This week, NBC 5 in Dallas/Fort Worth did a two-part investigative story on a Texas family’s repeated trouble with balance billing. Melinda Allen went to the emergency room of a Fort Worth hospital with what she thought was appendicitis. She was diagnosed with a large ovarian tumor that was removed two days later. She went to a hospital that was in her insurance company’s network, but she was treated by an emergency room physician who was out-of-network. She later received a $670 bill from that doctor. The practice is called “balance billing.” Melinda’s doctor charged $947 for the ER visit. Her insurer paid the doctor $277. The doctor then charged the balance—$670—to Melinda.
Melinda was upset, as many Texans are, when they get balance billed. She’d already paid $5,000 out-of-pocket for health care on top of her $1,500 monthly premiums – yet she still got a large and unexpected balance bill, even though she went to an in-network hospital.
A few months later her husband went to the same in-network ER and was treated by the same out-of-network ER doctor. The family was balance billed again. This time for $530.
Balance billing is especially concerning when a patient has no ability to choose providers, as in an emergency. We don’t get to choose which doctors treat us when we go into an emergency room. And unfortunately, there are no guarantees that if you go to an in-network hospital in an emergency, the doctors who treat you—ER doctors, anestiologists, radiologists, and pathologists, for example—will also be in the network. This reality leaves even diligent consumers at risk of an unexpected balance bill in an emergency.
In the videos, you can hear the Allens’ frustration of being trapped between an emergency room doctor and an insurance company that couldn’t agree on the right price for an ER visit.
We have some important protections in place in Texas, highlighted by the second half of the two-part series. Texas consumers with certain types of health plans who are balanced billed at least $1,000 by an out-of-work hospital-based physician at an in-network hospital can request mediation from the Texas Department of Insurance (the balance bill must reach $1,000 from any one provider, not cumulatively across providers for the same visit). TDI has received relatively few requests for mediation since the program started in 2009, but we understand that where mediation has been requested, doctors and insurers suddenly reach an agreement on price before mediation begins.
Probably even more meaningful for most consumers are new rules that took effect in the summer of 2013 related to network adequacy and balance billing in Preferred Provider Organizations (PPOs). CPPP followed the multi-year path of these rules and hailed the final result from the Texas Department of Insurance as offering the most protection against balance billing to consumers as is possible until the legislature takes decisive action to end the practice. Both doctors and insurers denounced the rules.
The new rules raise the standard for what insurers have to pay doctors in an emergency, which will reduce the frequency and amount of balance bills. The new rules also say that any amount consumers pay toward a balance bill from an emergency must be credited toward their in-network deductible and in-network out-of-pocket limit. (Unfortunately, it appears that at least Melinda’s ER visit happened before these new rules took effect, and neither of the Allens’ balance bills was large enough to trigger a mediation right.)
During the 2013 Texas legislative session, insurance companies backed efforts to prevent these key balance billing protections from taking effect. Those efforts failed in 2013, but unfortunately, we may see similar attempts to weaken balance billing protections next legislative session. Texas needs to continue making progress—not moving backward—in protecting consumers from unexpected balance bills.
Consumers do not have the ability to prevent balance billing in situations like emergencies when they can’t select the doctors who’ll treat them. That’s why consumers need strong laws in place to protect them.
