To Encourage Telehealth, Insurer to Penalize Patients who Rely on Emergency Room Care

The biggest health insurer in Georgia’s health insurance exchange will penalize beneficiaries who go to the emergency room (ER) instead of using the carrier’s telehealth option for conditions deemed non-emergent after the fact.

Blue Cross Blue Shield of Georgia, which says it’s only trying to contain unnecessary spending and to temper rising healthcare costs, informed its subscribers that if BCBS later deemed an ER visit as not a true emergency, the patient would be left to pay the full cost of the visit.

In a letter to patients, as mHealth Intelligence reported, BCBS defined an emergency or “emergency medical condition” as:

“a medical or behavioral health condition of recent onset and sufficient severity, including but not limited to, severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness or injury is of such a nature that not getting immediate medical care could result in:

  • placing the patient’s health or the health of another person in serious danger or, for a pregnant woman, placing the woman’s health or the health of her unborn child in serious danger;
  • serious impairment to bodily functions; or
  • serious dysfunction of any bodily organ or part.

Such conditions include but are not limited to, chest pain, stroke, poisoning, serious breathing problems, unconsciousness, severe burns or cuts, uncontrolled bleeding, or seizures and such other acute conditions as may be determined to be emergencies by us.”

Instead of going to the ER, BCBS advises them to use an urgent care clinic—if there is one within 15 miles of their home—or use BCBSGa’s LiveHealth Online telehealth service. This rule does not apply to children under the age of 13.

“This is not to discourage somebody with an emergency condition who needs to go to an ER to go there,” BCBS spokesperson Debbie Diamond told the Atlanta Journal Constitution. “Health care is becoming more and more expensive. It’s a way to make sure that people are getting quality and affordable care.”

But critics of the policy note that laypersons aren’t trained to recognize emergencies on the spot, and that this presents another barrier to care. Others have pointed out that there are still plenty of people without smartphones or Internet access, which is required for telehealth consultations.

Dr. Matthew Keadey, a physician who leads a group representing ER physicians, is worried that lives are at stake with this policy.

“Patients will die because they’re going to think twice about going to the emergency department. One person goes and it turns out they just had reflux or a stomach problem; the next person has the symptoms and it’s a heart attack, Keadey told the newspaper. “To me it’s one more way that we’re seeing the insurance company trying to take their financial responsibility and place it back on the patient.”

Mary Butler is the associate editor at The Journal of AHIMA.

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