E.R. Visit with Insurance? You Might Pay Out of Pocket

If you are a fully insured group or retail HMO member of Blue Cross Blue Shield (BCBS) of Texas might have to pay for your emergency room visit. This may come to a surprise to the nearly 500,000 Texans with this kind of coverage. Whether or not they have to pay for the emergency room bill would depend on the severity of the initial reason going. For example, BCBS might see a rash differently than a broken bone, a stomach ache different from a foot sprain, and so on.

The biggest factor considered in this new policy is, you guessed it, money. In a memo to consultants and brokers, BCBS stated that the new policy is being enacted to save insurance members’ money from what could otherwise be treated in a doctor’s appointment. The new policy goes into effect June 4th of this year.

What Would Be Considered an Emergency?

This is one of the biggest questions – and concerns – that people have with the new policy. In other words, what injury or symptom is considered important enough to merit a visit to the emergency room? On one hand, it is understandable for people who know they have a minor injury to care for it at home until they can visit their primary care physician. Take, for instance, someone who was playing a sport and got a small scrape. That scrape can probably be cared for with hydrogen peroxide and a band-aid. On the other hand, let’s say that same person got their arm broken. This would require a doctor to properly care for the broken bone and intense pain.

There is an issue with self-diagnosing worth looking into, though. Self-diagnosing – or in this case, diagnosing to see the potential value of an emergency room visit – could involve inaccurate diagnosis that could be harmful to a person. For example, if someone has a strong stomach ache-type pain, they might rule it out as something they ate recently in order to avoid worrying about a medical bill. However, what if that person’s appendix burst and requires immediate medical help? This misdiagnosis could result in a serious abdominal inflammation (peritonitis), which untreated can be fatal.

As you might tell, there is a very gray and blurry line between which injuries and symptoms require emergency care. BCBS should, if anything, have a general list of what their insurance would consider acceptable for a claim. Also, whether or not this new policy violates state insurance laws would be up to the Texas Department of Insurance.

What Are Your Thoughts?

On one side, BCBS is attempting to keep the costs of their insurance the same rate for the HMO members mentioned above. On the other side, there could be potential risks dictating what emergency is considered valid for a policy holder to not pay out of pocket for their emergency room visit. Whether or not this can influence other insurance companies’ policies would be up to the response of the policy holders and with fiscal analysis after the policy rolls out; in other words, does the policy actually save BCBS money, and if so, at what costs?

Do you consider the new policy to be fair? Why or why not? Let us know in the comments below.

Mark A. Anderson
Board Certified Personal Injury Lawyer in Fort Worth, Texas
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