Like New York State Attorney General Andrew Cuomo, TMA is aggressively investigating how health plans determine "usual, customary, and reasonable" (UCR) out-of-network payments. These payments are widely inconsistent across health plans for the same service. We want to help the Texas Department of Insurance, the Texas Legislature, and others decide how best to correct this problem.
The issue will come up in the 2009 session of the legislature. Sen. Eliot Shapleigh (D-El Paso) has filed a bill - Senate Bill 351 - that prohibits out-of-network physicians from balance-billing patients for emergency services and allows the Texas Department of Insurance to set an interim payment rate for those services to be paid by the insurers. The interim rate would be based on Medicare rates that may be adjusted by the Consumer Price Index for all Urban Consumers for Medical Care Professional Services published by the Bureau of Labor Statistics. An independent review organization would decide disputes by either the physician or the health plan over the interim payment amount. Its decisions would be binding on the physician and the health plan.
We need information about problems with UCR charges/maximum allowables from as many practicing physicians as possible.
Please share your stories that illustrate the problems of low or inconsistent payments for out-of-network services. We will not share your personal information with anyone without your permission.
Action , Jan. 16, 2009
Last Updated On
May 13, 2016
Originally Published On
March 23, 2010