BlueCross BlueShield’s controversial new policy denies coverage for ER visits, unless it is a ‘true’ emergency

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HOUSTON — You may not be a doctor, but you need to think like one, according to BlueCross BlueShield.

"They're putting it on the patient to determine if they really have an emergency or not," Dr. Gary Sheppard said.

The insurance giant's controversial new program is its way of treating insurance fraud. It will affect about 500,000 Texans with HMO plans. But doctors aren't pleased with the protocol.

"They're not covering non-emergent visits in an out-of-network emergency room. That's all their policy says. Out-of-network means it's not covered by your insurance. In network means it is covered by your insurance."

Simply put, BlueCross BlueShield won't pay out-of-network ER costs if it isn't a true emergency and that will be decided after the fact by the insurance company.  The Texas Medical Association would rather call a code blue on the program.

"So if a person is somewhere and they have an emergency they may not remember or they may not have a chance to look up who's in network, who's not. And they go to the closest emergency room."

Chances are you know which hospital ER is part of your network. But things get tricky when you factor in all those free-standing med centers. "They are still emergency rooms. They can still take care of you. But they're not in your network."

Let's say you've got severe indigestion in the middle of the night. "Actually, that can be a sign for a heart attack."

What do you do?  Life-threatening or not, how do you know? "Will this stop patients from seeking emergency care when they need it?"

Bottom line: know your insurance policy and the docs in your network.

And don't self- diagnose! Those are doctor's orders.

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