Caught Blue-Handed

Kevin Herrington

Board Member of My Emergency My Choice and President at Altus Lumberton Hospital

Blue Cross Blue Shield of Texas Fined Millions For Denying & Deceiving Patients about Legitimate Emergency Care.

We’ve all been there. You pick-up your mail and see that there’s a statement from your health insurance company. Instantly, you feel a sense of dread. You had an emergency recently and you made the correct choice to find the nearest ER. You find out later that the facility or a physician wasn’t “in-network” with your plan. You’ve heard horror stories of the charges others have had to pay when claims have been denied or partially covered. 

You open your “Explanation of Benefits” and it looks like a bill rather than a benefits statement.  The insurance company says your “patient responsibility” is going to cost you thousands and you should have gone to an in-network ER. Naturally, you are confused, despondent and angry.

Turns out these kinds of statements are intentionally designed to make you feel exactly like that. Even if your emergency provider hasn’t billed you, companies like BCBS of Texas want you to think you are responsible for how you chose to handle your emergency. This is a DECEPTION, and recently they were caught “blue-handed.”

The truth is, there are laws in place to protect patients. First, emergency coverage regardless of a facility’s network status is REQUIRED to be covered under the Federal Affordable Care Act. Also, Texas state law has banned balance billing for state-regulated health plans. Meaning as a patient with one of those plans, you are not obligated to pay more for out-of-network emergency care than in-network emergency care.

Last year, Blue Cross Blue Shield of Texas was fined $10 million after a state investigation found multiple billing mistakes and a pattern of misinforming their members. The Dallas Morning News reported the following summary of results found from the State’s review of BCBSTX bad practices:

  • Incorrect information about how to resolve bill balances on explanation of benefits forms sent to HMO members receiving out-of network emergency care.
  • Delays in processing out-of-network claims that went through a review process Blue Cross began using in August 2018. Those payments failed to meet the state’s prompt payment requirements.
  • Errors in marketing materials about Blue Advantage Plus plans offered in 2018 and 2019. More than 70,000 people signed up for the 2018 plan on the federal health care exchange.

While they claimed they wouldn’t be looking at the final diagnosis to decide if a claim would be approved or denied, many people found the exact opposite  For example, if a patient prudently sought care when they had severe chest pains, but after triage and testing they were diagnosed with esophageal reflux; that patient would often be told they shouldn’t have gone to the ER and their claims were denied.


According to federal law, the 1986 “Emergency Medical Treatment and Labor Act” (EMTALA) requires ANYONE coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay. This means that any licensed emergency room is required by law to never refuse care to a prudent layperson who seeks treatment for what they feel is an emergency.

What if those chest pains were the beginnings of a heart attack? Deceptive insurance denial and delay practices like these trick patients into believing that they are responsible for what their final diagnosis will be if they seek emergency care. This results in patients delaying time-critical care instead of trusting themselves. It has disastrous consequences for patients and providers alike, but insurance companies always come out on top with their ever increasing record profits.

There seems to be no limit to the creative ways insurance companies come up with in order to justify not paying for your claims. That is why we are fighting so hard to defend EMTALA and the Prudent Layperson Standard, so that you and your family can expect to have your emergency care covered.

Remember, it’s your emergency and it’s your choice to put your health ahead of insurance company profits.