Becker's Hospital Review

28 CFO / FINANCE BCBS of Texas: Some members may have to pay entire bill for nonemergent use of out-of-network ED By Morgan Haefner B lue Cross Blue Shield of Texas may be- gin requiring some members who access nonemergent care at out-of-network emergency departments to pay their bills in full. Here are five things to know about BCBSTX's emergency benefit management process. 1. e process will affect BCBSTX's fully in- sured group and retail health maintenance organization members with out-of-network ED claims filed aer June 4. ose members may be on the hook for the entire out-of-net- work ED bill if they use the facility for care the insurer deems not serious or life-threatening. 2. BCBSTX said some of its members are "using the emergency room for things like head lice or sprained ankles, for convenience rather than for serious or life-threatening issues. Doing so not only drives up costs for our members, but uses limited ER resources," according to a document obtained and shared on Twitter by Ed Gaines, chief compliance officer at the emergency medi- cine division of Zotec Partners. 3. In the document, BCBSTX said aer June 4, it will begin reviewing out-of-network ED claims by requesting medical records and an itemized bill for the claim. e payer will consider mem- bers' medical record and presenting symptoms during the review to ensure the services ren- dered were accurately billed to eliminate inap- propriate charges. While the review takes place, members' claims will be pending, and will not be denied without physician review. 4. BCBSTX spokesperson Chris Callahan told Becker's in an emailed statement, "We also want to make sure that what the ERs are billing us for is in line with the testing, med- ications and level of service our members actually received. For example, during some recent reviews, we discovered that a facility billed our member for an MRI that the medi- cal record didn't support." He added, "Our focus has been how to put the member first in reviewing these out-of-net- work ER claims so that we can be good stew- ards of their money and manage the cost of premiums." 5. BCBSTX's emergency benefit management process is the latest in insurers' attempts to push members with nonemergent care needs toward cheaper urgent and primary care ser- vices. However, similar policies rolled out by Anthem have drawn considerable backlash from providers and lawmakers. n BCBS parent company posts $1.3B profit in 2017: 4 things to know By Morgan Haefner C hicago-based Health Care Service Corp., the umbrella company of five Blue Cross and Blue Shield plans, re- ported a $1.26 billion surplus in 2017, turning around three years of losses and modest growth, Crain's Chicago Busi- ness reported. Here are four things to know about the insurance company's results for 2017. 1. HCSC's more than 10-fold increase in net income, compared to 2016, puts the payer back in line with its financials before it shouldered losses on its ACA exchange plans. 2. HCSC lost $281.9 million and $65.9 million in 2014 and 2015, respectively. In 2016, HCSC earned $106.3 million in profit. 3. The parent company of Blues plans in Illinois, Montana, New Mexico, Oklahoma and Texas collected premiums of $32.5 bil- lion in 2017, up 7.4 percent year over year, Crain's reported. This is after its premium revenue was down 3 percent in 2016. 4. In March 2018, HCSC announced it will invest $1.5 billion in initiatives to cut its members' healthcare costs due to the turn- around. The three-year effort, dubbed Affordability Cures, tar- gets five areas: collaborative care, household financial security, productive employees, healthy communities, and digitally-driv- en and data-rich actions. n Rush axes merger with 272- bed Chicago hospital By Alyssa Rege C hicago-based Rush Health and Evergreen Park, Ill.-based Little Company of Mary Hospital and Health Care Centers terminated their plans to integrate, according to the Chicago Tribune. The organizations "mutually agreed" to back out of the nonbinding agreement, which they entered into last October, according to an April 11 internal memo to employees by Rush University Medical Center CEO Larry Goodman, MD, and President Michael Dan- dorph, obtained by the Chicago Tribune. "Though a difficult decision for both parties, we are confident that it is the right one," the memo stated. "Both organizations maintain their mutual respect for each other and have decided to pursue efforts inde- pendently to advance care and service to Chicago area patients and communities." Representatives of both institutions declined to answer the Chicago Tribune's questions as to why discussions fell through, and did not comment as to whether the institutions were looking to partner or merge with oth- er hospitals or health systems, according to the report. Little Company of Mary began its partnership search in 2016. n

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