Blue Cross and Blue Shield of Texas is pushing back its policy not to reimburse for unnecessary emergency department (ED) visits until August.
The payer planned to start the program Monday, but pushed it back two months after hearing concerns from the state’s Department of Insurance (TDI).
The TDI sent a two-page letter to the insurance company last week requesting the delay and provided a list of six questions that the state wants answered, including the payer’s reasoning behind the new process.
Health insurers have used multiple cost-saving levers in hopes of bending the healthcare cost curve. Prior authorization, provider tiering and value-based contracting have become regular parts of healthcare.
Payers believe that nudging patients from EDs to less expensive locations like urgent care centers and physician offices can reduce healthcare spending. However, declining to pay for ED visits deemed unnecessary is still a rarity.
Anthem, another Blues plan, expanded a policy to deny ED visits that were deemed medically unnecessary, but ultimately softened its plan earlier this year after complaints from providers that patients would self-diagnose or avoid care. Anthem added exceptions, including patients sent to an ED by a provider, those who are from out of state or go to the ER on a weekend and those who end up receiving certain medical care, such as surgery, IV fluids or an MRI or CT scan.
Anthem recently told Healthcare Dive in a statement that it remains “committed to providing our members access to high quality, affordable health care.” The payer added: “An important part of fulfilling that commitment is our work to reduce the cost of healthcare while simultaneously improving the quality and efficiency of the healthcare system for consumers."
Other major payers have implemented their own ED cost-saving measures. UnitedHealthcare, the nation’s largest private payer, implemented a policy in March that includes reviewing ED claims with the most serious conditions (Level 4 or Level 5) evaluation and management codes in commercial and Medicare Advantage plans. UnitedHealth reduces or denies the claim depending on the contract if it finds incorrect claims for the ED visits.
In Kentucky, the state’s Medicaid program will soon penalize Medicaid patients who visit EDs for what’s deemed unnecessary care. Beginning next month, Medicaid recipients who receive coverage through Medicaid expansion will get penalized between $20 and $75 for visiting an ED for non-emergency care. The state Medicaid program will waive the penalty if the patient contacted an insurance company’s nurse hotline before going to the ED. Kentucky was also the first state that got a work requirement for its Medicaid program this year, which is another attempt to reduce Medicaid costs and cut the size of the program.