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Caffery, Oubre, Campbell & Garrison, L.L.P.
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Major health insurer cites justification for policy change

You want it, we’ve got it.

Evidence, that is. Scores of pages of it, which sets forth in numbing detail shockingly high medical charges levied by emergency room care providers.

Here are just a few examples:

  • $7,000 bill applicable to a patient’s sunburn
  • 15 lab tests for a bronchitis patient
  • $45,000 for tonsillitis treatment and 18 hours of observation
  • $8,700 charge for a bronchitis patient

It is hardly surprising that a major American health insurer spotlighted such excessive gauging for regulators in a state where the company insists it needed to make changes to economically survive.

That company is Blue Cross and Blue Shield of Texas, which recently launched new ER-linked rules and standards for insureds in that state who go to emergency rooms.

BCBS’s bottom line: It might just limit payments – or not even pay at all – in cases where a policyholder could have reasonably gone to an in-network facility and opted not to or, alternatively, could have waited and seen a family doctor.

The company is taking some heat for its stance. It is unwavering, though, in the view that the time has come to check impermissible gauging and to make insureds engage in at least some level of due diligence prior to seeking treatment.

BCBS principals reportedly “bristle at the accusation they are putting anyone at risk” because of a chilling effect the policy might have on patients who will now balk at receiving care. The company says that keeping care in network helps rather than harms insureds, and it states that the fraud, waste and abuse it has uncovered fully justifies a change in tactics.

The insurer stresses that claim challenges will issue only in outlier cases where notably high charges are levied or when a patient purposely visits an inappropriate facility for care.

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