When Jay Garnett began to feel severe chest pain during a workout about a year ago, his son called 911. Garnett was having a heart attack. An ambulance rushed him to the nearest hospital in Denton, where doctors saved his life.
The 58-year-old entrepreneur from Argyle says he had health insurance. So when the $124,000 medical bill came in the mail a few weeks later, he immediately submitted his claim.
But things did not turn out as he anticipated.
“Insurance won’t pay the bill,” he said flatly in a phone call. The ambulance had taken him to a hospital that was not in the network of hospitals his insurer works closely with.
It’s like “financial roulette,” Garnett said. Sick people can’t direct where an ambulance goes. “But where you end up can cost $5,000 or over $100,000. That’s not the way it should be.”
The Texas Legislature agreed. On May 15, lawmakers approved Senate Bill 507, which expands an existing law and helps more people in situations like Garnett’s fight surprise medical bills.
Gov. Greg Abbott signed the bill into law Tuesday. Advocates call it a big win for Texans, as more people will be able to use a statewide program that dates to 2009.
No one looks forward to an emergency room visit, said Sen. Kelly Hancock, R-North Richland Hills, who championed both SB 507 and the 2009 legislation.
“But when it happens, hidden charges and surprise bills should be the last thing on the patient’s mind,” he said. “When you start asking around, that’s what so many people have had to deal with.”
While people expect their health insurance to kick in when they get emergency care, patients too often find themselves in the battle over bills. Sometimes it happens when patients go to in-network hospitals, but doctors working there are out-of-network and send a bill unexpectedly.
In emergency cases, patients may be rushed to the nearest medical center, but the location chosen may not be in the patient’s insurance network.
“Hidden charges and surprise bills should be the last thing on the patient’s mind. When you start asking around, that’s what so many people have had to deal with.” Sen. Kelly Hancock
Then patients, despite having a health insurance policy, get smacked with charges that can result in “a financial tragedy,” as Garnett describes it. And they don’t get far trying to negotiate on their own. “It’s been dead end, after dead end, after dead end,” Garnett said.
Surprise bills — sometimes called balance billing — are a national issue. There are virtually no federal protections, and the response in most states has been inadequate. Texas, at least, is actively collecting data, and is one of a handful of states that has proactively enacted laws to protect consumers.
For eight years, the state has allowed patients to fight charges through a program managed by the Texas Department of Insurance. The insured patient remains off the hook while the hospital and health insurance company negotiate a payment. If they can’t agree, they could end up battling it out in a court, an option neither side likes.
Only a handful of the more than 1,300 requests for help from patients made it to arbitration last year. Overall, the state insurance department recouped nearly a half-million dollars through its mediation process.
“That was the intent of the law … that it would never be used,” Hancock said. “It forces both sides to resolve the conflict and not push their desire for more revenue onto the patient.”
Still, while the 2009 legislation was a great first step in protecting consumers, many acknowledged the limitations.
“It was a brand-new concept, and it only applied in very limited situations,” explained Jamie Dudensing, CEO of the Texas Association of Health Plans.
For example, the program was only available to patients when their medical bills came from specific types of physicians: radiologists, pathologists, ER doctors, neonatologists, anesthesiologists and assistant surgeons.
The patient had to have a major-medical preferred provider organization plan, or PPO. The hospital had to be in-network for that insurance plan.
An update to the law in 2015 reduced the size of the bill that patients could contest, dropping the amount from over $1,000 to over $500. The law signed by Abbott makes even broader enhancements.
For Texans with shocking medical charges, bill that governor signed can’t come soon enough
Patients now have expanded protections under Texas law against surprising, often hefty medical bills from doctors who offer medical care at…
Patients can now get help contesting medical bills of more than $500 when they come from any out-of-network provider working at a hospital that is in-network for their health policy. They can submit bills from out-of-network hospitals in emergency situations.
Surprise bills from freestanding emergency rooms, facilities that offer emergency care but are not attached to a hospital, are now included.
The bill also expands the program to include those enrolled in the Teacher Retirement System health plan and the self-funded TRS-ActiveCare program, which together include an estimated 680,000 individuals.
The changes will take effect on Sept. 1. Texans with questions can contact the Department of Insurance’s consumer protection division at (800) 252-3439.
“It’s been dead end, after dead end, after dead end.” Jay Garnett
Garnett is glad to hear about the updates and says it’s a good step forward. “People are getting taken advantage of,” he said. Meanwhile, the fight over his bill — which he says has now been sent to collections by Medical City Denton — continues.
His insurance provider, Scott and White Health, says it is looking into the case.
“Our members’ experience is of utmost importance to us, and we are currently working to review this particular member’s case and will contact him directly when we have a conclusion,” a spokesperson said in an emailed statement.
While the latest proposal generated support on both sides of the aisle, more can be done. The law only protects consumers that have a plan regulated by the Texas Department of Insurance, which does not include Medicare, Medicaid and most marketplace health plans.
There’s also a bigger demand for transparency in health care pricing and addressing the challenges that cause providers to remain out-of-network could be next on the horizon.
There is also a need for education, especially in the current market where consumers purchase new plans each year. A plan can be markedly different from one year to the next, and rising deductibles and co-pays shift more out-of-pocket expense to the consumer.
“You can always do more,” Dudensing said. “But this is really about ensuring that a base level protection is there. It’s a big deal.”