DALLAS (CBSDFW.COM) – Blue Cross Blue Shield of Texas is calling it a change in the way it reviews out-of-network ER bills of its members.

The issue came to light in an April letter to brokers and consultants where the insurance giant said, “Our HMO members may be required to pay for the entire emergency room bill– if they go to an out of network emergency room as a convenience.”

Some doctors are concerned, saying the company forces patients to “self-diagnose” before heading to the emergency room.

Dr. Bob Hancock, the executive board for the Texas College of Emergency Physicians says the new policy will have patient’s second guessing going to the ER when seconds count. “All my colleagues agree with me that if this policy is implemented, it’s going to hurt patients and there are going to be people who are going to die… All it takes is one person to sit at home for an extra 20 minutes second guessing whether their chest pain is from stomach or reflux or from their heart.”

The Texas Medical Association, which also opposes the policy, said in a letter saying, “BCBSTX is asking that patients act as highly trained diagnosticians, skills that our members spend many years of the lives to acquire.”

Now the state regulating agency wants to know exactly how it will implement the policy.

BCBSTX agreed to delay the implementation by 60 days.

Dr. Paul Hain is the market president at BCBSTX. He says the policy is meant to curb abuse and fraud.

“We’re going to request the medical records and look at why they came to the emergency room,” he said.

Dr. Hain said sometimes people end up using the ER for convenience. Like for medicine refills, head lice or even school physicals. But he said that the company will base the decision to pay on the symptoms that brought you to the ER and not the diagnosis you walk out with. “If you think you are having an emergency that makes you think it’s an emergency and turns out not to be one. That is of course covered,” he said.

The Texas Medical Association and Dr. Hancock says the policy is not clear and leaves a lot of room for interpretation. CBS11 brought their concerns to BCBSTX.

“They say you are asking patients to be diagnosticians.” Dr. Hain told her that’s just wrong, “I don’t think they truly understood that we are requesting medical records and looking at symptoms,” he said.”We’re not asking anyone to not self-diagnose. We’re asking you not to get your allergy medicine refilled there.”

BCBS said they won’t cover things like planters warts, school physicals or head lice at out of network emergency rooms.

Dr. Hain added that 80 percent of out of network ERs are freestanding emergency rooms we see all over Texas.

The new policy goes into effect on August 6, 2018. Meanwhile the Texas Department of Insurance is asking BCBSTX to answer their questions on exactly how the review process is going to work.
BCBS TX statement:

“Blue Cross and Blue Shield of Texas (BCBSTX) is pleased to work closely with TDI over the next 60 days. During this time, BCBSTX will provide any further information TDI or Commissioner Sullivan requests while continuing to educate our members on the importance of appropriately using emergency services. We anticipate this thoughtful, multi-step review process will be implemented on August 6, 2018 to provide protection for our members from inappropriate billing, egregious charges and fraud, waste and abuse by out-of-network emergency departments.”