New Rules Empower Patients Fighting Surprise Medical Bills

The Texas Department of Insurance added new rules that give a patient leverage in balance billing

By Deanna Dewberry
|  Wednesday, Feb 5, 2014  |  Updated 11:28 PM CDT
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New state rules empower patients in the fight against a common practice, balance billing, which occurs when a patient is treated at an in-network hospital by an out -of-network doctor.

Deanna Dewberry, NBC 5 Investigates Consumer Unit

New state rules empower patients in the fight against a common practice, balance billing, which occurs when a patient is treated at an in-network hospital by an out -of-network doctor.

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New statewide rules help Texans avoid surprise hospital bills from a common practice which occurs when consumers are billed for out-of-network care.

The practice is called balance billing.  It often happens when patients go to facilities in their insurance network but are treated by doctors who are not in that network.  As a result, the patients are on the hook for the balance of the bill not paid by insurance.

The new rules, which went into effect last summer, fall under the umbrella of the Texas Department of Insurance and are designed to minimize balance billing.

“It’s focused more on really preventing occurrences of balance billing by insuring that networks and health plans have an adequate number of hospitals and physicians, and other types of facilities to accommodate consumers for the services that are delivered in their health plan,” explained Katrina Daniel, with the Texas Department of Insurance.

The rules also give Texans the right to ask TDI to step in and mediate if a patient’s portion of one doctor bill is more than $1,000. But TDI also told NBC 5 it would look into bills that were less than $1,000.

“We’re happy to look into any consumer complaint,” Daniel said.

State Sen. Kelly Hancock sponsored the bill, which took years of legislative slogging and negotiating just to get passed.

“I think we’ve made a lot of progress in giving some consumers some leverage in dealing with this issue,” said Hancock.

Stacey Pogue, a senior policy analyst with The Center for Public Policy Priorities, called the rules a good first step.

“We’re far ahead of where many other states are at this point, but the rules don’t end balance billing,” Pogue said.

“Why Am I in the Middle?”

Last year, Melinda Allen ended up in the emergency room a Texas Health Harris Methodist in Fort Worth, a hospital she know was in-network with UnitedHealthcare, her insurer. She was ultimately diagnosed with a large, benign ovarian tumor. Later she got an unexpected bill from the ER doctor.

“I get this bill that said I owed $669 to the ER physician, and I thought, ‘OK, that’s a mistake,’” said Melinda.

But it was no mistake. 

Melinda had received a balance bill.  While Harris Methodist was in-network with UnitedHealthcare, the doctor was not. He was out-of-network and contracted by a private company called Emergency Medicine Consultants.

“I was floored and I was angry,” Allen said. “I’m angry with Harris. I’m angry with the doctor and I’m angry with my insurance company. I’m angry with all of them.”

And as fate would have it, a few months later, her husband, Bob sliced his finger and ended up in the same emergency room, treated by the same doctor.

“I couldn’t believe it. I said, ‘You’re out of my network,’” said Bob incredulously. “I want another doctor. And he just laughed and said, ‘Let me see your finger.’”

By law, emergency room doctors have to treat every patient regardless of if they pay or how they pay. 

Bob also ended up with a balance bill from that doctor.

“I think a lot of consumers have experience with it, but don’t know what to call it, don’t know it’s something that shouldn’t be happening, and they don’t know who to complain to if they did figure it out,” said Pogue.

Texas Health Resources spokesman Wendell Watson said via email the hospital doesn’t mandate doctors contract with insurance companies.

“UnitedHealthcare uses rates determined by Medicare Centers for Medicare and Medicaid (CMS) Fee Schedules to process claims,” said Kim Whitaker, spokeswoman for United Healthcare.

Ben Stolz, executive director of Emergency Medicine Consultants said that rate is typically lower than his company thinks is adequate.

“Any emergency doctor knows that the skills and the attributes that you need in your most emergent times are very different from that of other specialties,” Stolz said.

Stolz also believes the rates for ER doctors should be higher because of the round-the-clock nature of emergency care.
“Why am I in the middle of this? Why am I here in the middle of this?” Bob asked.  “Why is the consumer having to deal with this?  That’s not right. It’s not fair,” said Bob Allen.

“Consumers are stuck in the middle because an insurance company and a doctor or hospital disagree on how much the insurance company should pay for a procedure or treatment,” Pogue said.

After calls by NBC 5 Investigates Consumer Unit and the Allens, both Bob and Melinda’s bills were finally dropped.

UnitedHeathcare and Emergency Medicine Consultants are also in late-stage negotiations to bring the practice in-network.

Ask questions

Emergencies aside, when possible it’s best for patients to ask questions ahead of any procedure.

Ask if all the doctors involved in the treatment are in-network.  Get an estimate of costs if a doctor or facility is not in network.  And negotiate rates. 

FairHealthConsumer.org and a section of TDI’s website, can help consumers see average costs and reimbursements for particular procedures in their geographic area.

TDI doesn’t regulate doctors or hospitals. It does, however, regulate about one-third of health insurance plans in the state of Texas including fully-inured plans and some state government plans too.

A fully-insured health plan means an employer pays all or some of the premium to an insurer and the insurer pays claims from the pot of premiums collected by everyone it insures.

Other health plans called self-insured plans fall under federal regulation.  A self-insured plan means the employer is responsible for collecting premiums and paying health care claims out of company assets. In general, larger companies are self-insured. 

Human resource departments or employee benefit administrators can often tell employees what type of plan they have.

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