Despite years of legislative work on the issue — including Senate Bill 507 from earlier this year — patients will continue to struggle with surprise bills until lawmakers clean up health insurance companies’ business plans, Houston-area emergency physician Arlo Weltge, MD, told the House Insurance Committee last week.
“Patients and employers are purchasing their insurance with an expectation of having adequate coverage for unforeseen, as well as planned, life events. However, consumers’ expectations are not always consistent with their plan’s design,” Dr. Weltge told the panel.
“To reduce the likelihood of an unanticipated balance bill, it is crucial that health plans provide adequate networks,” he added. “This is true because if a plan provides an adequate network, patients are less likely to receive services out of network. Balance billing occurs only when services are received out of network.”
With the opening of the 86th legislative session still thirteen months away, the Insurance Committee convened a mid-December hearing and launched into the interim studies assigned by House Speaker Joe Straus (R-San Antonio). One of the most contentious issues revolves around surprise medical bills that a patient may receive from a physician once their health plan has paid its portion of the bill. Beyond agreeing that unsuspecting patients do in fact receive balance bills, there was zero consensus among the multitude of parties present about the reason or the solution.
Testifying on behalf of TMA, Dr. Weltge – who is vice speaker of the TMA House of Delegates – reminded legislators of physicians’ concerns that all patients receive necessary care regardless of ability to pay and the importance of compensating physicians for the work they perform and care they provide.
While TMA is grateful for the progress made in the 2017 legislative session – expanding mediation for certain out-of-network claims – considerable work remains, he said. That includes:
- Patient literacy and education on insurance plans;
- Expanded network adequacy and opportunities for physicians to join networks;
- Price transparency so patients can make informed decisions;
- Provider network accuracy; and
- Proactivity on behalf on insurers regarding prior authorizations for elective procedures and maximum allowable out-of-pocket amounts for procedures and office visits.
Several speakers at the hearing noted that the Texas Department of Insurance (TDI) should be given authority not only to review the adequacy of PPO networks periodically, but also to ensure that third party administrators adhere to transparency standards — both of which would likely result in far fewer surprise bills.
The discussion was vigorous with all parties holding someone other than themselves responsible for surprise medical bills. After more than two and a half hours of questions, storytelling, debate, and finger pointing, the only clear conclusion to reach is that finding equitable and palatable resolution will be a marathon indeed. TMA will keep you apprised of developments.
Action, Dec. 15, 2017