FOR IMMEDIATE RELEASE
September 16, 2014
CONTACT: Darrell Farr, 512-476-2091
AUSTIN, TX – In response to a report by the Center for Public Policy Priorities (CPPP) detailing the rising trend of a practice known as “balance billing,” the Texas Association of Health Plans called for key reforms to health care policy and advised consumers on how to avoid the associated sticker shock.
“As America grapples with the challenge of making affordable health care available, there are certain situations emerging where competitive business practices and inadequate government regulation collide,” said Jamie Dudensing, CEO of the Texas Association of Plans. “We believe that stronger regulations and heightened consumer awareness will reduce the incidents of balance billing which have put a growing number of Texas patients in difficult financial situations. Consumers should not be caught in the middle of the debate."
A national issue for more than a decade, “balance billing” occurs when people seek care at a facility identified as “in network” by their PPO plan, but are treated by medical personnel who are “out of network” because in-network practitioners are not available. The result takes the shape of charges that can range upwards of 400-500% above commonly accepted rates, such as Medicare. While the use of out-of-network providers can give patients access to a wide variety of skilled physicians, the resulting cost can be financially harmful.
Although national figures are not available, some health economists and patient advocates estimate that consumers pay $1 billion or more a year in balance billing.
TAHP has advocated for regulatory modifications to better address balance billing. Rules adopted by the Texas Department of Insurance have helped fuel a negative trend of incentivizing hospital-based physicians to drop out-of-network. Within six months of TDI’s adoption of the balance billing rules, one health plan had 12 emergency care physician groups drop out-of-network. This seems to be an ongoing trend for hospital emergency care physician groups around Texas.
There have been efforts to minimize the impact of balance billing on consumers. The Texas legislature passed comprehensive transparency legislation in 2007, SB 1731, to provide consumers more information related to the costs of using network and out-of-network providers. In 2009, Texas adopted HB 2256 that gives Texans the option to request mediation between the health plan and the provider when they are balance-billed. The Affordable Care Act also contains some provisions to protect patients from balance billing for emergency medical care.
“When it comes to the cost of health care, TAHP and our members believe Texans deserve consumer protections and transparency beyond those given by the Affordable Care Act, SB 1731, and HB 2256,” continued Dudensing. “As we continue pressing Texas legislators to improve those protections, we encourage Texas consumers to educate themselves on how to avoid the sticker shock of balance billing.”
TAHP offers Texas consumers the following advice;
- When planning a medical procedure, ask detailed questions about the potential role of out-of-network doctors in your care. Specialist like anesthesiologists, radiologists and pathologists are often the most likely to be out-of network. Whenever possible, request an in-network physician. If that is not an option try to work out a plan with the treating physician and your health plan.
- For planned procedures, call your health plan for an estimate of out-of-pocket costs. Many plans offer web based tools or mobile apps to provide information on costs. If you will be treated by an out-of-network provider, you can request an estimate of the charges from the provider.
- After any medical treatment, there will be out-of-pocket cost for any co-payment or co-insurance fee, and any deductible that your health plan requires. If a bill exceeds those charges, call your health plan representative and the physician’s office for an itemized bill.
- Ask if you are being balance billed by the treating health-care provider in your network, for a service covered by your health plan. If the doctor is not in your health plan’s network, there still might be steps you can take. Texas law allows patients covered by a preferred provider plan (PPO) to request mediation for an out-of-network claim settlement if the balance bill exceeds $1,000 and the facility-based physician provided the service in a participating hospital. If you have HMO coverage, call your health plan and let them know you are being balance billed.
- Ask “Do I need to go to the emergency room?” Understanding that balance billing is most likely to occur for treatments in an emergency room setting, will help reduce the shock of being balance billed.
- In any case, call your health plan before agreeing to pay any medical bills you feel are unwarranted.
About Texas Association of Health Plans (TAHP)
Texas Association of Health Plans (TAHP) is a statewide trade association representing effectively all health plans (Commercial, Medicaid, CHIP and Medicare) doing business in Texas and is committed to improving access, value and quality of care throughout Texas. Utilizing legislative advocacy, education and collaboration with other member organizations, TAHP brings together industry leadership to develop answers to critical health care issues in the state. For more information, please visit www.tahp.org or call (512) 476-2091.