CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment Policy | Self-Treatment and Treatment of Family Members

This payment policy governs Blue Cross & Blue Shield of Rhode Island's position on providers treating themselves or members of their household/family, indicating such services are not covered under member contracts and describing related professional/ethical constraints.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayment Policy | Self-Treatment and Treatment of Family Members

Policy CodePolicy N/A

Change TypeClarified

Effective DateOct 6, 2009

Next Review DateN/A

Key ActionDo not submit claims for services provided to a family member or household member because member contracts do not cover those services; such claims may be denied.

SourceLink

POLICY UPDATE CHANGES

Policy references AMA Code of Medical Ethics Opinion 1.2.1 and defines treatment and family member terms.

0Covered when treating self/family

1Policy stance (not covered except emergency)

2018-06-05Last policy update

Policy summary

Blue Cross & Blue Shield of Rhode Island (BCBSRI) states that member contracts for all products do not cover services provided to a family member or member of the provider's household. BCBSRI aligns this position with ethical guidance and notes services provided to self, family, or household members are not covered except in emergency or isolated settings where no other qualified physician is available. The brief raises ethical concerns about objectivity and patient autonomy when physicians treat themselves or immediate family and provides high-level advice to avoid such arrangements except in true emergencies.

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Coverage stance & applicability

Prohibition on Covered Services to Self/Family/Household Members

Member contracts for all products do not cover services provided to a family member or member of the provider's household.

ALL of the following

Services provided to a family member or member of the provider's household are not covered under member contracts.
Physicians should not treat themselves or members of their own families except in emergency settings or isolated settings where there is no other qualified physician available.
It is not appropriate for physicians to write prescriptions for controlled substances for themselves or immediate family members except during an emergency.
A physician may not serve as a primary care physician (PCP) for self, or a family member or household member.
Physicians cannot order medications without a professional doctor–patient relationship.

This policy governs providers across all products/member contracts and makes clear that services provided to a family member or household member are not covered. The policy follows AMA ethical guidance and includes an explicit emergency exception: physicians may treat themselves or family members only in emergency or isolated settings where no other qualified physician is available.

Defined terms used in this policy

Definitions

Definitions used in the policy

ALL of the following

BCBSRI defines treatment as evaluation, thorough examination, testing and ordering of services.
BCBSRI defines family members as a spouse or domestic partner, natural, adopted or step- children, grandchildren, parents, parents-in-law or grandparents.

TreatmentEvaluation, thorough examination, testing and ordering of services.

Family membersSpouse or domestic partner, natural, adopted or step-children, grandchildren, parents, parents-in-law or grandparents.

Billing, documentation, and operational requirements

Denial Risk

Claims for services to family/household members are not covered

Do not submit claims for services provided to a family member or household member; member contracts for all products do not cover those services and such claims may be denied.

Documentation Required

Maintain professional relationship documentation

Ensure there is a documented professional doctor–patient relationship before ordering medications; avoid ordering medications without such a relationship.

Billing Rule

Do not bill member for non-covered services without advance agreement

If services are determined to be non-covered, providers may not charge the member unless the member was informed and provided written agreement in advance to continue treatment at their own expense as required by participation agreements.

Operational requirements: do not submit claims for services provided to a family member or household member because such services are not covered and claims may be denied. A member may only be billed for non-covered services if the member was informed and provided written agreement in advance to continue treatment at their own expense per participation agreements. Providers must document a professional doctor–patient relationship before ordering medications and may not order medications without such a relationship.

Clinical & ethical considerations

BCBSRI cites several ethical and clinical concerns when physicians treat themselves or immediate family members: professional objectivity can be compromised; physicians may fail to probe sensitive areas or perform intimate examinations; patients (especially minors) may be uncomfortable disclosing sensitive information or refuse care; physicians may treat beyond their expertise; family tensions after adverse outcomes can harm personal relationships; and patient autonomy and informed consent may be undermined. The policy specifically advises avoiding sensitive or intimate care for family members, particularly for minors.

Policy revisions & notes

2018-08clarified

No clinical policy statement changes indicated; published provider updates listed

2018-06-05clarifiedLatest

AMA Code of Medical Ethics Opinion 1.2.1 referenced and BCBSRI definitions for treatment and family members added

2009-10-06clarified

Policy effective date established; reinforces that member contracts do not cover services to family or household members