Evening Out the Scale: TMA Gears Up for Another Legislative Battle Over Surprise Bills
By Joey Berlin Texas Medicine November 2018

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Surprise medical bills are awfully persistent zombies. 

The House of Medicine does what it can to address the factors that increase the odds of patients getting blindsided by unexpected, costly medical bills, and yet, the undead issue rises again and again.

Over the summer, surprise billing came back into public focus with the story of an Austin man who received hospital bills totaling nearly $109,000 after a four-day hospital stay in 2017. Following negative nationwide press, the hospital knocked his bill down to a miniscule fraction of that. But the conditions that lead to such stories haven’t gone anywhere.

The Texas Medical Association is once again gearing up to tackle balance billing when the Texas Legislature convenes in 2019. TMA will push to hold insurers more accountable for network adequacy while preserving a physician’s right to bill for his or her services.

“Individuals need to know what they’re covered for,” said Arlo Weltge, MD, a Houston emergency physician and vice speaker of TMA’s Board of Trustees. “The insurance companies need to make clear what they will and will not cover, and provide alternatives when issues need to be addressed. And the disclosures of what the costs are … need to be included by the health plans.”

A big unwanted surprise

The passage of Senate Bill 507 by Sen. Kelly Hancock (R-North Richland Hills) marked one of medicine’s top achievements during the 2017 legislative session.

The TMA-backed measure opened up the highly successful mediation process to more out-of-network practitioners at in-network facilities. More than 90 percent of the billing disputes that go to mediation — which can be used for bills totaling more than $500 after copayments, deductible, and coinsurance — are resolved in the initial informal conference call. SB 507 also expanded mediation to out-of-network emergency care.

But in August, the story of Austin schoolteacher Drew Calver shined a light on a problem that’s far from fully fixed.

According to a story from Kaiser Health News and NPR, Mr. Calver suffered a serious heart attack in April 2017, and a neighbor rushed him to the emergency department at St. David’s Medical Center. The hospital was out-of-network under his school district health plan. He was hospitalized for four days. Although insurance picked up nearly $56,000 of the cost of his hospitalization, St. David’s billed him for the remaining $108,951. Some of the largest components of the overall bill, according to the report: nearly $43,000 for four stents and almost $11,000 for room charges.

After the negative publicity the story generated, St. David’s lowered Mr. Calver’s bill twice, finally settling on a balance of $332.29, which he paid over the phone, according to NPR.

Houston emergency physician Jeremy Finkelstein, MD, says patient education is key to addressing surprise bills. For example, even patients who understand their option to mediate don’t always understand what they can mediate, he says. 

“We have patients that call up to do mediation with the Texas Department of Insurance (TDI), and they’re calling about their deductible or copay,” Dr. Finkelstein said. “Well, that’s not a balance bill; that’s your deductible that you contractually agreed to with your insurance company. That’s not a surprise bill.”

A November 2016 study released by PolicyGenius surveyed 2,000 health insurance consumers. Just 4 percent correctly identified the meaning of all four of the terms deductible, copay, coinsurance, and out-of-pocket maximum.

Insurer accountability

TMA lobbyist Clayton Stewart says Mr. Calver’s story illustrates that the physician should not be the only one held accountable for surprise bills.

“It’s kind of showing the [whole] equation. You’ve got the health care provider, you’ve got the facility — because, without the physician, the hospital is just a really expensive hotel — and you’ve got the insurer as well,” he said. “It’s showing that it’s not just on the physician. I think for several years, the finger has been pointed at the physicians because they’re in the most direct contact with the patient. And they should be. It’s just that sometimes that bears negative consequences, unfortunately.”

Mr. Stewart says TMA’s legislative agenda on balance-billing for 2019 could include advocating for: 

  • More frequently updated online network directories: Health plans are now only required to update their directories monthly. TMA backed one bill during 2017 that would have required health plans to update their directories daily, and another that would have required it every two business days, but both bills died. 
  • A data call by TDI to provide a full picture of network adequacy, billing, and related issues.
  • PPO network adequacy examinations by TDI.

Cost transparency, or lack thereof, is one aspect of surprise billing that’s largely up to the insurer, Mr. Stewart says. While physicians can help patients by telling them their out-of-network cash price up front, the onus on finding out what insurance covers ahead of time is up to the patient and the health plan.

“The physician has no way of doing it, and the physician doesn’t have time to get on the phone and call the insurance company for every patient,” Mr. Stewart said. “They wouldn’t see half their patients if they did that.”

In 2019, TMA will again stress to lawmakers that narrow networks are a large part of the problem. 

“I know several people that run emergency room groups, and insurers just won’t come to the table with them. They won’t contract with them,” Dr. Finkelstein said. “Either [practices are] too small or they’re a single hospital group or they’re in a very competitive market, or … [health plans have] made a special deal with a larger hospital in the area to kind of squeeze other practices.” 

One other aspect of surprise billing that Dr. Weltge says should be part of the discussion is the fact doctors now have resources and interventions that were “‘Star Wars’ sorts of things” 15 or 20 years ago. Those high-tech, high-cost tests can save lives and rule out serious illnesses.

“We don’t want to be missing treatable diseases that will be giving a lifetime deficit. We’re not dealing with, ‘Gee, I stubbed my toe and it’s sore today.’ These are potential things that the individual may lose their ability to speak, or lose their ability to walk around on their own, or lose their ability to climb a flight of stairs, without the appropriate due diligence and expectation,” Dr. Weltge said.

“We as a society, I don’t think want to lose that. Even though the evolution of this process, where we’ve come from in the last decade, is miraculous, it is currently expensive. And we as a society haven’t decided how we’re going to deal with it yet. But we need to maintain it.”

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Tex Med. 2018;114(11):44-46
November 2018 Texas Medicine Contents
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Last Updated On

March 20, 2019

Joey Berlin

Associate Editor

(512) 370-1393
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Joey Berlin is associate editor of Texas Medicine. His previous work includes stints as a reporter and editor for various newspapers and publishing companies, and he’s covered everything from hard news to sports to workers’ compensation. Joey grew up in the Kansas City area and attended the University of Kansas. He lives in Austin.

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