Been surprise billed?
Consumers who have received surprise bills for out-of-network health care may seek relief by applying online at tdi.texas.gov/consumer/cpmmediation.html or calling (800) 252-3439.
Some Texans who visit hospital emergency departments, undergo surgery or both are facing sticker shock upon learning a sizable portion of their medical bills will not be covered by their insurance companies.
It happens because, while they are visiting a hospital that's within their insurance network, the ER doctors and other medical professionals such as radiologists and anesthesiologists may not be hospital employees - and thus outside the patient's network.
That provider can accept the insurance payment, then is allowed to do what's called a "balance bill" - a bill for the additional amount, the balance, that they'd like to charge directly to the patient.
Some also call it surprise billing, and it's been outlawed in many states - but not in Texas. Here, most patients learn about it only when the bills start hitting their pocketbooks.
That's what happened to Gilmer machinist Mike Newland, who said he visited the emergency department at Good Shepherd Medical Center in Longview on Jan. 28 after falling and hurting his shoulder.
Newland, 59, said he later received bills for $1,533 from the hospital emergency department and $1,020 from Acute Care Specialists in Dallas. He said his hospital bill was discounted by $628, and he paid $905 that he applied toward his annual deductible with Blue Cross and Blue Shield, his insurance provider.
His insurance company did not cover the bill from Acute Care Specialists because it was out of network. He said the bill was adjusted to $816 after he called its billing service.
"I can afford to pay the bill, but that is not the point," Newland said. "You have no control of seeing anybody who is out of network in an emergency situation."
Newland complained about the out-of-network costs to state Sen. Kevin Eltife, R-Tyler, who notified Newland via email about Senate Bill 481. The measure, which took effect a year ago, allows consumers to seek mediation through the Texas Department of Insurance for bills that exceed $500 and requires a physician to notify patients of that right when sending the bill. SB 481 lowered the threshold from $1,000.
The measure applies when patients go to an in-network hospital or facility and later receive a bill from a doctor who does not have a contract with their health plan, according to the insurance department. The recourse applies to consumers who enroll in preferred provider organizations or if they have coverage through the Employees Retirement System of Texas.
The new law covers consumers with PPOs because PPOs give consumers more options on health care providers than health maintenance organizations, according to insurance department spokesman Ben Gonzalez.
Many seek help
Consumers may seek the relief by applying online at website at tdi.texas.gov/consumer/cpmmediation.html or calling the Consumer Help Line at (800) 252-3439 during business hours weekdays.
Many consumers apparently have sought recourse, according to Gonzalez. As of Thursday, the insurance department had received 1,469 out-of-network mediation requests since the bill went into effect Sept. 1, 2015.
Of the total, the insurance department resolved 1,385 out-of-network requests through initial conference calls with the health care provider and the insurers, Gonzalez said. Consumers may take part in the conference calls.
Gonzalez said 84 of the requests were referred to the state Office of Administrative Hearings; the health-care providers and insurers split the court costs of the hearings.
Newland said he filed for mediation July 5 but did not take part in any conference call.
"I'm still talking to my insurance company," he said.
Blue Cross Blue Shield spokeswoman Edna Perez-Vega said in an email that such billing issues are "complex and clearly an issue of concern for our members and health care consumers across the state and nation."
She declined to discuss Newland's complaint on confidentiality grounds.