Update to Out-of-Network Emergency Room and Hospital-Based Physician Policy
In response to the significant changes BlueCross will face in 2014 with the implementation of the Affordable Care Act, we recently evaluated areas where we could help control costs with limited member impact. We found opportunities already existed in the form of more closely following some of current policies. One of those policies is how we manage claims payments for out-of-network (OON) providers in an ER setting.
We have historically paid billed charges on claims for visits to out-of-network ERs and care from out-of-network hospital-based physicians. However, this practice was actually outside of our written policy, which is to pay those claims based on the maximum allowable charge (MAC). We began to more closely follow this existing policy May 1.
Our top priorities are to take care of our members and provide value to your clients. Following this policy more closely will help us maintain competitive and stable provider networks, which will ultimately benefit you clients.
BlueCross member materials already address the importance of using in-network facilities, and we have made additional efforts to educate members about the value of choosing in-network facilities and physicians. Group administrators can help educate their employees about this policy and the importance of confirming all providers are in-network. Please click here to download a flier that your groups can give to their employees to help them better understand the importance of using in-network emergency rooms and hospital-based physicians.
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