News Round-Up: Dangerous Insurance Practices of 2018

This year, big insurance has continued to use questionable ethics as they’ve rolled out new policies and continue to cut in-network deals. While insurance companies and their CEOs become wealthier, patients are directly discouraged from seeking care as they experience emergency medical symptoms. When they seek care, insured patients often suffer from crippling medical debt as a result of their treatment. To give you an idea of the effects of these practices this year, here are a handful of news articles: 

Prudent Layperson Under Attack

1.       “Blue Cross Blue Shield of Texas Delays Controversial Change After Backlash”

This mid-2018 article showcases emergency physicians’ drive to protect patients in the wake of dangerous insurance practices.

2.       “BCBS of Texas To Stop Reimbursing Nonemergent ER Visits”

Despite push back, BCBS TX rolled out a policy that goes against the Prudent Layperson standard, following the establishment of similar policies in other states throughout 2017.

3.       “Physicians Say BCBS of Georgia Has Denied Hundreds of Patients’ ER Claims: ‘This Puts Patients in A Terrible Position’”

Risk to patient health is discussed in this article about big insurance’s denial of its Georgia policyholder’s ER claims.

Surprise Bills

1.       “Taken for A Ride: M.D. Injured In ATV Crash Gets $56,603 Bill For Air Ambulance Trip”

Big insurance business deals increase insurer profits but saddle ER patients with extreme amounts of debt, as discussed in this article about one patient’s balance bill for a life-saving air ambulance trip.

2.       “A Jolt to The Jugular! You’re Insured but Still Owe $109K For Your Heart Attack”

As part of Kaiser Family Foundation’s “Bill of the Month” series, this article takes an in-depth look at the practice of balance billing by highlighting one insured patient’s $109k bill after life-saving treatment for a heart attack.

The Prudent Layperson Standard: Patient Rights Under Attack as Insurance Companies Put Profits Over Patients

Health insurance was designed to keep patients from being hit with medical debt, but the current state of insurance does not have patients in mind. In fact, many of the biggest insurers are actively going against a patient protection known as the prudent layperson standard. Recently, Blue Cross Blue Shield of Texas (BCBS TX) decided to move forward with a controversial new practice of charging patients for their visits if the final diagnosis isn’t reflective of an emergency situation. This article will provide background on the prudent layperson standard, will explore the current state of this patient protection.

What is the Prudent Layperson Standard?

Due in large part to the advocacy of emergency physicians, congress enacted the prudent layperson standard in 1997. This standard requires that a health plan must cover any emergency visit that results from presentation of symptoms that a “prudent layperson”—someone with average medical knowledge—could reasonably expect to result in a serious adverse health event. Essentially, this means that health insurance carriers must cover the cost of an insured patient’s visit based on the patient’s symptoms, not their final diagnosis. For example, chest pain brings you to the emergency room but a physician finds that your symptoms are related to indigestion, your insurance carrier cannot legally deny coverage for your ER visit because you—a prudent layperson—experienced symptoms that gave you reason to believe your life might be in danger.

Why does this standard exist?  

The fact is, there are thousands of conditions with overlapping symptoms.  A person with average medical knowledge cannot be expected to know whether their severe abdominal pain is related to a ruptured appendix (life-threatening) or an ovarian cyst (non-life-threatening)—especially when they are experiencing extreme pain. With so much overlap in symptoms, even emergency physicians can’t be expected to diagnose a patient without seeing them. This is why ER doctors advocated for this standard—they didn’t want the threat of medical debt to influence a patient’s decision to seek potentially life-saving medical care.

Originally, this standard only applied to Medicare and Medicaid managed care plans. In 1999, it was extended to all federal employee medical plans, and in 2010, the Affordable Care Act (ACA) applied it to individual, small-group, and employer coverage plans. The ACA even established that the prudent layperson standard must appear in any revisions or replacement legislation of the act.

Current state of prudent layperson

As we mentioned above, the prudent layperson standard is—and must continue to be—law. Even so, recent and continuing changes to the ACA are empowering insurance carriers to push the boundaries of this legal requirement. For example, in 2017, Anthem Blue Cross Blue Shield (BCBS) sent a letter to policyholders in Georgia, Kentucky and Missouri stating that they would no longer cover “inappropriate” emergency room visits. The letter included a list of 200 medical diagnoses that would not be covered by the insurance carrier.

In early August of 2018, despite major pushback from emergency physicians, Blue Cross Blue Shield of Texas (BCBS TX) decided to move forward with new billing practices that involve basing coverage decisions on claims reviews, ultimately deciding whether a visit will be covered based on the patient’s final diagnosis.

Why Are Insurance Companies Doing This?

Insurers claim that their goal is to help keep the emergency room, its physicians and resources available for people with “true emergencies.” With 24/7 access to the best medical technologies, life-saving drugs and top physicians, the cost of emergency care is necessarily higher than it would be if you were to be seen by a physician at an urgent care facility or your primary care provider.

While insurance companies claim their new policies will keep costs down and lower premiums for all policy holders, it shouldn’t be overlooked that top insurance companies saw profit margins in Q1 for 2018 that were the highest in a decade, and all six of the largest insurance companies paid their CEOs over $17 million in 2017, while patient access to care has decreased significantly.


Due to recent policies established by major insurance companies, patient health is in jeopardy while insurance companies’ profits increase. Emergency physicians offered major push back to the new BCBS TX policy, with concerns over the ethical nature of this practice—how will this practice impact a person’s willingness to seek medical attention in the event of an emergency? Dr. Renee Hsia, MD, MSc, and professor of emergency medicine at the University of California, San Francisco, says, “From a policy perspective, you can understand the insurance companies' desire to contain costs in ways that don't waste unnecessary societal resources…but even if the intentions are well-meaning, the consequences of a policy like this are potentially dangerous.”

Freestanding Emergency Centers, Part II: Why is Health Insurance Keeping Patients Away?

As we discussed in our previous blog, freestanding emergency centers (FECs) are a convenient option for patients in need of quality emergency care. Unfortunately, insurance companies tend to be unsupportive of these facilities, and they work to actively deter patients from utilizing them when the need arises. In this article, we will discuss the misguided reasons health insurance companies are working so hard to keep patients away from FECs, learn how these actions harm patients, and present a possible solution to the problems created by insurance companies’ lack of support for these independent emergency care centers.

Freestanding Emergency Centers, Part I: Know Your Options

In recent years, the number of freestanding emergency centers (FECs) has grown as patients in the U.S. healthcare system have made a simple request: they want immediate access to emergency healthcare when the need arises. With shorter wait times than hospital emergency rooms (ERs), 24/7 access to care, and ER-trained physicians on staff at all times, FECs are specifically designed to meet this need. Despite high rates of patient satisfaction1, insurance companies are funding campaigns against FECs and penalizing patients who receive treatment from these facilities. They are even going so far as to contact patients directly to discourage them from seeking care from FECs. Why are they doing this, and is this negative image of FECs fair? To help you understand your options, this article will discuss the differences between emergency healthcare models and dispel some of the myths surrounding FECs.

How to Create New Revenue for Your Medical Practice in 2018

The business of medicine in 2018 is more difficult and complex than ever before. Political trends and policy changes have left the state of health coverage in flux, directly affecting healthcare on all levels and creating wide-reaching uncertainty across all patient populations. In today’s healthcare world, managed care groups can change the rules of engagement, and health insurance carriers annually lock medical professionals into opaque agreements that make doctors reconsider their independence. With continued policy changes likely, you can expect a major reshaping of the ways both consumers and providers will be able to obtain and utilize insurance. This blog post explores a few strategies your practice can implement to ensure maintenance of clinic revenue and quality coverage for your patients.