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A physicians group is raising concerns about a planned Blue Cross & Blue Shield of Mississippi policy change it says could lead to less care being covered when a patient comes into the emergency room.

The Mississippi chapter of the American College of Emergency Physicians said it's worried about a change where the insurer will review ER bills so "level of care" charges more closely align with the patient's diagnosis and not their symptoms.

The group is concerned the policy — set to take effect next year — means tests and treatments related to the "ruling out" process would no longer be covered. But Mississippi's insurance commissioner said the move is meant only to stop hospitals from over-billing related to the severity and complexity of an ER visit. 

"A patient experiencing chest pain who fears that he or she may be experiencing a heart attack should be covered for his or her visit, even if the condition turns out to be a non-urgent medical condition, such as a hiatal hernia," the ER doctors wrote in a recently distributed letter, which has not been sent to the insurance company. 

More: Medical billing 'in la-la land': UMMC changes policy amid probe into expensive ER visit

Patients expect ER doctors to "use their medical expertise and the tools at their disposal to 'rule out' the life-threatening condition" such as a heart attack. But the new billing policy "completely ignores" these precautionary steps, it said.

The doctors added the new policy does not follow the "industry standard" for medical billing. A federal policy called the Prudent Layperson Standard guarantees insurers cover visits based on the patient's symptoms, not the final diagnosis, they said.  

In a statement, Blue Cross & Blue Shield of Mississippi said it is "committed to managing healthcare costs while also ensuring quality care is available to our members when they need it." But the company said it would not comment further until it had discussed the issue with its network physicians, and officials did not respond to a request to further clarify the new policy. 

The insurer sent a notice to providers earlier this month saying it would "ensure visit levels are aligned with the severity of the diagnosis" submitted by the hospital. It said customers had brought concerns over the past year related to levels of care hospitals bill for ER visits. 

Hospitals charge fees for ER use that reflect the severity and complexity of the visit, ranging from a level 1, or less severe, to a level 5, which could be life threatening and involve significant tests and treatment. These ER fees at University of Mississippi Medical Center, for example, could range anywhere from $468 to nearly $5,000 for a single visit. 


A Clarion Ledger analysis earlier this year showed UMMC almost never charged for the lowest ER visit levels, and a trip to the ER at UMMC's Batson Children's Hospital always ran at least $2,000, no matter how minor the reason. (Batson's later said it would change its method for determining severity levels of visits.)

A report last year by Vox and the Health Care Cost Institute also found these facility fees have risen dramatically in recent years nationwide, with a higher percentage of visits being charged at levels 4 and 5. 

State Insurance Commissioner Mike Chaney said last week that the move by Blue Cross & Blue Shield appeared to be intended to crack down on this "improper use of upcoding" by hospital ERs — a practice of billing a fee for a service or level of care that is higher than what the patient actually received or needed. He said the policy change does not require state approval.

"Blue Cross is trying to protect exorbitant payments that shouldn't be paid out," Chaney said. He added the new policy doesn't prohibit testing by a provider, nor does it say Blue Cross would no longer pay for certain tests. 

But American College of Emergency Physicians members in Mississippi say they are worried patients could be on the hook if Blue Cross chooses not to cover higher facility fees due to a complex ER visit — such as a patient reporting severe chest pain — that actually turns into a less serious diagnosis, such as acid reflux. 

"Patients who fear their visits will not be properly covered may delay seeking care and thus put at risk their health — and worse: their lives," the letter said.

Gregory Patino, an emergency room physician and past president of the group, said it also could unfairly penalize providers who carry out significant testing and evaluation on a patient, but are ultimately able to send them home quickly because their condition is not as serious as initially thought.

"Why is there less worth in being able to give someone good news, and preventing them from having to come into the hospital (for a longer stay)?" he said. 





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