In an emergency, where you end up getting care can be out of your hands, and that can mean being treated out of your insurance coverage network.
Blue Cross and Blue Shield of Texas (BCBSTX) agreed this month to pay a $10 million fine after the Texas Department of Insurance found billing mistakes in the insurer’s out-of-network emergency claims.
Richardson-based BCBS will begin sending notices to affected consumers by May 1.
One of the major concerns was resolving bill balances and delays in processing the out-of-network claims that did not meet prompt payment requirements. Also, false advertising and errors in marketing materials for Blue Advantage Plus plans caused alarm, the Dallas Morning News reported.
“BCBSTX issued explanations of benefits with incorrect notices to consumers, failed to timely process some out-of-network emergency claims, provided inaccurate summaries of policy information to consumers in its marketing materials,” The Texas Department of Insurance enforcement order states. “TDI conducted a market conduct examination for the period beginning January 1, 2016 and ending September 30, 2018, focusing on BCBSTX’s out-of-network emergency claim processing and Explanations of Benefits.”
If you are a Blue Cross customer, you may have received a notice stating your claim may be eligible for mediation.
The enforcement order includes details of this notice: “You may have received services from a facility, physician or another health care professional that is out-of-network. If you get a bill from the out of-network provider for $500 or more (not including your copayment, coinsurance, and deductible), you may have the right to dispute and ask for a mediation of the claim amount.”
“If you get a bill from the out-of-network provider for under $500, you can call customer care at the number on your ID card for a claim review.”
“Consumers who had higher out-of-pocket costs due to the errors will get refunds,” state insurance commissioner Kent Sullivan said.
Blue Cross Blue Shield of Texas acknowledged in a statement to Reform Austin that some of its members received inaccurate or inapplicable information.
“BCBSTX takes responsibility for any confusion caused to our members or delayed payments to providers. The issues have been resolved. We continue to focus on supporting the health care needs of Texas consumers providing access to quality, cost-effective healthcare for our more than 6 million members across the state.”
BCBS has been providing Texans health care coverage for over 90 years and is Texas’ largest health insurer, according to its website.