According to a 2017 Kaiser Family Foundation analysis of health insurance claims, more than 25% of all hospitalizations in Texas resulted in out-of-network charges. That ranked the state 3rd in the nation. In the context of emergency room visits, Texas led the nation with a 38% rate of out-of-network charges.
The Texas Department of Insurance (TDI) regulates about one-third of the health insurance programs in the state. In response to this staggering rate of out-of-network charges, TDI is working with other state agencies to implement Texas Senate Bill 1264. Taking effect on January 1, 2020, Bill 1264 is intended to protect patients from surprise medical bills that might arise from their care and treatment. It prohibits balance-billing practices in healthcare billing, but only for the healthcare plans that TDI governs.
Here is everything you need to know about surprise billing and how legislation like Texas Senate Bill 1264 may end it.
WHAT IS SURPRISE BALANCE-BILLING IN TEXAS?
In 2017, an Austin high school teacher with a wife and two daughters suffered a heart attack. A friend took him to the nearest hospital, where doctors implanted two stents. The man’s health insurance paid about $55,000, and he later received a hospital bill for nearly $109,000. This is referred to as surprise balance-billing. After months of fighting the bill, the hospital settled for $353.
In another instance, a man cut his thumb and went to a nearby urgent care center. He needed seven stitches. The facility billed his insurance more than $4,000. The insurer paid about half of that, and the man was billed for the remaining balance. If he would have paid cash, the total charge would have been about $200.
If you are injured by a Personal injury attorney in Austin an accident far from home, you will likely need to seek medical services outside of your health care provider’s network. You may even do this by accident if you go to a hospital in your network, but you receive care from out-of-network providers within that hospital. The provider would then bill you in excess of an applicable copayment, coinsurance rate, or deductible.
Theoretically, Senate Bill 1264 will prohibit this surprise balance-billing. The bill primarily focuses on balance-billing by providers of out-of-network emergency and non-emergency services, because surprise bills typically only occur for services from out-of-network providers.
A FEW OTHER SURPRISES IN TEXAS
When you sign up for a managed care plan, you receive a directory of health care providers, leading you to believe that these providers are in your network. Then, without notice, a provider might drop out of the plan. Sometimes, the provider was never a part of the plan, to begin with. In both cases, you will likely become a victim of surprise balance-billing. This approaches consumer fraud and deceptive business practices.
NONEMERGENCY SERVICES IN TEXAS
Unfortunately, Senate Bill 1264 will not protect you against balance-billing for non-emergency medical services. However, the nonemergency health services provider must give you advance written notice disclosing the following:
- The expected amount of your financial responsibility for the services.
- The circumstances under which you would be financially responsible.
- A statement that they are not in a contractual relationship with your health care provider.
PROPOSED FEDERAL LEGISLATION IN TEXAS
In the past year, Congress has launched a variety of proposals to protect consumers from unexpected and drastically inflated balance bills. On both sides of the aisle, members of Congress have been floating trial balloons on what type of legislative intervention might operate in consumers’ best interests.
Here are some of their ideas:
- Place a ceiling on how much out-of-network providers can charge for their services. A formula would dictate how much is owed, and the patient would be held harmless (i.e. protected from financial responsibility).
- Force providers and plans into arbitration to negotiate a fair price. The patient would be held harmless.
- Bundle doctor’s fees into a hospital bill. This would prevent patients from receiving surprise bills from doctors.
Patient-protection legislation appears to be heading to the governor’s desk for his signature. One such bill would prohibit disputed medical charges from harming a patient’s credit score. A second bill is targeting free-standing emergency rooms and their extremely high rates. Legislators allege that these types of emergency rooms hold themselves out as taking or accepting insurance plans, but the facilities are out of many insurers’ networks, resulting in surprise charges.
Texas now has the strongest balance billing laws in the country, and it appears as though the legislation will continue to get stronger in the near future.
Are You Struggling to Pay a Medical Bill You Didn’t Expect?
At Glen Larson Law Injury Attorneys, we have years of experience representing victims of negligence, misrepresentation, and greed. After handling thousands of cases, we have developed a multidisciplinary approach that allows us to see cases from critical perspectives. We are deeply passionate about protecting the rights of Texas communities, and we look forward to taking on your case as soon as possible.