New BCBSTX ER Patient Penalty Policy Goes Into Effect Today

Statement from Rhonda Sandel, RN, CEO of Texas Emergency Care Centers, and Board Member of the Texas Association of Freestanding Emergency Centers (TAFEC):

Houston, Texas (August 6, 2018)—On April 18, 2018, Blue Cross Blue Shield of Texas (BCBSTX) announced a new “HMO Emergency Benefit Management Process.” Citing that their members were using the ER “for things like head lice or sprained ankles, for convenience rather than for serious or life-threatening issues,” the company announced the creation of a new policy that greatly restricts Texas patient access to the Emergency Room (ER).

Dr. Matthew Cross

Over a year ago, the way I practiced medicine disgusted me. I worked in a busy emergency room in a large metropolitan hospital in San Antonio that had long waits, no available hospital beds, overworked staff, and a continuous flow of ambulances waiting outside.

Like a handful of others, many years ago we made the decision to invest the necessary time and resources to properly serve the FEC Texas market. Even with our 30 years of revenue cycle management (RCM) experience partnering with Texas ER Physicians, properly assisting the FEC client is apples to oranges. Our introduction to the FEC industry came about over four years ago, from a referral from a long‐time ER Physician client who was working shifts at a local FEC location. Like so many others, the FEC owner had entrusted a RCM company proficient in billing the professional component of the ED visit, but after a year left the FEC hanging on financially by a thread.

The timing was ideal for us as we had just recruited a new Coding Manager with a wealth of experience in facility / ancillary services coding. Concurrently our programmer and long‐term clearing house partner completed the design and testing of the UB‐04 format vs. HCFA‐1500 format. Lastly, we created a separate “Customer Care” team to make outgoing and receive incoming calls from FEC patients. Speaking with the FEC patients allows us to educate them on the health claim adjudication process along with assistance understanding the health plan benefits – this has been a critical step for us and our clients.

Coalition Outlines Unethical Health Insurance Practices that Place Texas in 'State of Emergency'

In recent testimony, the Texas Association of Health Plans (TAHP) referenced a large medical bill, $53,000 for an ingrown toenail, as an example of price gouging by independent freestanding ERs. However, analyses by multiple third-party billing companies show that the patient was treated at a hospital outpatient department (HOPD), and that the reason for the large bill was due to a billing error by the facility’s billing company.

A close look at the bill issued to the ingrown toenail patient makes it clear the facility that issued this bill is not a freestanding ER at all, but is an ER affiliated with a larger hospital. The bill includes the CPTO 11755 and 20972 medical codes, however independent freestanding ERs do not bill for these services. Also, the use of an S medical code indicates that the facility can accept Medicare, which independent freestanding ERs are not currently able to accept.

In my 10 years of experience working at a healthcare billing company in Houston, I’ve seen it all. Every tactic, strategy, and policy by insurance providers to deny a patient’s claim or reduce payment to healthcare providers across the state. And as the healthcare landscape changes, insurers appear to operate with less and less regulations and oversight. It’s a rigged system, and it’s Texas patients who pay the price.

Unfortunately, as time passes, it is becoming more difficult to interact with insurance companies. These days my company must fight tooth-and-nail over every single claim to ensure our customers are getting the coverage to which they are entitled – coverage outlined in their individual health plan. If we don’t, insurers will cut every corner and not hold up their end of the bargain.

Dr. Jorge Trujillo M.D.
Medical Director Frontline ER Richmond Location

After completing my residency in emergency medicine in 1994 at Texas Tech Health Science Center in El Paso Texas, I returned to Houston and began my hospital based emergency medicine career. At that time Texas Tech was the only school in Texas offering training in emergency room medicine. It is amazing how much patient care and the landscape has changed since those early days of emergency room medicine.

Adeptus Bankruptcy Sparks Industry Response to Increase Insurance Oversight

Adeptus Health announced today that it and certain subsidiaries have filed voluntary petitions for relief under Chapter 11 of the United States Bankruptcy Code. This announcement comes after Adeptus was named in a class action lawsuit regarding the company’s billing practices, which were alleged to be excessive and deceptive. While Adeptus and First Choice are not active members of the Texas Association of Freestanding Emergency Centers (TAFEC), this event highlights several ongoing concerns for freestanding emergency center operators.

It is now the responsibility of our legal system to determine whether these accusations against Adeptus have merit. TAFEC expects its members to be transparent and honest with patients throughout their freestanding emergency center experience (including regarding the facility’s charges and billing), and to educate the communities in which our members operate about their capabilities and levels of service.

Part of TAFEC's mission is to provide high-quality, accessible, emergency medical care options. At G&A Partners, we specialize in providing business owners high-quality and high-touch HR and payroll administrative solutions via access to a team of HR, benefits and payroll experts, all for about the same cost of hiring one full-time employee.

At G&A Partners, we focus on a few core areas:

One of the most critical issues impacting the healthcare of Texans is timely access to healthcare. In fact, the American College of Emergency Physicians gave Texas an F in access to emergency care in their 2014 Report Card. Unethical business practices and nefarious actions by health insurance companies are keeping Texans from being able to choose expeditious and cost effective emergency services.

The State of Texas is one of Austin’s largest employers, with about 70,000 workers locally. If an addition to the senate budget bill passes, those employees will have less options to choose from in the event of a medical emergency.

That is because of a “rider” the Senate Finance Committee voted to add to Senate Bill 1, the Senate’s budget bill. A rider is a provision added to a bill under consideration by the legislature having little connection with the subject matter of the bill.

The issue of surprise medical bills is getting plenty of attention in Texas these days, and the freestanding emergency center industry has become a popular target. An innovative model that provides reduced wait times compared to traditional hospital ERs, freestanding emergency centers have increased access to emergency care in a state that sorely needs it. Today, these facilities number more than 325 throughout Texas.

Despite the access they provide, misconceptions about freestanding emergency centers persist, and false accusations of lack of transparency and misleading patients are common. It is telling that this is the narrative coming from health insurance companies, as their responsibility to cover the cost of emergency care for those they insure is at the heart of this issue. That responsibility is outlined in the insurance code statute that includes emergency care as an essential health benefit.

A recent study published in the Annals of Emergency Medicine, which was conducted by Rice University and funded by Blue Cross Blue Shield, finds that freestanding emergency centers (FECs) are cheaper alternatives for emergency medical care than hospital-based emergency centers.

Outside of that critical finding, the study diverges on a less academic path to intentionally criticize the FEC model, misattributing or mischaracterizing data along the way.

AUSTIN, Texas, April 3, 2017 /PRNewswire/ -- The Texas Association of Freestanding Emergency Centers (TAFEC) supports legislation introduced in the Texas Legislature aimed at increasing oversight of health insurance companies and protecting consumers from surprise medical costs.

The bills, many of which have bi-partisan support, seek to increase transparency in the health insurance industry, ensure the Texas Department of Insurance has the resources to enforce current statutes regulating health insurance companies, and allow healthcare providers to advocate on behalf of their patients for fair payment.

AUSTIN, Texas, Feb. 28, 2017 /PRNewswire/ -- The Texas Association of Freestanding Emergency Centers (TAFEC) has called on the Texas Legislature and the Texas Department of Insurance (TDI) to increase the collection of health insurance payment data to establish clear standards for the usual and customary reimbursements that insurance companies are required by law to pay healthcare providers on behalf of policyholders.

Currently, Texas law requires insurance providers to pay for non-contracted emergency health care at the usual and customary rate for emergency care. However, there are no uniform guidelines for insurance companies to follow, which allows insurers to determine their own arbitrary rates. While some insurers provide adequate payment for services, others are paying at a percentage below what is legally required, which means patients do not receive the full benefit of the coverage they purchased.

My name is John Hennessy, I am a registered nurse and I am also the Charge Nurse at Golden Triangle Emergency Center Orange. I have worked with GTEC since we opened on April 1^st 2015. A typical day at GTEC Orange involves assessing and treating patients. Being the charge nurse, I also assume managerial responsibilities. I am an advocate for my fellow nurses and patients and make sure everything runs smoothly.

AUSTIN, Texas, Feb. 13, 2017 /PRNewswire/ -- The Texas Association of Freestanding Emergency Centers (TAFEC) is releasing a recent analysis of complaints made to the Texas Department of Insurance (TDI) on behalf of out-of-network health care providers that demonstrates how chronic and abusive underpayment by insurance companies is the primary cause of surprise medical bills for patients.

In the fall of 2016, a third-party billing company acting on behalf of freestanding emergency centers filed complaints alleging that insurers ignored their legal obligations to pay all or part of claims for reimbursement submitted on behalf of policyholders for services rendered at the centers, and requested TDI's intervention. The billing company filed so many complaints that the agency's resources were overwhelmed and the company began holding complaints until those that had been filed were resolved.

Hello, my name is Annie Kovatch, I am the Charge nurse at Golden Triangle Emergency Center in Port Arthur.

By Dr. Janna Welch
Dr. Janna Welch is an ER physician at Five Star ER, the Assistant Program Director – University of Texas at Austin Dell Medical School Emergency Residency Program.

Following the election, we have been made painfully aware of the problems facing our country. The many challenges of our changing healthcare system are among the biggest, and that is no less true for Texas.