Legislation protecting Texas patients from surprise medical bills was signed into law on June 14 by Gov. Greg Abbott.
State Sen. Kelly Hancock (R-North Richland Hills) authored SB 1264, which prohibits health care providers from sending patients surprise bills in situations in which patients have no choice of provider, such as when a patient receives care from an out-of-network doctor at an in-network emergency room or when they receive care from an out-of-network doctor at an in-network facility.
● Ends surprise billing by out-of-network doctors and facilities when patients have little or no choice over who provides their care.
● Removes patients from the middle of the payment dispute resolution process between health care providers and insurers.
● Makes patients responsible only for their applicable co-pays, coinsurance and deductibles amounts with no additional amounts due resulting from arbitration between the out-of-network provider and health plan.
● Requires health plans to pay reasonable or agreed-to amounts to out-of-network emergency care and facility-based providers and allows those providers to dispute payment amounts through binding arbitration.
● Protects consumers and employers from premium increases and high out-of-pocket costs from excessive billing and charges in Texas.
TAHU’s President Nicole Scott of United Healthcare said, “TAHU thanks Sen. Hancock and his bipartisan Senate co-author and bill sponsors in the House of Representatives: Sen. John Whitmire (DHouston),
Rep. Tom Oliverson (R-Houston) and Rep. Trey Martinez Fischer (D-San Antonio).”
“SB 1264 is a groundbreaking solution for Texas consumers who have had to deal with surprise bills fordecades,” Scott continued. “TAHU is proud of the Texas Legislature for addressing this problem.”
It’s a nationwide problem.
Roughly one in every six times someone is taken to an emergency room or checks in to the hospital, the treatment is followed by a “surprise” medical bill, according to a study released Thursday. And depending on where you live, the odds can be much higher.
The report from the nonpartisan Kaiser Family Foundation finds that millions of people with what’s considered solid coverage from large employers are nonetheless exposed to “out-of-network” charges that can amount to thousands of dollars. It comes as congressional lawmakers of both parties and the Trump administration move to close the loophole, with a Senate panel scheduled to vote on legislation next week.
A patient’s odds of getting a surprise bill vary greatly depending on the state he or she lives in. Texas seems like a bit of a gamble, with 27% of emergency room visits and 38% of in-network hospital stays triggering at least one such bill. Minnesota looks safer, with odds of 2% and 3%, respectively.
Researcher Karen Pollitz of the Kaiser Foundation said the reasons for such wide differences are not entirely clear, but seem to be related to the breadth of hospital and doctor networks in each state, and the ways those networks are designed.
Patients in New York, Florida, New Jersey and Kansas were also more likely to get surprise bills. Among the other states where it was less likely were South Dakota, Nebraska, Maine and Mississippi.
Averaging the results nationwide, 18 percent of emergency room visits and 16 percent of stays at an in-network hospital triggered a surprise bill for patients with health insurance through a large employer, the study estimated.
That illustrates the need for Congress to get involved, said Pollitz, since large-employer plans are regulated by federal law and surprise billing protections already enacted by states like New York do not apply to them. “This is a prominent problem affecting patients, and it is beyond the reach of state laws to fix, and it is by definition beyond the ability of patients to fix on their own,” she said.
Next Wednesday, the Senate Health, Education, Labor and Pensions committee plans to vote on bipartisan legislation that would limit what patients can be charged to their in-network deductibles and copays. The bill from Sens. Lamar Alexander, R-Tenn., and Patty Murray, D-Wash., would require insurers to pay out-of-network doctors and hospitals the median — or midpoint — rate paid to in-network providers. The House Energy and Commerce committee is working on similar legislation. President Donald Trump has said he wants to sign a bill.
Major industry lobbies are going to battle over the issue. Insurers and employers generally favor the approach the Alexander-Murray bill takes on how to pay out-of-network providers, using an in-network rate as the reference point. But hospitals and doctors instead want disputed bills to go to arbitration. New York has an arbitration system and a recent study found it has worked well. However, some lawmakers are concerned that on a national scale it may lead to a costly new bureaucracy.
Surprise bills can come about in different ways. In an emergency, a patient can wind up at a hospital that’s not in their insurer’s network. Even at an in-network hospital, emergency physicians or anesthesiologists may not have a contract with the patient’s insurer. For a scheduled surgery at an in-network hospital, not all the doctors may be in the patients’ plan.
Bills can amount to tens of thousands of dollars and hit patients and their families when they are most vulnerable. Often patients are able to negotiate lower charges by working with their insurers and the medical provider. But the process usually takes months, adding stress and anxiety. When it doesn’t work out bills can get sent to collection agencies.
The Kaiser estimates are based on insurance claims from 2017 for nearly 19 million people, or more than 1 in 5 of those covered by large employers. The claims details came from an IBM Health Analytics database that contains information provided by large-employer plans. Researchers excluded patients 65 or older, most of whom are covered by Medicare.
The Alexander-Murray legislation also includes other ideas aimed at lowering medical costs by promoting competition to brand-name drugs, blocking health industry contracting practices can bid up prices, and requiring greater disclosure of information. A public health section of the bill would authorize a national campaign to increase awareness of the role vaccines play in preventing disease.