Blue Cross Blue Shield Will Limit Georgia Emergency Room Coverage for Individual Health Insurance Plans

As has been reported now by WABE, the Atlanta Journal-Constitution, Becker’s Hospital Review, The Fiscal Times, and The Intercept, Blue Cross Blue Shield of Georgia sent letters last month to individuals who purchase their plans on the health insurance exchanges stating the company will no longer pay for services rendered in emergency rooms that it deems unnecessary.

Blue Cross Blue Shield hopes this policy will prompt consumers to use primary care or urgent care for non-life threatening health issues, pointing out that emergency services are meant for true emergencies. Emergency care is more expensive than most other types of health care, and most emergency rooms are already handling a full load with actual emergency situations. This change in policy is also meant to save Blue Cross Blue Shield and hospitals money, according to the insurer. They’ve built in safeguards, so the policy excludes Sunday visits and visits on major holidays, those who live more than 15 miles away from an urgent care clinic, and anyone under the age of 14. The AJC notes that while Blue Cross Blue Shield relayed those exceptions to their reporter, they were not listed in the letter sent to customers dated May 19, 2017.

If you’re thinking, “well duh, of course you shouldn’t go to the emergency room for a cold,” I agree, and I am aware that a small percentage of patients go to the emergency room if they so much as stub their toes. Of course, the are some murkier areas than black and white examples, particularly outside of our urban and suburban areas of the state.

As has been discussed several times on this blog, rural hospitals in Georgia are in trouble, and many are closing. Rural hospitals rely on payments from insurers to stay afloat. Now that Blue Cross Blue Shield will force consumers to pay out of pocket for visits classified as unnecessary, there is a worry that hospitals won’t get paid for some — if not many — of the treatments provided that fall under this category, exacerbating their financial woes.

The American College of Emergency Physicians believes Blue Cross Blue Shield’s new policy violates the Patient Protection and Affordable Care Act, which is still the law, even as a repeal plan works its way through Congress (maybe). PPACA contains the “prudent layperson” provision, which requires that insurance coverage be based on a person’s symptoms, not their final diagnosis. For example, a person having chest pains should go to the emergency room without a worry that their treatment won’t be covered if it turns out to be indigestion instead of a heart attack. Blue Cross Blue Shield gave conflicting answers on this topic to two different outlets, so it’s unclear how cases will be reviewed. One option is that such cases will be reviewed by their company’s medical director using the “prudent layperson” provision as a guide before making final decisions about payment. The other is that a “panel of experts” would make decisions on these cases.

The Georgia Medical Association has come out against this policy change, claiming it will disproportionately affect elderly and rural Georgians. The rural residents claim is reasonable, though it seems many would fall under the provision where those more than 15 miles from an urgent care would be exempted when looking at individuals. When looking at communities, I suspect they have a point. (More below.) On the other hand, I have no explanation for the claim about the elderly, as they should be covered by Medicare, not Blue Cross Blue Shield’s exchange plans. If y’all know of a wave of seniors spurning Medicare for the exchange plans, let me know, because it will be news to me.

Laura Harker of the Georgia Budget & Policy Institute pointed out a potential issue with consumers who hold exchange plans from Blue Cross Blue Shield being surprised by what doesn’t qualify as an emergency after the fact, and thereby racking up unforeseen medical debt as a result. This and the repayment to rural hospitals are the biggest underlying dangers of this policy change as I see it.

According to the Kaiser Family Foundation, three percent of Georgians purchased insurance on the exchanges in 2015 (non-group category). Health and Human Services has an enrollment profile from 2014 showing 316,543 individuals purchased plans. 57 percent were women, and 64 percent were between the ages of 35-64. 87 percent had financial assistance under PPACA for purchasing plans. The Kaiser Family Foundation surveyed non-group health insurance consumers in 2014, but unfortunately their survey didn’t offer state-by-state results. It also included compliant and non-compliant plans. Nationally, six in ten of the non-group enrollees surveyed were uninsured before purchasing their current non-group plans. 47 percent had either attended or graduated from college, with an additional 31 percent having graduated from high school. 69 percent were white, and the majority were over 250% of the federal poverty level but under 400% of the federal poverty level. In 2014, that would have been an income range of $29,000 to $46,000 per year.

The Washington Post found in 2014 that rural southwest Georgia had some of the highest exchange insurance rates in the nation. Think in the range of $837 a month — two years ago. Imagine these individuals, who likely have that amount subsidized (though 13 percent do not), fall into the trap of going to an emergency room thinking they have an emergency but thankfully do not. The hospital sends the bill to the insurance company, and the medical director or panel of experts decides the situation does not fit the “prudent layperson” threshold. Now, the consumer has the full cost of the emergency room visit to pay on top of the astronomical premium. If they don’t pay the hospital, the hospital is out the cost of care. Again, Georgia’s rural hospitals are already in dire financial straits. The hospital will inevitably chase the debt, and it will negatively affect the credit of the patient, who will either be sent to collections or who will possibly declare bankruptcy. Of course, this scenario is merely a possibility, and it could be that it doesn’t come to fruition. However, the best case scenario is rarely ever reality.

There are only two other states where Blue Cross Blue Shield has enacted a similar policy — Missouri and Kentucky. I suspect they’ll have the company of other states falling under this policy shift very soon. It will be worth watching to see what happens, particularly if my concerns become actual problems with Blue Cross Blue Shield’s policy change.

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ScottNAtlanta
ScottNAtlanta

If the ACA stays in place this is absolutely illegal. Looks like BC is taking a pretty risky gamble here. Insurance companies ALWAYS try to deny care and in my experience dealing with them almost always back down when you get aggressive with them. Problem here is that the ACA says they must cover emergency care. BC will be hard pressed to after the fact try to deny coverage because the emergency is defined by the patient. BC cant expect patients to be doctors and self diagnose.

GeneHartke
GeneHartke

The insurance industry is killing themselves for short-term greed. Keep it up. Making single payer look better and better for those still on the fence.