Blue Cross Blue Shield will stop reimbursing some ER visits on July 1st

Starting July 1, Blue Cross Blue Shield of Georgia is implementing a new policy that may result in unpaid bills for patients on the individual market who go to hospital emergency rooms for non-emergencies. Anthem, the parent company of Blue Cross in Georgia, offers insurance in 14 states and has implemented similar policies in New York, Kentucky and Missouri. This decision will impact many Georgians because, for 96 of the state’s 159 counties, Blue Cross is the only insurer on the Affordable Care Act (ACA) exchange. Blue Cross wants patients to use their best judgment when deciding whether to use the ER for care and cites cold or sore throat symptoms as obvious examples of instances when going to the ER may not be necessary. Blue Cross defines an emergency as:

A medical or behavioral health condition of recent onset and sufficient severity, including but not limited to, severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness or injury is of such a nature that not getting immediate medical care could result:

(a) placing the patient’s health or the health of another person in serious danger or, for a pregnant woman, placing the woman’s health or the health of her unborn child in serious danger;
(b) serious impairment to bodily functions; or
(c) serious dysfunction of any bodily organ or part.

Such conditions include but are not limited to, chest pain, stroke, poisoning, serious breathing problems, unconsciousness, severe burns or cuts, uncontrolled bleeding, or seizures and such other acute conditions as may be determined to be Emergencies by us.

Exceptions: The covered patient is 13 or younger; the member doesn’t have an urgent care clinic within 15 miles; the visit happens on a Sunday or major holiday

The definition is gray enough that it will likely leave patients wondering what constitutes a necessary trip to the ER. Patients are not trained clinicians and should not be forced by their insurer to self-diagnose the severity of their illnesses. Furthermore, a study published in JAMA found that six of the top ten patient symptoms described during non-urgent ER visits are also among the top ten symptoms of true emergencies (lower back, abdominal and chest pain, sore throats and headaches).  Georgia Watch is concerned that the new Blue Cross policy could exacerbate conditions among patients who delay care fearing that a trip to the ER may not be covered.

Blue Cross urges patients who do not need the ER to utilize their personal physicians, urgent care clinics or ‘LiveHealth Online’, Blue Cross’s 24-hour online medical service. These can be limiting choices for consumers who may not have easy access to a computer. Also, many urgent care clinics are not open 24 hours a day, and symptoms can arise in the middle of the night. If you are definitely not experiencing an emergency, these can be good cost-saving alternatives. We describe these alternatives in more detail below:

Telemedicine

Telemedicine is not always the right substitute for emergency care, but it is a healthcare option with increased convenience and significantly reduced costs. For those with company-sponsored healthcare plans, telemedicine is likely available as a supplement.  If this is not an option, there are services for general consumers as well.  Call a Doctor Plus and Doc on Call 24-7 cost about $20 per month and MD Live costs about $50 on a per session basis.

Retail Clinics

These clinics can usually be found in supermarkets, drug stores and discount stores.  They offer basic medical care, often through nurse practitioner providers, and are a cheaper and faster alternative to the hospital ER. Studies have shown that the quality of care received at these clinics is no less effective than that of physician offices or urgent care facilities, and the overall costs of care at retail clinics were substantially lower. Most retail clinics are open 12 hours per day, five days per week, and 8 hours per day on the weekends.

Urgent Care Facilities

Urgent care centers are a type of clinic with extended hours (although typically not 24/7) that accept walk-in patients requiring medical attention during their hours of operation. These facilities provide care under the direction of a physician and are equipped to diagnose and treat non-life threatening illnesses and injuries.  This is a great after-hours alternative to the hospital ER for the kinds of diagnoses and/or treatments that one might expect to receive at a physician’s office during regular office hours.

Consumer advocate Clark Howard offers some great suggestions for what you can do to protect yourself from unpaid ER visits, including the alternatives described above. Clark warns patients to beware of standalone ERs. These standalone ERs are NOT the same as urgent care facilities. Stand-alone ERs are often fancy, very expensive emergency rooms that are not attached to a hospital. Even simple tests and procedures can cost thousands.

Filing Complaints

The Georgia Insurance Commissioner’s Office is monitoring this new Blue Cross policy and tracking related consumer complaints. If you visit an ER for a perceived emergency and find that you are denied coverage, you should alert the Insurance Commissioner’s Office.  Georgia Watch is also monitoring this issue.

For more information see:

Atlanta Journal-Constitution: Blue Cross in Georgia to limit emergency room coverage

The Intercept: Blue Cross Blue Shield wants people in Georgia to self-diagnose before heading to the emergency room

Georgia Health News: State agency to monitor Blue Cross rule on ER use

Written by: Benjamin Olivari, graduate student extern, and Beth Stephens, Senior Director of Public Policy & Advocacy

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