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TDI: BCBSTX To Repay Consumers For Out-Of-Network ER Claims

Texas Department of Insurance on March 6, 2020, reported that Blue Cross Blue Shield of Texas ha been ordered to pay an administrative penalty of $10 million and agreed to repay consumers for alleged delays in handling out-of-network emergency claims and incorrect information in consumer notices and marketing materials.

“Consumers who had higher out-of-pocket costs due to the errors will get refunds,” said Texas Insurance Commissioner Kent Sullivan. “Ensuring the fair treatment of consumers and clear, timely consumer information are priorities for TDI.”

TDI reported a review of BCBSTX communications and how it processed out-of-network emergency claims revealed:

  • Incorrect information about how to resolve balance bills on explanations of benefits for many HMO members who received out-of-network emergency care.
  • Delays in processing out-of-network claims that went through an Emergency Benefit Management review process the company began using in August 2018.
  • Errors in marketing materials about plans offered in 2018 and 2019.

BCBSTX also, according to the Texas Commission of Insurance order marked March 6, 2020, and posted by TDI, agreed to begin sending the consumer notices by May 1, 2020

Those potentially eligible for a refund include current and former BCBSTX members in fully insured HMO plans, including Affordable Care Act plans, who received out-of-network emergency care between August 1, 2017, and December 31, 2019; and who paid or have an unresolved balance bill for that care, according to TDI.

Eligible BCBSTX members eligible individuals will be required to provide proof they paid the bill or have an outstanding bill for out-of-network emergency care received between August 1, 2017, and December 31, 2019 in order to receive a refund. Proof of payment may include credit card receipt or statement, canceled check, receipt from the medical provider or a similar document, TDI reported.

Current BCBSTX members may call the member phone number on the back of their ID cards. Former BCBSTX members who no longer have an ID card may call 972-766-6900.


Click here to view the enforcement order.

Author: Faith Huffman

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