On May 4 at 9 a.m. the Senate Business and Commerce Committee will hold an interim hearing to monitor implementation of SB 481 from the 2015 session intended to help protect consumers from surprise medical bills.
SB 481 was an important step in the right direction, allowing more Texas consumers to challenge surprise medical bills. But the work to fully protect consumers is not done. CPPP is advocating with a coalition of consumer and patient groups to stop surprise medical bills in emergencies.
Background on Surprise Bills
Consumers can get surprise medical bills when they are unknowingly treated by an out-of-network provider. This is especially likely to happen in emergencies. Consumers cannot select the doctors who treat them in an emergency room, and they cannot control which hospital an ambulance goes to.
When treated by an out-of-network provider, not only must a consumer pay the cost-sharing they’d expect—their deductible, copayments, and coinsurance—they can also be “balance billed” for everything the insurer did not pay up to the provider’s billed charge. There is often a significant difference in what providers charge and what insurers actually pay, and that difference is passed onto consumers in the form of surprise bills.
Patients who are at their most vulnerable when they have medical emergencies shouldn’t later be faced with a financial emergency because of a surprise bill.
Consumers do not get to choose their providers in emergencies and have no ability to ensure that all of their care will be in-network. Texas has a surprise bill mediation system that is good, but loopholes keep it from fully protecting consumers in emergencies. We should build on the current system to better protect consumers by:
- Stopping surprise bills from emergencies.
- Preventing consumers from being on the hook for extra charges from out-of-network providers they did not choose; they should be responsible for their deductibles, copays, and coinsurance, but not balance bills.
- Ensuring providers and insurers can directly utilize Texas’ mediation system to reach fair payment amounts in out-of-network billing disputes.
- Ensuring consumers are informed about payment disputes and their right to participate in mediation, if desired.
Who is Left Out in Texas?
In 2009, Texas created a mediation system to help consumers challenge surprise medical bills. Access to mediation was increased in 2015, and while requests for mediation have grown, relatively few consumers use it today. The following loopholes keep too many consumers trapped in a billing tug-of-war and unable to access help they need:
- Consumers must first know that they have a mediation right, then complete paperwork to request mediation, and attend a pre-mediation teleconference. These are significant administrative hurdles for the average consumer, much less for people recovering from emergencies.
- Only bills from 6 types of physicians can be challenged: radiologist, anesthesiologist, pathologist, emergency department physician, neonatologist, and assistant surgeon. Other bills are ineligible for mediation.
- Bills can only be challenged if care was delivered at an in-network hospital. Consumers are locked out if the closest emergency room was in a free-standing ER or an out-of-network hospital.
- Consumers are also locked out if their bill is less than $500, even if they receive several surprise medical bills that add up to more than $500. Only individual bills that top $500 can be challenged.
Progress in Other States
At least nine states have banned surprise bills in emergencies and three of them, including Florida, allow insurers and providers to directly resolve payment disputes. Florida serves as a good model for Texas. In 2016 the Florida Legislature passed and Gov. Rick Scott signed a bill that stops surprise medical bills. Consumers must pay their deductibles, copays, and coinsurance. Providers and insurers have access to independent dispute resolution to resolve any payment disputes.
More information on the surprise emergency medical bills in Texas is available in CPPP’s report: Surprise Medical Bills Take Advantage of Texans.