Out of Network

Physicians Applaud State for Fining Health Plan - 03/09/2020

Statement by Texas Medical Association (TMA) President David C. Fleeger, MD, about the Texas Department of Insurance (TDI) sanction of Blue Cross Blue Shield of Texas (BCBSTX) for delaying payment of certain out-of-network emergency care claims. TDI also found the plans distributed incorrect information about how to resolve balance bills to many HMO members who received out-of-network emergency care.

Making Billing More Balanced: Congress Considers Surprise Billing Legislation - 03/05/2020

The widespread call to severely curb or end “surprise” medical bills prompted competing federal legislation during the summer and fall of 2019. The negotiations, maneuvering, and bill markups have continued into this year.   

Plan Directories Should Cross-Reference Physician Network Status - 03/25/2019

As a physician, I rely on online health plan network directories to see not only my own network status but also that of physicians and facilities I refer patients to for additional care and treatment. While I can find what physicians are in network and what facilities are in network, there is no easy or uniform way to cross-reference the facilities at which the facility-based physicians provide services.

Protect Physicians from Billing-Situation Burden - 04/27/2018

SB 2127 generally would prohibit a credit reporting agency from including on a credit report a collection account for certain health care services if (1) the consumer was covered by a health benefit plan when he or she received services, and (2) the collection was for an outstanding balance (after copays, deductibles, and coinsurance).  While physicians are not in the business of, or interested in, reporting a patient to a credit agency, this legislation could result in consequences adverse to the health care market and patients as it relates to out-of-network care.

Transparency in Out-of-Network Payments Needed - 04/27/2018

Since the health plan’s contract or agreement is with the enrollee, we hope health plans don’t use the same argument, saying, “It’s proprietary” to circumvent the spirit of this legislation when their own enrollees make the same inquiry about the out-of-network payment methodology.

TMA: CHIP Managed Care Plans Responsible for Out-of-Network Payments - 04/27/2018

Because federal law prohibits patients covered by the Children's Health Insurance Program (CHIP) from paying anything other than a copay, the state of Texas should require managed care organizations in CHIP to cover the costs for out-of-network physicians. That's the position TMA takes in a formal letter to the Texas Health and Human Services Commission.

TMA Continues Push Against Surprise Billing - 04/27/2018

Following a big legislative win last year to protect physicians’ rights on balance billing, TMA weighed in Tuesday on how lawmakers can further reduce surprise medical bills. At a hearing of the Texas Senate Business and Commerce Committee in Houston, Beaumont anesthesiologist Ray Callas, MD, stressed the importance of improved patient education and accurate network directories.

Keep Monetary Threshold for Mediation - 04/26/2018

We are in opposition to House Bill 3133 as filed. The bill as filed expands the applicability of claim-dispute mediation to out-of-network assistant surgeons by adding them to the definition of “facility-based physician.” It also eliminates the $1,000 balance threshold for out-of-network claims eligible for mediation. We can support the addition of the assistant surgeon to the definition of “facility-based physician.” However, we have continued concerns about and oppose the elimination of the existing $1,000 balance-due threshold that makes a claim eligible for mediation after the patient’s copays, coinsurance, and deductibles have been paid.

Insurers’ Delays Burden Patients, Physicians; Could Cost Patients More - 11/16/2016

A growing number of physicians say health insurers are slow to enroll them as plan providers in the health plan’s insurance network, which spells fewer physician choices for patients and financial strife for the doctors. The process of “credentialing” — when plans contract with a doctor, finalize enrolling him or her in their system, and acquire hospital and facility privileges for the doctor — is taking twice as long as normal. Physicians say three of the state’s biggest health plans, UnitedHealthcare (UHC), Aetna, and Blue Cross and Blue Shield of Texas (BCBSTX), are delaying enrolling doctors in networks to reduce plan costs and increase the plans’ revenue.