A diverse coalition of Texas health insurers, business organizations and consumer groups on Monday called on state lawmakers to better protect patients from the financially devastating effects of surprise medical bills.
In a consensus letter, the groups representing millions of Texans issued a challenge to political leaders to keep patients out of the middle of billing fights between insurers and medical providers. When those battles occur, patients who try to follow the rules often get hit with charges — sometimes in the thousands of dollars — that they believed their insurance would cover.
“We are committed to working with the Legislature this session to put an end to surprise billing and make sure patients are no longer held hostage,” Jamie Dudensing, CEO of the Texas Association of Health Plans, the states’ insurance lobby, said in a statement.
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Other groups that signed onto the letter include AARP Texas, the Texas Association of Business, Center for Public Policy Priorities, the National Multiple Sclerosis Society, the Texas Association of Life & Health Insurers, Texas Association of Health Underwriters and the National Federation of Independent Business.
Multiple pieces of legislation on medical billing are expected to be filed in coming weeks. Consumer advocate groups for years have tried to untangle the murky billing practice called balance billing where any or all of a billed charge that insurance does not pay can get passed onto unsuspecting patients.
This happens most often in emergency rooms where patients don’t have the luxury of time and often have no idea when they walk in the door if the doctor treating them or the facility itself is fully covered by their health plan. If the treatment is in-network, balance billing is illegal. But if the provider is out-of-network, there is no limit to the billed charge, often double or triple had it been in-network.
Texas has one of the worst records in the nation for balance billing. The Chronicle previously reported that in Texas, 48 percent of overall claims from emergency-room physicians were outside the networks of the state’s three largest insurers, Blue Cross and Blue Shield of Texas, Aetna and UnitedHealthcare. Health economists also have found that the likelihood of Texas patients getting an out-of-network bill after out-patient emergency room treatment is 27 percent — nearly double the national average of 14 percent.
Patients who think they have been wronged can dispute their bill through the Texas Department of Insurance mediation process. More often, though, they try on their own to fight the insurers and providers over the bills.
In previous years, lawmakers fine-tuned the mediation mechanism for disputed medical bills, declaring a victory each time. And while mediation has been successful in resolving the bill in the patient’s favor, few know about the process or are eligible for its protection. Roughly 75 percent of insured Texans remain shut out of the system, including those with federally regulated self-funded plans in which large employers take on the risk and pay claims, Medicare and Medicaid recipients, or members of health maintenance organization (HMO) plans.
Those with HMOs or government plans, however, are generally already protected from balance billing.
Similarly, a law passed in 2017 was supposed to bring transparency to the state’s free-standing emergency clinics and require facilities to disclose insurance network status. It, too, has had limited success as the language used by some of facilities remains confusing and, critics say, misleading.
Consumer groups feel hopeful this time will be different. “For the first time you have these diverse groups coming together and saying one thing: The consumer needs to be protected and out of the middle of billing disputes,” said Blake Hutson, associate state director of AARP Texas, the elder advocacy group.
He would like to see Texas model the system used in a growing number of other states where charges to patients can’t exceed their in-network co-pays and deductibles. Any dispute over the treatment charge must be settled between the insurer and provider without patient involvement.
“I feel the ground has shifted this year,” agreed Stacey Pogue, senior health policy analyst for the Austin think tank Center for Public Policy Priorities. While consumer groups have long backed reform, it is notable that this year health insurers and business groups have joined, she said.
But changes to billing practices are unlikely to come easily. Medical providers still say the solution lies squarely with insurers that won’t cover necessary medical costs.
The Texas Association of Free Standing Emergency Centers, the trade group representing more than 200 stand-alone emergency clinics in the state, said Monday in a statement it was “fully in favor of patient-centered solutions to reinforce the responsibility insurance companies have to their policy holders to fairly cover their emergency care and other medical needs.”
The Texas Medical Association, the largest state doctor group in the nation with 53,000 members, echoed the free-standing clinics. “The health plans need to be accountable to patients for the product they are selling and not pass the buck to the physician,” said Dr. Douglas Curran, president of the Texas Medical Association.
Going it alone
Congress has vowed to tackle balance billing on a national level. Last week, more than 60 national medical organizations, led by the American Medical Association, sent a letter to U.S. House leadership urging accountability by insurers, limits on patients’ financial responsibility, better dispute resolution and keeping patients out of the middle of the fight between insurers and doctors.
That letter was also signed by 41 state medical associations. Texas Medical Association was not among them. The group said it would come up with its own recommendations.