Beginning Sept. 1, 2007, Texas physicians must maintain written policies regarding any discounts they provide for medical services to uninsured or indigent patients. Additionally, some physicians must disclose a variety of information when billing insured patients for out-of-network services.
The discount policy and disclosure requirements are part of Senate Bill 1731 by Sen. Robert Duncan (R-Lubbock) that passed the Texas Legislature earlier this year.
A second bill by Senator Duncan and Rep. Dan Gattis (R-Georgetown), Senate Bill 1832, also requires physicians to provide an itemized statement of charges when they bill any patient for anatomical pathology services they did not personally perform or supervise.
SB 1731 requires physicians to develop and enforce written policies within their practices regarding the discounting of charges for medical services for uninsured or indigent patients. The policies also must state whether any interest -- and the rate -- will be applied to billed charges not paid by a third-party payer. The policies must also include procedures for handling patient complaints related to such charges.
Physicians must post a notice (PDF) in their offices informing patients of the policies.
Lee Spangler, JD, associate general counsel for the Texas Medical Association, says many physicians already have such written policies on discounted services for the uninsured. The TMA Office of the General Counsel has updated policies for disclosure law compliance to address the new law. The majority of the manual is still under revision, but a model policy for disclosure law compliance is available to members.
Sample billing policies:
Physicians who have questions about the new law or are unsure how to implement the written policies because of the specialty they practice or the type of patient population they serve should consult their attorney, Mr. Spangler says.
Estimates Required
In addition to the written policies, SB 1731 requires physicians to estimate the cost of a proposed medical service if requested by an uninsured patient, a patient not covered by a government program, or an insured patient seeking out-of-network services.
The estimate may be qualified to indicate that:
-
Charges may vary based on the patient's condition and other factors related to the art of practicing medicine;
-
The request can delay the scheduling of care;
-
The actual charges may differ from the amount paid by the third-party payer; and,
-
The patient is personally liable for the services not paid by health insurance.
Health plans also must estimate the amount an insured patient will pay for proposed services if requested. For in-network services, physicians may direct patients to make such inquiries to their health plan.
Additionally, SB 1731 allows a patient to request an itemized statement of the charges for professional services within one year of receiving care. The physician's office has 10 business days to comply.
Physicians, upon request, also must provide a plain language explanation of charges previously made on a bill or statement. And, a physician has 30 days to refund any overpayment by a patient once he or she becomes aware of the overpayment.
Facility-based physicians -- which include only radiologists, anesthesiologists, pathologists, emergency physicians, and neonatologists -- also have separate disclosure requirements when billing an insured patient for out-of-network services.
When billing patients for out-of-network services, those facility-based physicians must itemize services and supplies provided, along with the date of service. The bill also must state in plain language that the physician is not in the patient's health plan network, and that the health plan has paid a rate below the actual cost of the service and the physician's billed amount.
The statement also must include a telephone number for someone in the physician's practice who can discuss payment issues, including alternative payment arrangements, as well as a notice that the patient may file a complaint with the Texas Medical Board (TMB). That notice must give the TMB's mailing address and telephone complaint number.
SB 1731 places a similar disclosure requirement on health plans.
Billing statements greater than $200 over any applicable copayment or deductible must state in plain language that the physician will not furnish adverse information to consumer reporting agencies regarding amounts owed by the patient if the patient finalizes a payment plan agreement within 45 days of receiving the first statement. There is no requirement that physicians and patients agree over payments; rather the law requires physicians to offer patients an opportunity to discuss payments.
Under the new law, the TMB can discipline physicians for not complying with the disclosure requirements. A TMB spokesperson says the board likely will develop regulations on enforcement of the new law, and that violations likely will be considered "administrative violations," which usually carry a lower range of possible sanctions than violations dealing with patient care.
Pathology Services Billing
Meanwhile, SB 1832 places new disclosure requirements on anyone who bills for anatomic pathology services that they did not directly supervise or perform.
The bill requires that physicians, hospitals, laboratories, or other entities billing for pathology services give a health plan or third-party payer the name and address of the person or laboratory that actually performed the service, along with the amount the billing physician or entity paid; or they must give patient an itemized statement of the services and net charges paid. The law offers physicians the flexibility to choose which method of disclosure to utilize – to plans or to patients.
The disclosure requirement covers such anatomic pathology services as Pap smears, biopsies, hematology, sub-cellular pathology, molecular pathology, blood matching services, or any other microscopic examination of cells.
The new law applies only when a physician, hospital, or other entity bills for anatomic pathology services provided by another physician or laboratory. No disclosure is required when the physician or laboratory who actually performed or supervised the services bill the health plan or patient directly.
The TMB spokesperson said the board also will develop rules dealing with failure to comply with these requirements, and that they also likely will be treated as administrative violations. To learn the formal definition of anatomic pathology services and what efforts you should make to comply with SB 1832, click here.
NOTICE: The Office of the General Counsel provides legal representation for TMA in its activities and assists county medical societies physicians and their attorneys and the public with questions regarding medical law. The Office of the General Counsel of the Texas Medical Association provides this information with the express understanding that 1) no attorney-client relationship exists, 2) neither TMA nor its attorneys are engaged in providing legal advice and 3) that the information is of a general character. You should not rely on this information when dealing with personal legal matters; rather legal advice from retained legal counsel should be sought.
Last Published: 5/10/2010
Print this page