AUSTIN—Texas’ high rate of surprise billing is driven primary by out-of-network emergency care doctors who provide services at network hospitals and by freestanding ERs, according to new data released today by the Texas Association of Health Plans (TAHP). The data lines up with other research showing surprise billing is not driven by narrow health plan networks or network adequacy.
In Texas, more than 30 percent of all ER physician services are out of network, and 65 percent of those occur at network hospitals. When freestanding ERs are excluded from the analysis, 94 percent of out-of-network physician claims for emergency services occur at network hospitals.
When patients are treated by an out-of-network doctor, they run the risk of receiving a surprise medical bill for the amount not covered by their insurance. Because patients usually cannot choose the ER doctors who treat them and because of Texas’ prevalence of out-of-network emergency care doctors, Texas patients are at an uncommonly high risk of receiving expensive surprise bills.
“Our new data confirms that out-of-network ER docs and freestanding ERs are behind Texas’ high rate of outrageously-priced surprise billing, which lines up with other studies we’ve seen from around the country,” said Jamie Dudensing, TAHP CEO and a former practicing nurse. “It’s time to get patients out of the middle of these billing disputes and off the hook for medical debt they don’t deserve.”
In a recent investigation, AARP discovered some Texas freestanding ERs are knowingly misleading patients and violating state transparency laws. These facilities are responsible for 83 percent of all out-of-network emergency room services and lead to more than $3 billion a year in avoidable health care costs.
Among other findings, TAHP’s data also shows:
- Almost 50 percent of ER physician claims are out of network—substantially higher than all other physician specialties.
- More than 30 percent of claims from all facility MDs performing ER services are out of network, a rate more than five times higher than all facility MDs for all services—this further illustrates that out-of-network rates are higher for services where patients are unable to choose their provider.
- 10 percent of anesthesiologist services are out of network.
- Only 6 percent of all facility-based physician services and 5 percent of all non-facility-based physician services are out of network.
The data in TAHP’s report is based on a survey of 2017 network and out-of-network PPO claims from Blue Cross and Blue Shield of Texas, UnitedHealthcare and Aetna.
To view TAHP's findings from the out-of-network claims survey, click here.
To view TAHP’s press release on new surprise billing legislation, click here.
To view TAHP’s fact sheet on the new legislation, click here.
To view TAHP’s fact sheet on surprise billing in Texas, click here.