The already baffling emergency room billing landscape is about to become even more perplexing for some consumers covered by Blue Cross and Blue Shield of Texas, the largest health insurer in the state.

Starting in June, when some policyholders go to the emergency room, if their ailment is later determined to be not be serious enough, they could be on the hook for 100 percent of the medical costs.

In a memo shared with brokers and consultants on April 18, Blue Cross said the new policy — which takes effect June 4 — applies to fully insured group and retail HMO members.

An HMO is a type of health insurance plan that limits coverage to in-network providers, except in emergency situations. About 500,000 of the more than 5 million Texans insured with Blue Cross statewide have that type of plan.

But if they get treated at an out-of-network emergency department “as a convenience, rather than for serious or life threatening issues,” they’ll be required to pay the entire emergency bill. The new policy would not apply to infants 12 months and younger.

Blue Cross joins a handful of other insurers to adopt policies aimed at preventing consumers from going to high-cost emergency facilities for conditions which can be treated at doctor’s offices or urgent care clinics for less.

“Some of our members are using the emergency room for things like head lice or sprained ankles” the memo said. It did not indicate how frequently that occurs. "We want to make health care affordable for our members, and to do so, we have to be good stewards of their money.”

North Texas market president Dr. Paul Hain, said Blue Cross has logged year-over-year increases in out-of-network emergency claims since 2014 as people purchased plans on the the marketplaces. But the problem, he said, has been exacerbated by Texas’ proliferating freestanding emergency care market.

Read the full memo here:

A concerning new trend?

Consumer advocates and emergency room clinicians see these types of policies as an emerging trend that may be good for the insurance business but bad for patients.

"They talk about being fiscally responsible. But they're placing patients at risk," said Dr. Vidor Friedman, vice president of the American College of Emergency Physicians. The national medical specialty group based in Irving lobbied heavily against similar policies in other markets.

Last year, Indianapolis-based health insurance giant Anthem Blue Cross Blue Shield introduced a controversial policy change that sparked outrage, partly because it included a list of medical conditions that would not be covered.

Minnesota-based UnitedHealth Group followed suit in March with a system to review and adjust claims for the most severe and costly emergency patients.

Some, worry such efforts violate language written into the Affordable Care Act that's meant to protect patients from "retroactive second-guessing" and put a large burden on the consumer.

“The patient is being asked to make a medical judgment, a diagnosis, solely based on their symptoms, without training or the information need to make those decisions,” Friedman argued.

“Meanwhile the insurance companies are reviewing it retrospectively, after having all the data.”

And making the wrong decision can result in high financial stakes for the consumer, in a landscape where it’s not easy to get it right, said Stacey Pogue, a senior policy analyst with the Center for Public Policy Priorities in Austin.

She noted several challenges already facing Texas consumers: surprise bills, confusion over the difference between a freestanding emergency room and urgent care, and disputes between providers and insurers that can disrupt coverage a consumer has already purchased.

“This is a symptom of longstanding problems, big systemic failures,” Pogue said. “And then we place tremendous burden on consumers’ shoulders if they mess up in the highly complex, broken system.”

The Texas Department of Insurance, which mediates certain big bills for consumers as the providers and insurers dispute charges, said it would need to investigate whether the new policy required state approval.

It could not immediately answer whether the policy violates state laws regarding how HMO plans must operate, or "prudent layperson" laws, which protect patients in need of emergency care.

"We'll be watching this closely to make sure consumers have access to care and understand their rights," the agency said in an emailed statement. The department's medical billing mediation program does not yet extend to HMO plans.

How will it work?

Blue Cross of Texas said Wednesday that the policy is compliant with the law because it will only apply to HMOs, which do not have an out-of-network benefit, and to “very obvious” situations that “most people” would understand not to be emergencies, like head lice and ankle sprains.

That’s an aspect being questioned by consumer advocates and others, who say it’s never that simple. But it’s not that people are being told not to go to the emergency room, said Hain.

If you’re not well and it’s 2 in the morning, and you’re debating whether to go to an emergency room, “just don’t go out of network if you’re on an HMO” he said.

The new policy is in response to higher than usual out-of-network emergency room usage, of which “freestanding emergency rooms are a huge problem,” he added.

Not every Blue Cross of Texas member with an HMO will receive notice of the new policy by mail. Letters being mailed on May 1 will go to individuals who have visited an out-of-network emergency room over the past calendar year.

“Out-of-network ER utilization is reflected in people’s premiums and costs them a lot of money,” Hain said. “While we want to be sure people get care whenever they need to in an emergency situation, it is reasonable to look at presenting symptoms if you’ve gone to an out-of-network ER and had symptoms that no prudent layperson would think of as an emergency.”

Before a claim is accepted or denied, a licensed physician will review the patient's itemized bill as well as the medical record, which includes the symptoms that sent that patient to the emergency room. Patients will be able to appeal a denied claim through the insurer’s already existing appeal process.

For now, the new policy will apply only to Blue Cross of Texas, and not to the nearly 15 million policyholders in the four other states that operate under the Health Care Service Corp. umbrella.