazy. Third, with a $6,000 deductible this year, NOBODY is going to the ER anyway.

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