Kelsey-Seybold Clinic to open location in Houston’s downtown tunnels – Houston Business Journal

Houston-based Kelsey-Seybold Clinic plans to open a new clinic location in the downtown tunnels this summer.

Kelsey-Seybold will start construction on a 2,200-square-foot clinic beneath the Niels and Millie Esperson Buildings. The clinic will be located at 815 Walker, suite T-14A, according to a press release from Kelsey-Seybold. Construction has not yet started on the new location, but it is scheduled to open in the summer of 2019, according to a Kelsey-Seybold spokesperson.

The new clinic facility will have room for one medical provider as well as two exam rooms for its virtual health systems, where Kelsey-Seybold patients can connect with primary care and specialty physicians using telemedicine technology, according to the release. Kelsey-Seybold already has one clinic location in downtown Houston, in The Shops at 4 Houston Center.

“Since 1975, Kelsey-Seybold Clinic has had a location in the downtown area,” Tony Lin, chairman and managing director of Kelsey-Seybold Clinic, said in the release. “Eight years ago, we built a new clinic — Downtown at the Shops — to expand our services and specialties to meet the growing needs of our patients. The addition of this new primary care location in the downtown tunnels will make it easier for individuals who work west of Main Street to walk to a Kelsey-Seybold provider.”

Virtual health and telemedicine are big projects for Kelsey-Seybold, Dr. Donald Aga, medical director of health care innovation at Kelsey-Seybold Clinic, told the Houston Business Journal in October. The virtual options allow Kelsey-Seybold patients to talk with physicians and receive diagnoses and medications without ever having to attend an appointment in-person. In an industry seeing growth in local urgent care clinic locations and an emphasis on telemedicine, quick and convenient access for patients remain some of the most important missions for health care organizations.

Kelsey-Seybold Clinic was founded in Houston by Dr. Mavis P. Kelsey in 1949 and modeled itself after Minnesota’s Mayo Clinic, according to the company’s website. It was the first clinic in Houston to combine primary care and specialty care under one roof. More than 400 Kelsey-Seybold physicians and allied health professionals practice at 20 locations and an accredited sleep center across the greater Houston area, per the release.

In November 2018, Kelsey-Seybold closed on 5.5 acres of land in unincorporated Montgomery County where it will build its new three-story Kingwood clinic location. The new Kingwood location will replace the area’s previous clinic on Lake Houston Parkway, which was damaged during Hurricane Harvey.

Source: Kelsey-Seybold Clinic to open location in Houston’s downtown tunnels – Houston Business Journal

Ohio Expands Telemedicine to Include Teledentistry 

It should come as little surprise that teledentistry would soon follow. On December 19, 2018, former Governor Kasich signed Senate Bill 259into law, which addresses access to teledentistry in Ohio.

Teledentistry means the delivery of dental services through use of synchronous, real-time communication, including by a dental hygienist or EFDA under a dentist’s authorization. The elements of the bill went into effect Wednesday, March 20, 2019 and include:

  • Allowing for the use of teledentistry to extend care into underserved areas of Ohio;
  • Promoting licensure portability to enhance Ohio’s attractiveness as a state in which qualified dentists establish their dental practices;
  • Generally prohibiting an insurer from denying coverage for any services provided to an insured through teledentistry if the services would be covered when delivered other than through teledentistry; and
  • Allowing dentists to prescribe non-controlled substances, including antibiotics via teledentistry.

The Ohio Dental Association (“ODA”) released their Policy Statement on Teledentistry, which provides further clarification on the teledentistry law.

Generally, treatment provided via teledentistry must be properly documented and should include providing the patient a summary of services. As such, dentists must establish protocols for appropriate referral when necessary.

As for patients’ rights, they have the right to:

  • Have services delivered by a dentist licensed in the state where the patient receives services, or be provided the services as otherwise authorized by that state’s dental board;
  • Have services delivered that follow evidence-based practice guidelines, to the degree available, as a means of ensuring patient safety, quality of care and positive health outcomes;
  • Be informed of the identity of the providers collecting or evaluating their information or providing treatment, and, of any costs they will be responsible for in advance of the delivery of those services;
  • Have their relevant patient information collected prior to performing services using teledentistry technologies and methods including: medical, dental, and social history, and other relevant demographic and personal information;
  • Have their services properly documented and records and documentation collected provided or otherwise made available to the patient upon request;
  • Be involved in treatment decisions and able to choose how they receive covered services, including considerations for urgency, convenience, and satisfaction; and
  • That the delivery of services will be performed in accordance with applicable laws and regulations addressing the privacy and security of their private health information.

A dentist who wants to provide dental services through teledentistry must apply to the state dental board for a teledentistry permit, pay the application fee of $20, and otherwise be eligible for permit under Ohio Revised Code 4715.436. The Ohio Medical Board (the “Board”) must issue the permit if the dentist is in good standing and satisfies all pre-requisite requirements. A teledentistry permit expires on December 31 in the first odd-numbered year after issuance. The Board must renew the permit if the dentist submits a complete application, pays the $20 renewal fee, and verifies the locations where teledentistry services have been provided since the permit was most recently issued or renewed.

In terms of technical considerations, dentists are encouraged to consider conformance with applicable data exchange standards to facilitate delivery of services via teledentistry modalities, such as Digital Imaging and Communications in Medicine (DICOM) when selecting and using imaging systems; X12/HL7 for the exchange of information; and JCD-9/10- CM/SNOMED/SNODENT for documentation consistency.

Takeaways

While the expansion into teledentistry expands how and where dentistry can be performed, it does not change the fact that standard terms and conditions apply, essentially. This means that, in terms of documentation and security, there are no shortcuts. Teledentistry requires the same level of documentation and security as in-person care, and more. Dentists seeking their permit should ensure they have proper documentation and security protocols in place to ensure they meet compliance standards.

Source: Ohio Expands Telemedicine to Include Teledentistry | Dickinson Wright – JDSupra

How one family’s letter prompted the creation of a new telehealth program

Jared and Kristina Burns went through a harrowing experience: Their sick child was airlifted out for specialized care. That encounter led them to write a letter to Providence St. Mary Medical Center in Walla Walla, Washington. In it, they requested that the organization implement a telemedicine tool so infants and kids could get better access to specialized care during emergencies.

Providence St. Mary liked the idea, and more than a year and a half later, the pieces were in place. The medical center is now a pilot site to bring telemedicine neonatologists and pediatric intensivists to Walla Walla, according to a news release.

The telehealth doctors can also give virtual guidance when a child needs specialized care but can’t be airlifted out immediately.

“This supports the care the child needs,” Dr. Christopher Hall, a pediatrician and the CMO of Providence St. Mary, said in a statement. “It also supports the pediatricians here. The pediatricians in Walla Walla operate at a very high level, but there are very complex, sometimes rare, conditions that require specialists, such as a baby born with an unusual abnormality.”

Ultimately, the goal of the telehealth program is to ensure the medical team has specialized assistance so they can give the child the best possible care.

“Our family’s desire to do something stems from our feeling of helplessness with our own children needing specialty care,” Jared Burns said in a news release. “St. Mary provides good care, but we didn’t have the specialty care. Had (telemedicine) been available, I think our children might have been able to stay in Walla Walla.”

Source: How one family’s letter prompted the creation of a new telehealth program – MedCity News

Utah Sets Reimbursement Guidelines for Telehealth through Medicaid

Utah’s governor has signed legislation expanding Medicaid payment parity for telehealth and telemedicine services.

Gov. Gary Herbert’s signature on HB 392 mandates that the state’s Medicaid program reimburse providers to designated connected care services “at the same rate that the Medicaid program reimburses for other health care services.” It also requires the state’s public employee health plan to reimburse, at the provider’s request, “medically appropriate telemedicine services at a commercially reasonable rate.”

The state has, in the past, reimbursed providers through Medicaid for what was called “mental health therapy.” Under the new law, it redefines that as “telepsychiatric consultations” and includes it under the list of telemedicine services reimbursed by the state program.

With the bill’s signing, Utah joins a number of states moving to mandate that telehealth and telemedicine services by reimbursed at the same rate as if those services were delivered in person. Some states and payers have pushed back at that concept, saying reimbursement rates should be negotiated by payers and providers and not tied to in-person standards.

Included in a bill is a reminder that the Legislature’s Public Utilities, Energy, and Technology Interim Committee and Health Reform Task Force will be studying:

  • How the payment parity rules are used;
  • “Practices and efforts” by healthcare providers, payers, employers and HMOs to reimburse for telehealth and telemedicine services;
  • Existing telehealth programs and the potential for expansion;
  • Any reimbursement issues experienced by providers; and
  • Any new legislation or rules that may be needed in the future.

Source: Utah Sets Reimbursement Guidelines for Telehealth through Medicaid

Barron’s: For Telemedicine to Change Health Care, We Need to Change How we Pay Doctors

Barron’s: For Telemedicine to Change Health Care, We Need to Change How we Pay Doctors.
https://www.barrons.com/articles/for-telemedicine-to-change-health-care-we-need-to-change-how-we-pay-doctors-51553259601

How To End The Scourge Of Surprise Medical Bills In The Emergency Room

Senator Bill Cassidy, a Republican from Louisiana, has proposed legislation to address the problem of surprise medical billing. Photographer: Al Drago/Bloomberg© 2018 BLOOMBERG FINANCE LP

Opponents of the role of consumers and markets in health care have one go-to argument above all others: that you can’t shop for health care when you’re unconscious. The rising problem of gargantuan, surprise medical bills in surgical wards and emergency rooms shows that they have a point. The good news is that constructive, bipartisan reforms may be on the horizon.

A close encounter with surprise billing

A few years back, my wife and I had an up-close look at how surprise billing works.

We were about to have our first child. I had warned my wife, Sarah, about the problem of surprise billing. She meticulously researched everything to make sure that the hospital she chose—part of the St. David’s HealthCare system in Austin—was part of our insurer’s provider network. She then did the same for her obstetrician and her anesthesiologist.

When Sarah went into labor, and we got to the hospital, the receptionist asked me to sign a form, agreeing to allow the on-call pediatrician to see our baby once he was born.

I asked, “Is the pediatrician in our network?” The receptionist, visibly annoyed, said, “I have no idea.” I replied, “Well, I’m not signing any form allowing for an out-of-network pediatrician to see our child. That could cost me thousands of dollars!”

Her frustration rising, the receptionist handed me a clipboard with a list of a hundred pediatricians on it, and said, “pick one.” So, as Sarah was being wheeled away, I pulled out my smartphone, went to the web browser, logged into my health insurer’s website, and began painstakingly typing in the names of the on-call pediatricians, one by one. Finally, after 15 tries, I found one who was in our network, and picked that one.

I was shaken by the experience. I guessed that fewer than 0.1 percent of Americans would have known to do what I did—to insist, in an emergency setting, on an in-network pediatrician. How can anyone accept such a system?

’Drive-by doctoring’

I was lucky, first because I had access to the internet in my hand, and second because it’s my job to read and write about health care policy. Prior to the birth of our child, I’d come across a 2014 front-page story in the New York Times by Elisabeth Rosenthal. In it, Rosenthal told the story of Peter Drier, a 37-year-old bank technology manager who had undergone surgery for herniated disks in his spine. The surgeon who operated on Drier participated in his insurance network, and so for the surgery, Drier’s out-of-pocket cost was $3,000 out of a total charge of $6,200. But later on, Drier received a bill for $117,000 from a neurosurgeon whom he never met, but may have stopped by to see Drier while he was unconscious: a practice dubbed “drive-by doctoring.”

The practice is especially egregious in emergency rooms, where freelancing, out-of-network doctors are granted free rein in hospitals to charge whatever they want to patients who, at best, are confused about what they’re agreeing to, and at worst, are being billed at insane rates while being wheeled into the ER after a car accident or a stroke.

Egregious pricing practices

Hospitals and physicians charge far higher rates to the privately insured than to those in Medicare.GE BAI & GERARD ANDERSON / JAMA

An analysis by Ge Bai and Gerard Anderson of Johns Hopkins, published in the Journal of the American Medical Association, compared what physicians charge in the Medicare program to what they charge people who are privately insured or uninsured. Most of the medical specialties with the highest ratio of private prices to Medicare prices were related to surgeries and emergencies, including anesthesiology (5.8x the Medicare rate), emergency medicine (4.0x), neurosurgery (4.0x), and diagnostic radiology (3.8x). And that includes in-network prices for insured patients; out-of-network physicians charge 9 to 10 times what Medicare pays for the same service. And, rest assured, this isn’t because Medicare’s rates are too low; Medicare determines its reimbursement rates in large part by outsourcing the job to the very medical specialists who stand to benefit from higher Medicare prices.

Yale researchers Zack Cooper and Fiona Scott Morton looked at emergency department visits that occurred at hospitals that were in insurers’ networks, in a paper for the New England Journal of Medicine. “On average,” they found, “in-network emergency-physician claims were paid at 297% of Medicare rates,” while “out-of-network emergency physicians [within in-network hospitals] charged an average of 798% of Medicare rates.”

A study from UnitedHealthGroup, looking at its own claims nationwide, recently estimated that out-of-network emergency physicians increased health care charges by $6 billion per year.

The problem is especially bad in Texas, where, according to Cooper and Morton, in some regions a majority of in-network hospital visits were accompanied by an encounter with an out-of-network physician. On top of that, Texas has seen a proliferation of for-profit, free-standing emergency rooms, that refuse to contract with insurers, so as to retain their flexibility to charge the highest prices possible to patients with medical emergencies. The free-standing ERs make even more money by resembling urgent care clinics, luring in patients who need treatment for minor conditions, but end up with bankruptcy-inducing bills. Overall, the incidence of surprise billing in Texas doubles the national average.

The problem of out-of-network physician visits is endemic in Texas, Florida, New York, and New Jersey.ZACK COOPER & FIONA SCOTT MORTON

The solution: Learn from Medicare Advantage

Legislators at both the federal and local level are trying to do something about the problem of surprise billing, what wonks often call “balance billing.” A modest, bipartisan measure proposed by state legislators in Texas would penalize emergency rooms that charge more than 200 percent above the average hospital charge for a comparable service.

A plethora of bills introduced in the U.S. Senate, including one from a groupled by Sens. Michael Bennet (D., Colo.), Tom Carper (D., Del.), Bill Cassidy (R., La.), Chuck Grassley (R., Ia.), Claire McCaskill (D., Mo.), and Todd Young (R., Ind.), would limit out-of-network prices in the emergency setting to the greater of (1) the median in-network rate for a particular geographic area; or (2) 125 percent of the “average allowed amount” in a geographic area: a proxy for what hospitals charge regardless of insurer contracts.

Both of these bills represent constructive—but insufficient—improvements upon the status quo.

There are two problems that legislation should try to solve here. The first is the surcharge of out-of-network prices relative to in-network prices. The second is the surcharge of in-network prices relative to Medicare prices. As I mentioned above, in-network prices for emergency care are also exploitative; out-of-network prices even more so.

Here, we can learn from Medicare Advantage. For the most part, Medicare forbids out-of-network providers from charging more than what traditional Medicare would pay for a given service. This has given insurers critical leverage against hospital monopolies, because the worst-case scenario is paying an out-of-network provider at Medicare rates. That means insurers have the ability to negotiate even lower rates with in-network providers.

Similarly, the solution to exploitative pricing in the private market is to cap out-of-network prices at the lower of the median privately contracted rate and Medicare’s rates. Not only will such a policy end price exploitation by out-of-network emergency care providers, but also by in-network providers. It will also give market participants the opportunity to do better than Medicare, whether through value-based contracts, simple price competition, or other innovations.

The provider lobby is no longer all-powerful

Politicians are understandably scared of crossing hospital lobbyists, who represent the second-largest employer in your typical congressional district, right behind the public schools. But we’re at a point now where the average household is spending more to pay for hospital bills—between out-of-pocket payments, insurance premiums, and subsidies for others’ coverage—than they send to the IRS each year. This cannot last.

If we do nothing, the problem will get far worse. If we do something that is too incremental, we’ll pat ourselves on the back and then be forced to revisit the problem in a few years.

Americans deserve market-based alternatives to single-payer health care. Without reform of exploitative hospital prices, we’ll never get there.

Source: How To End The Scourge Of Surprise Medical Bills In The Emergency Room

Amended telemedicine bill clears House committee

A bill allowing health care providers to offer diagnoses over the phone to patients they have never seen in person or via a video connection cleared a House committee on Tuesday after an unsuccessful attempt last month.

The House Committee on Public Health, Welfare and Labor advanced House Bill 1220 after it was amended to require the provider to have access to a patient’s medical record.

Claudia Duck Tucker, vice president of Dallas-based Teladoc, said that record could be a questionnaire that the patient filled out online.

Sponsored by Reps. Dan Sullivan, R-Jonesboro, and Justin Gonzales, R-Okolona, the bill would amend a 2017 law requiring a professional relationship to be established through more than just an audio-only phone call, even when combined with the patient’s responses to an online questionnaire, before a provider can treat a patient using telemedicine.

The law allows the relationship to be established through an in-person examination or through several other means, including those specified by state licensing boards.

A state Medical Board regulation allows the relationship to be established through an examination using “real time audio and visual telemedicine technology.”

Annette Guarisco Fildes, chief executive of the ERISA Industry Committee, which represents large employer health plans, said the current law presents a barrier for people without broadband Internet connections.

Employers “want their employees to receive access to care when and how they need it,” she said.

David Wroten, executive vice president of the Arkansas Medical Society, said the 2017 law was crafted in consultation with large employers, including J.B. Hunt.

He said HB1220 was being pushed by Teladoc, which offers health services over the phone through employer health plans.

“The other vendors are not here asking for this change, because most of them do not utilize this type of a business model,” he said.

HB1220 last month fell three votes short of the 11 it needed to clear the committee. On Tuesday, it cleared the committee without a vote to spare. It next goes to the full House.

Source: Amended telemedicine bill clears House committee

OnMed Launches Interactive Telemedicine Center on Cheddar

Austin White, CEO and Founding Partner at OnMed, joined Cheddar to discuss the new technology that makes going to the doctor as easy as stepping into the a phone booth.

 

Source: OnMed Launches Interactive Telemedicine Center on Cheddar

How Telehealth is Impacting Employers in Dallas-Fort Worth

Over the last several years, virtual health has grown exponentially in the United States, overcoming political hurdles, legislation, and medical societies fighting tooth and nail to stop its proliferation. Employers are starting to recognize the value of telemedicine as well, with 65 percent of companies offering telemedicine through their health plan.

The Dallas-Fort Worth Business Group on Health hosted a luncheon on the current and future state of telemedicine, bringing in a panel of experts on the topic. Moderator Eric Bassett, who is Senior Partner and the Central Market Business Leader for Mercer Health and Benefits, talked about how telemedicine is being implemented by small employers and those with 5,000 or more employees, but many of the middle market companies have been slow to adopt.

Nita Stella, the vice president of product and strategy at Teladoc, a leading telemedicine company, said that telemedicine is responsible for sees 2 million consults a year, comparing it to the transition to digital banking in the way it keeps most of us out of a bank. “Telemedicine is here to stay,” she said. In Texas, Senate Bill 1107 opened the door for telemedicine in 2017, but Stella is looking to see how it can move beyond primary care and into mental health, prenatal support, and other areas where access to healthcare can be difficult.

But connecting employees to telemedicine isn’t always straightforward. Stella discussed the disconnect employers and their employees often experience. In their studies, employers are more interested in biometric screening and diabetes measurement, while employees are concerned with weight loss and saving money. Creating systems that address all those needs is possible but not always easy.

Stella stressed the importance of a clear entry point, comprehensive clinical services, and integrating other providers when implementing telemedicine. Overall, when properly implemented, she said telemedicine should be able to simplify access, change behavior, reduce costs and connect the dots between the entire health ecosystem while improving outcomes. She highlighted increased efficiency for mental health appointments, which she said can result in a 45-day wait through normal avenues but take less than 5 days when using Teladoc.

Andrea Cockrell, the Administrative Services Manager for the City of Plano spoke about their use of telemedicine. She noted that city government is not always the quickest to adopt the latest technology, and that many employees are out in the city and don’t have easy access to technology throughout the day, but that their implementation had been relatively successful.

For Plano, the low cost of telemedicine visit (just $5) had lowered the barrier to use. Many panelists noted that the major challenge was getting an employee to use telehealth for the first time, and that they were often hooked on the service after the first visit.  A low copay provides an incentive. She also said sharing testimonials can be a great motivator for others to join. “Word of mouth tends to go a long way; people don’t trust HR,” she said.

The speed (average visit was 5 minutes with a 7 minute wait time), quality (4.94 out of 5 stars) and impact (83 percent of appointments resulted in a prescription) of the program made it worthwhile for Plano, but they also experienced cost savings by avoiding urgent care or the emergency room. In one year, the city went from 300 to 550 virtual visits.

Bassett closed the program explaining how telehealth could help relieve physician shortages, especially in rural areas, but he isn’t sure if it will improve efficiency enough. “It is something we are all going to have to watch, especially in rural locations. That is where these things have the most promise.”

Source: How Telehealth is Impacting Employers in Dallas-Fort Worth « D CEO Healthcare

Will Texas Legislators Finally Do Something About Surprise Medical Billing

In February, a bill arrived at our house. It was from some doctor we’d never heard of, who, the bill said, “assisted” in some relatively minor surgery my husband had in early November, more than three months before.

Turns out, the bill had already been through my husband’s insurance company which covered just a small amount ($28). There was a sizable discount, but we were still left with a bill of about $275. My husband had never been told by the surgeon about the need to bring in an assistant, before or after. We had thought we’d settled all the bills months before

Something similar had happened to me several years ago involving a different doctor and a different medical insurer. When I received the unexpected demand for payment I contacted the insurance company and they told me in no uncertain terms not to pay it. They didn’t owe it and I didn’t owe it. They had approved the procedure in advance and it did not include tacking on additional personnel after the fact, they said. And that, was the end of that.

So naturally I urged my husband to contact his insurance company to go to bat for him. Which he did the next day and after 30 delightful minutes on the phone with them, he was informed that the insurance company was still not paying anything more but that he had to.

Turns out, the “assistant” was out of network, the insurance company told him. But my husband had specifically selected the doctor he did because the surgeon was in-network and the medical center where the procedure was performed was in-network. This was no emergency surgery, but a longtime planned procedure complete with pre-op scrutiny and paperwork.

We paid the bill. And while the amount was not enormous, it was hard not to think about other times in our adult lives a $275 payment would have been difficult to come up with on the spot and that for many individuals and families it would still be a significant hurdle, one that might keep someone from paying other bills like rent or utilities. My husband sent a letter to the surgeon who did the operation expressing in polite terms his thanks for his surgery but his disappointment in the unexpected bill from the doctor’s non-network associate. To date there has been no reply.

Far more egregious cases occur every day in Texas, a state with a bad reputation for these distinctly unpleasant post-treatment surprises. Reports are legion of fully-insured Texans buried under thousands of dollars of bills because the medical facility they went to or the doctor they used was not in network. Or, like us, because someone in that operating room was out of network.

In fact, according to the trade group The Texas Association of Health Plans in Texas: “More than 65 percent of out-of-network ER doctor claims occur at network hospitals.”

Even more grinding: “300 of the 407 hospitals in Texas have NO network ER doctor for the three major health plans,” according to the association which represents health insurers, health maintenance organizations and other health-related groups.

Apparently it doesn’t matter how smart or knowledgeable you are, how much you do or don’t research your policy and its coverage ahead of time, how lucky you are that you’re on one of the major health plans and not some obscure fly-by-night concern – chances are better than 50-50 that are going to get nicked for some out-of-network bills.

Because of that, it appears some bi-partisan consensus has been reached on how to fix at least part of this – something that makes sense to a whole lot of people.

Under Senate Bill 1264 all emergency room visits would be considered in-network. Patients who went to an in-network facility would be covered by insurance, no matter who saw them. Kelly Hancock (R-North Richland Hills) has sponsored the bill in the Senate and Trey Martinez Fischer (D-San Antonio) has introduced a companion bill in the House. Doctors could not charge patients for what the insurance company didn’t cover.

Another important point is that when there are disputes over who should pay what, it will be the responsibility of the doctor and not the patient to start mediation with the insurance company.

It didn’t take long for the very powerful Texas Medical Association to raise its hand and demand state legislators hear from the doctors’ side of the equation. And as frustrating as this may be for patients looking for a quick cure to hear, TMA has its points as well.

The TMA insists the blame should not be placed on the medical personnel but on the insurance companies, who it says often deny doctors network status. On their website right now is a testimonial from a Beaumont anesthesiologist Ray Callas who, the story says, “is tired of beating his head against the wall trying to get ‘in-network’ with health insurance companies. And he’s tired of the surprise bills his patients receive when he can’t get in.”

“My responsibility as a patient’s physician is to know the risks of administering anesthesia, not administering their personal insurance plan,” Callas is quoted as saying. “Frankly, educating patients regarding their insurance plan and what is and is not covered, and how to meet deductibles — that’s the responsibility of the plan. Don’t just hand them a 75-page booklet and tell them their benefits are described within.”

One of the problems pointed out by the TMA is that approved provider information isn’t always up to date. While the split between Blue Cross Blue Shield from Kelsey-Seybold in October 2016 was well documented and patients received countless messages about it from both the insurer and the medical system, TMA notes that there are often abrupt changes that patients aren’t aware of. In its own legislative agenda, TMA wants a requirement that health plans “provide accurate information on physicians’ network status, updated in real time.”

Another is that insurance benefit explanations are often unnecessarily complicated, the TMA says. It urges a rewrite of insurance companies’ policies, putting them in plain language so patients can make sense of them.

Add in the complication of free-standing ERs who say they “take” or “accept” insurance but are not in major plans’ networks and you have a guaranteed recipe for surprise billing. And according to TAHP, out-of-network emergency care prices “are extremely high compared to what is usually accepted in the market.”

TMA wants doctors to be able to bill patients for all their costs and whatever insurance doesn’t pay, to still be able to recover that. Certainly, no one wants to see doctors not paid for their work. That’s not fair.

Source: Rating the Chances of Potential Houston Texan Salary Cap Cuts

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