Arbitration Requests Up, Consumer Complaints Down Under State Surprise Billing Law
By Joey Berlin

Texas’ law to prevent patients from getting unanticipated bills for out-of-network care is resulting in more requests for arbitration between practitioners and insurers this year, while consumer complaints are on the decline since the law’s implementation, according to a Texas Department of Insurance (TDI) report on the impact of the law six months into 2021.

Senate Bill 1264, which the Texas Legislature passed in 2019, introduced an independent dispute resolution process for physicians and health plans to resolve out-of-network billing disputes, and prohibited balance-billing patients in most cases for out-of-network services covered by the law. TDI is required to issue a biennial report on the impact of the law, and did so at the end of 2020, covering January to October of that year

The department also issued a midyear update in 2020 and did so again this year “to help monitor implementation” of SB 1264. Among other findings in TDI’s latest midyear report, the data show:

  • Arbitration requests in 2021 are way up from 2020. The first half of this year saw more than 50,000 arbitration requests, compared with just under 45,000 in the first 10 months of 2020. Of those 50,000 requests in the first six months of 2021, more than 35,000 came from emergency physicians.
  • Consumer complaints are down sharply since the law went into effect. In 2019, before the new law began applying to insurance claims, TDI received 1,031 complaints. In the 10-month period covered in the 2020 biennial report, it received 40, and there were 28 in the first half of 2021.
  • Arbitration cases in the first half of this year resulted in an average payment award of $883, compared with $967 in the first 10 months of 2020.

“We continue to see changes in the average original billed amounts, payment amounts, and settlement/award amounts. It’s unclear if these changes are related to the implementation of the new dispute resolution process, the pandemic’s effect on elective services in 2020, other causes, or a combination of factors,” the report said.

SB 1264 applies to state health plans that TDI regulates and to people with coverage through the state’s employee or teacher retirement systems. In the first 18 months of implementing SB 1264, TDI says it has received 98,586 requests to resolve medical billing disputes, which total $450 million.

Last Updated On

July 29, 2021

Originally Published On

July 29, 2021

Joey Berlin

Associate Editor

(512) 370-1393
JoeyBerlinSQ

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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