Blue Cross and Blue Shield in Georgia is looking to employ a lot of lawyers.
At least that will be a pragmatic effect of the proposed policy to deny emergency room claims if they are not deemed to be emergency reasons. Via WABE:
Starting in July, health insurance provider Blue Cross Blue Shield will stop covering emergency room visits it deems unnecessary….
Fusile says BCBS wants patients to use urgent care, retail health clinics and their LiveHealth app, which are all cheaper than an ER visit….
Hockenberry says, in his research, he’s found many people often use the emergency room inappropriately, for urgent care rather than emergency care.“This is a real problem. Emergency departments are expensive; they’re there for a different reason. Blue Cross is clearly staking a claim here that we’re going to try to change patient behavior,” Hockenberry says.
Donald Palmisano, president of the Medical Association of Georgia, paints a different picture when it comes to this policy: Imagine a BCBS member has chest pains in the middle of the night. He thinks it might be a heart attack, so he goes to the ER. But it turns out that it was just indigestion. Under BCBS’s new policy, he gets charged for using the emergency room inappropriately. So the next time, he has chest pains, he thinks, in case it’s just indigestion, he won’t go to the ER. But this time, it’s a heart attack, and he dies.
Everyone in insurance, everyone in emergency medicine has stories to tell about wildly inappropriate emergency room presentations. But the problem is that the decision to go to the emergency room is fraught with uncertainty. Most people know that something is wrong and they don’t know if it is really, really wrong or mildly wrong. The symptoms are broad enough that likely low acuity events are counterbalanced by unlikely but non-zero high acuity events.
Even some of the non-urgently needed for treatment individuals are admitted for an inpatient stay.
1 in 23 of those triaged 'nonurgent' (which is not same as safe to go home) admitted. https://t.co/mq8Un0youH 1/2
— Ari Friedman (@AriBFriedman) June 1, 2017
Yes, there is value in reducing ER utilization. It is expensive, disjointed and minimally connected to the primary care universe. However it also serves a real need in addressing uncertainty. Better triage, better distance learning tools and better interventions on the very few people who are frequently inappropriate ER utliizers would all be great things. Retrospective claims review with denials is too blunt of a tool to deal with a scenario with explicit uncertainty and information gaps.
There will be lawyers if BCBS-GA actually tries to deny claims. If this is purely a marketing campaign, there might still be lawyers but far fewer of them.