June 8, 2016
Texas patients sometimes feel
the pain from unexpected out-of-pocket costs not covered by their health insurance,
known as “surprise billing” or “balance billing.” The Texas Medical Association
(TMA) is taking aim at the problem, which occurs when a health insurance
company pays less than what a doctor charges, leaving the patient to pay the
balance of the bill.
TMA assembled a group of
physician leaders, the Balance Billing Task Force, to study the issue, reports Texas Medicine magazine. Among the causes TMA
research found for why patients are increasingly weighed down with unexpected
out-of-pocket costs: insurance companies selling plans with limited networks
and high deductibles, plus notoriously inaccurate network directories.
Often the “surprise” in this
billing is due partly to the health insurance companies’ failure to help their
customers understand how their insurance coverage works. Several things are happening
due to this lack of understanding:
- Patients might incorrectly assume the care they are receiving is
covered by their policy;
- The insured patient might not yet have met his or her deductible,
meaning he or she must pay more out of pocket before insurance benefits kick
- The physician or health care provider treating the patient might
not be in the network list for that patient’s health plan. In that situation,
when patients receive care from a doctor not listed in their insurance plan’s
network, the health insurance company can refuse to pay for some or all of that
out-of-network medical care. As a result, the out-of-network physician may charge
the insured patient for the remaining balance of the bill.
Some states are seeking to stop
surprise bills by limiting physicians’ ability to bill patients for the balance
owed in those situations, but TMA physician leaders say lawmakers must hold
health insurers accountable for the larger problems of inadequate networks,
policy limits, and other business practices.
“Nobody wants surprise
bills. But the real problem is not balance billing. The real problem is narrow
networks,” said Denton obstetrician-gynecologist Joseph Valenti, MD, Balance
Billing Task Force member and former chair of TMA’s Council on Socioeconomics. “Patients
are in the middle of this because it’s not made clear to them what they are
Health plans want to cut costs and
increase profits. One way to accomplish this is to pay less for care, and one way
to accomplish that is to have fewer doctors in the plan’s provider network,
forcing more patients to receive out-of-network care. Then the patient is
responsible for paying more of his or her medical bills, while the insurer pays
“The narrower [insurers]
make these networks, the more they shift costs onto patients and doctors, and
if regulators don't look at this, we are all in big trouble,” Dr. Valenti said.
It’s not for lack of trying
on physicians’ part, TMA leaders say. For 61 percent of doctors who tried to join a plan’s
network, the insurer essentially said no. (According to TMA and Texas physician surveys,
32 percent of those physicians received an unacceptable offer from the insurer,
while 29 percent received no response at all.)
"We try hard to be in
network,” said Keith A. Bourgeois, MD, chair of TMA’s Balance Billing Task
Force. “The big dilemma is that sometimes being out of network is not a choice
of the practice.” He said in those cases, the insurance company makes that
choice; doctors receive “low-ball, take-it-or-leave-it offers” from health
insurers, which are difficult for a business to accept (and doctors’ offices
are businesses with overhead and employees just like any other business).
“I just renegotiated my
lease, and the building expects a 3-percent rise every year,” said Dr.
Bourgeois, a Houston ophthalmologist. “Many of the [insurance] contracts I hold
are the same as they were 10 years ago.”
According to TMA research,
only two insurers offer broad preferred provider organization (PPO) networks ¾ containing ample physicians
for patients to see ¾ in Texas’ 2016 Affordable Care Act insurance
marketplace, and both sell only regional coverage. In the 2015 health insurance
marketplace, four health plans offered hundreds of PPO plans across the state.
says it will support legislation to preserve
physicians’ rights to bill for care they provide, while at the same time arming
patients with more information to lessen the likelihood of receiving a surprise
want physicians to be a part of the solution. And we want the same things our
patients want, which is transparency, not just from physicians but from all
health plans and all health care providers, because our patients don't deserve
to get a surprise bill,” said Beaumont anesthesiologist Ray Callas, MD, task
force member and chair of TMA’s Council on Legislation.
Dr. Callas recently presented TMA’s
new legislative recommendations to protect and inform patients to the Senate
Committee on Business and Commerce,
House Committee on Insurance. TMA recommends:
- Mandatory increase in state agency
oversight of the adequacy of insurer networks, especially for insurers often
brought to mediation by patients.
- Expanding the current mediation
process to include all out-of-network physicians, other health care professionals,
and vendors providing services at a facility. (The current mediation process
pertains only to some out-of-network, hospital-based physicians. The current
mediation threshold of a $500 balance after copayments, deductibles and
coinsurance should be maintained.)
- Expansion of the current mediation
process to apply to any out-of-network hospital, outpatient hospital,
ambulatory surgical center, free-standing emergency medical facility or
department, and ground ambulance services.
- Requiring that, prior to any
preauthorized elective services, the insurer inform the patient about the
network status of the facility-based physicians and others who may bill for
- Use of a standard form by physicians
and providers to tell patients which physicians and providers might be involved
in their care and how to contact them. Physicians and providers also should advise
patients that it’s possible that another doctor or provider might treat the
patient when unforeseen scheduling or staffing changes at the facility occur.
- Requiring insurers selling PPOs to
include “a clear and conspicuous notice regarding the implications of using or
receiving services from an out-of-network physician … and the potential for
balance billing” on their websites, policy documents, and directories.
- Requiring insurance brokers and
agents to educate consumers about the inherent limitations of the plans they
buy, especially their out-of-pocket responsibilities for care provided both in
and out of network.
TMA has also unveiled “Why Did I Get That Medical Bill?” to help explain to the
public the root causes of unexpected medical bills.
“[Having narrow networks with too few doctors]
is like buying a warranty on a car and finding out there’s only one shop in the
entire [town] you can take your car to,” said Dr. Valenti.
TMA is the largest state medical society in the nation,
representing more than 49,000 physician and medical student members. It is
located in Austin and has 110 component county medical societies around the
state. TMA’s key objective since 1853 is to improve the health of all Texans.
Contact: Brent Annear (512) 370-1381;
cell: (512) 656-7320; email: firstname.lastname@example.org
Cooper (512) 370-1382; cell: (512) 650-5336; email: email@example.com
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