Blue Cross Blue Shield ED pay denial

[Pudortu]

Not sure if you guys have been following this, but BCBS is going to start cutting pay for non-emergent ER diagnoses. Apparently Chest pain with breathing is one of these. I highly suggest you read these 2 articles. I'm afraid this is the next step in cuts to our pay. It's times like this I actually want to support ACEP.

Blue Cross Blue Shield To Launch Emergency Room Policy

This is ACEP's reply.
Emergency Physicians: Anthem Blue Cross Blue Shield Policy Violates Federal Law

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[NYEMMED]

Not sure if you guys have been following this, but BCBS is going to start cutting pay for non-emergent ER diagnoses. Apparently Chest pain with breathing is one of these. I highly suggest you read these 2 articles. I'm afraid this is the next step in cuts to our pay. It's times like this I actually want to support ACEP.

Blue Cross Blue Shield To Launch Emergency Room Policy

This is ACEP's reply.
Emergency Physicians: Anthem Blue Cross Blue Shield Policy Violates Federal Law

It would be better and more fair if BCBS added a coinsurance onto the insureds bill for anything non-emergent. We can't control the things people come in for...

 

[TMP-SMX]

While yes we as a society need to reduce cost, it's laughable to believe a for profit company has any desire to save lives. They desire reducing their costs. There is zero transparency in our system in terms of not only costs from the hospital side but also what kind of shady deals are going on behind the scenes with insurers, hospitals, pharmacies, and pharmaceutical companies. Why can't non-emergent cases be triaged through fast track to urgent care then you don't have to worry about being paid?

 

[Dr. Texas]

I believe this was tried in Oregon or Washington State and it was eventually struck down by the courts. I imagine the same will happen this time, but it won't if everyone stays silent. These kinds of news articles make me love ACEP's advocacy/legal wing.

 

[deleted109597]

Washington State Medicaid tried it. But yeah, it was found to be wanting.
This violates prudent layperson and won't win.

 

[TooMuchResearch]

While yes we as a society need to reduce cost, it's laughable to believe a for profit company has any desire to save lives. They desire reducing their costs. There is zero transparency in our system in terms of not only costs from the hospital side but also what kind of shady deals are going on behind the scenes with insurers, hospitals, pharmacies, and pharmaceutical companies. Why can't non-emergent cases be triaged through fast track to urgent care then you don't have to worry about being paid?

Because we don't have an urgent care?

 

[deleted109597]

Because we don't have an urgent care?

Correct. Hospitals make too much on the facility fee side to not get that money. You're legally allowed to MSE a non-emergency and send them home. But not many places want to do that. And many urgent cares aren't open late at night. The conveyor belt only goes one way in the ED, and it isn't out.
Some open up urgent cares down the road, but depend on self triaging.

 

[The White Coat Investor]

On a philosophical note, this is one of the things I hate the most about having income tied to professional fees. All of a sudden some crazy insurance company or government regulatory agency changes some little thing and the doc gets paid dramatically less. Some specialties like cardiology and radiology have seen cuts as much as 25% in years past just from relatively small changes. Imagine if you were a mammographer and all of a sudden insurance companies stop paying for mammograms or something.

Good reason to diversify your income. This sort of stuff really riles you up when 90%+ of your income comes from medicine, but if you can get yourself into the position where changes like this only affect how much you save or give to charity rather than your lifestyle, it's a lot less painful.

Medicine is a really weird way to make a living sometimes.

 

[GeneralVeers]

On a philosophical note, this is one of the things I hate the most about having income tied to professional fees. All of a sudden some crazy insurance company or government regulatory agency changes some little thing and the doc gets paid dramatically less. Some specialties like cardiology and radiology have seen cuts as much as 25% in years past just from relatively small changes. Imagine if you were a mammographer and all of a sudden insurance companies stop paying for mammograms or something.

Good reason to diversify your income. This sort of stuff really riles you up when 90%+ of your income comes from medicine, but if you can get yourself into the position where changes like this only affect how much you save or give to charity rather than your lifestyle, it's a lot less painful.

Medicine is a really weird way to make a living sometimes.

On the plus side for us, we don't have offices, and aren't fee-for-service. Our pay right now is largely governed by geographic area and supply and demand. A 5% decrease in professional fees aren't going to reduce the rate the CMGs pay me, as it is not altering the fundamentals. They have huge profit margins in many markets, and I feel that the CMGs with their economy of scale will be forced to absorb the hit first due to the physician shortage. Of course this could all change if the shortage vanishes.

 

[Dr. Texas]

Which it likely will, since we're creating EM residencies at a fever pace right now. I think the relative shortage will remain in more exurban/rural areas, but cities will eventually be overrun. Thoughts?

On the plus side for us, we don't have offices, and aren't fee-for-service. Our pay right now is largely governed by geographic area and supply and demand. A 5% decrease in professional fees aren't going to reduce the rate the CMGs pay me, as it is not altering the fundamentals. They have huge profit margins in many markets, and I feel that the CMGs with their economy of scale will be forced to absorb the hit first due to the physician shortage. Of course this could all change if the shortage vanishes.

 

[southerndoc]

Didn't Kaiser do this in California and got into trouble doing it?

We are still assessing the impact here in Georgia. Athem/Georgia BC/BS hasn't been very forthcoming with details. Theoretically, it could be based on the prudent layperson standard ("I'm having chest pain, it's an emergency") or it could be based on the final diagnosis (costochondritis isn't an emergency, so no matter if you had chest pain and had risk factors, you were ultimately diagnosed with something that wasn't an emergency).

On another note, one could post the home address and phone numbers of the executives of BC/BS. That would get their attention. However, I will refrain from doing so.

Anthem (the parent company of BC/BS of Georgia) makes about $17 million per year in salary and other compensation. Good ole' Joe Swedish has to deny claims in order to pay for his lavish lifestyle.

 

[GeneralVeers]

The real question is how do you stop people from using the ED as an outpatient clinic?

The onus should be on the insurance companies to direct people to TIMELY appropriate care. For questionably urgent cases they should be able to call a central scheduler for the insurance company who can get them 24-hour follow-up or refer them to urgent care. If the scheduler cannot do either one of those, then there should be immediate approval to go the nearest ED regardless of compalint.

 

[The White Coat Investor]

The real question is how do you stop people from using the ED as an outpatient clinic?

The onus should be on the insurance companies to direct people to TIMELY appropriate care. For questionably urgent cases they should be able to call a central scheduler for the insurance company who can get them 24-hour follow-up or refer them to urgent care. If the scheduler cannot do either one of those, then there should be immediate approval to go the nearest ED regardless of compalint.

That $200-500 copay seems to do the trick in my experience. The $3 Medicaid co-pay does not.

 

[turkeyjerky]

That $200-500 copay seems to do the trick in my experience. The $3 Medicaid co-pay does not.

Ha! Our states Medicaid has no copayment. I've often joked that if they even made it a dollar, we'd see a significant drop in volumes.

 

[alpinism]

Ha! Our states Medicaid has no copayment. I've often joked that if they even made it a dollar, we'd see a significant drop in volumes.

Considering the number of patients I see who demand a Motrin prescription and refuse to pay the $5 it costs to buy some at Walmart I would agree.

 

[Nikj]

Please excuse me if I'm missing something, but why aren't there stipulations/agreements with government/insurer and the patient. Something along the lines of the following:

The patient must see their primary care provider X times a year (to reduce the incidence of unexpected health problems) and then if an emergent issue comes up it probably does require a trip to the ED.

Simultaneously, the government/insurer negotiates with Primary care providers/urgent care centers to have 24/hour coverage for patient populations. This might be more tricky to accomplish but there are already people out there doing it. Or even EDs could all decide to have their own fast track/urgent care area and bill just for that as urgent care.

I mean something like that would drastically improve the health of people, reduce use of the ED for non emergent cases, and probably reduce the costs of healthcare(specifically on the government), while stilling lining the pockets of those companies.

 

[deleted109597]

We already have certain guidelines for well/chronic checkup visits. And when the patients don't meet those, guess who gets dinged. Yep, the docs. So how would this make a patient who already doesn't go to the doctor do so?

 

[Mad Jack]

Correct. Hospitals make too much on the facility fee side to not get that money. You're legally allowed to MSE a non-emergency and send them home. But not many places want to do that. And many urgent cares aren't open late at night. The conveyor belt only goes one way in the ED, and it isn't out.
Some open up urgent cares down the road, but depend on self triaging.

The ED I worked in back in the day actually had an urgent care built into the ED that they would bounce people over to if their conditions weren't truly emergent. It helped keep patient waits and people stuck in the halls to a minimum, improved efficiency, and was just a great system all around. It also saved patients a lot of cash.

This is exactly what I was warning people of last year when changes were made to reimbursement requirements for EDs. This is insurance companies testing the waters to see how far they can push- soon they're going to push harder for deeper cuts across the board is my bet.

 

[Nikj]

We already have certain guidelines for well/chronic checkup visits. And when the patients don't meet those, guess who gets dinged. Yep, the docs. So how would this make a patient who already doesn't go to the doctor do so?

Maybe I'm just young and naive, but wouldn't incurring extra fees, or even getting dropped from coverage, scare some amount of the population into looking after their health?

 

[deleted109597]

Maybe I'm just young and naive, but wouldn't incurring extra fees, or even getting dropped from coverage, scare some amount of the population into looking after their health?

Has requiring insurance under threat of IRS "tax" made everyone buy it?
Nope.

 

[GeneralVeers]

Has requiring insurance under threat of IRS "tax" made everyone buy it?
Nope.

I wouldn't buy Obamacare either if I earned less than 100K per year. The kind of coverage I had to buy is essentially worthless for anything except a catastrophic event, and I pay $6000 per year for the privilege.

I firmly believe we need user fees. If an MSE determines no emergency, then the hospital should be required to collect $5 cash from the medicaid patients.

 

[BAM!]

Maybe I'm just young and naive, but wouldn't incurring extra fees, or even getting dropped from coverage, scare some amount of the population into looking after their health?

everyone gets old and dies. everyone gets sick eventually. in many EDs the average age is 60 years old or more. These people often are compliant with their 10 different meds. But the body wears out, eventually they have strokes, heart attacks and the like even while maintaining a DASH diet.

"Looking after their health" --> sure it's good in certain populations, like diabetics. But people will get sick and go to the ED regardless. Or they'll look after their health so much that they come to the ED when their BP is 155 and they're worried about stroking out.

The point is that it's more unfair to ding docs for the behavior of patients that they cannot control.

 

[doctalaughs]

Also is there really any evidence that seeing your PCP regularly reduces ED visits? Didnt ED volume go up after we had more people insured?

I'm all for preventative medicine but I've yet to see any good studies that it does reduce cost (aside from vaccines), yet it's taken as gospel this is the cure-all for our broken healthcare system.


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[gutonc]

There's actually evidence against the routine annual physical in the otherwise healthy person.

But I'm not sure when the last time I saw one of those was.

 

[VA Hopeful Dr]

Also is there really any evidence that seeing your PCP regularly reduces ED visits? .


Sent from my iPhone using SDN mobile

It's not the regularity that prevents it, it's ease of access/cost.

 

[GeneralVeers]

All preventative care except for smoking cessation has a negative cost/benefit ratio. True we can prevent heart attacks by putting someone on statins, but the NNT means that the cost of putting all those people on statins for their whole lives far outweighs the cost of the one heart attack that has been prevented. The same holds true for diabetes, HTN, stroke, etc.

 

[Old_Mil]

if you can get yourself into the position where changes like this only affect how much you save or give to charity rather than your lifestyle, it's a lot less painful.

This is really good advice. For the majority of people it involves developing a side business that will eventually allow you to transition out of direct patient care.

 

[Nikj]

This is really good advice. For the majority of people it involves developing a side business that will eventually allow you to transition out of direct patient care.

Any examples or suggestions?

 

[Old_Mil]

Any examples or suggestions?

Well, that's a pretty open ended question. There are a lot of businesses you can get involved in. The what really depends on your personal interests.

The how should usually look something like this: since most physicians have little by way of a business background, after you identify the sector of the economy in which you want to be an enterpreneur, take an entry level part time position in an exsisting small business. Volunteer if you have to. That will give you an inside look at how that field operates and increase the chances that when you strike out on your own you will be a success.

Take real estate, just as an example. I'd call up an agent and introduce yourself, say that you had an interest in the field and volunteer your time as an unpaid assistant. Knowledge is its own form of compensation in some instances.

I had a background in something else to fall back on.

You spend half your life figuring out how to get into medicine...and the other half trying to get out.