When we find ourselves in the middle of an emergency medical situation, the first thing on our minds is getting the care and treatment we need in the fastest way possible.
Perhaps the last thing we’re questioning is if the physician who is caring for us at the emergency room is in or out of our insurance network.
Yet for many Texans, this piece of information can mean the difference between customary medical costs and unexpected and exorbitant out-of-network medical bills waiting for them in the mailbox when they return from the ER.
Thanks to an increasingly common practice known as “balance billing,” more and more patients are getting hit with outsize bills for care they received and were given little recourse.
This frustrating practice will likely continue to grow without the intervention of the Texas Legislature.
A national issue for more than a decade, balance billing occurs when people seek care at a facility identified as “in network” by their PPO plan, but are treated by medical personnel who are “out of network” because in-network practitioners are not available or are not allowed due to exclusive agreements — essentially monopolies — between the physicians and the hospitals.
The resulting charges, above and beyond insurance coverage, can be hundreds of times the accepted rates.
Across the country, consumers are estimated to be paying upwards of $1 billion in balance-billed charges.
Granted, some hospitals choose to engage with out-of-network providers as a way to give their patients access to a wide variety of skilled physicians.
But the potential financial burden is one that patients should not — and often cannot — handle.
Unfortunately, many of those bills end up in the hands of collection agencies that mercilessly hound patients for payment.
The Texas Department of Insurance has taken several steps to address balance billing, including boosting transparency, adopting stringent network adequacy regulations and implementing stronger payment protections.
Still, we must take further action to ensure the consumer is not left shouldering the burden of disputed charges.
To be sure, balance billing is just one symptom of the greater challenges posed by out-of-network care.
But it’s an issue that will only continue to grow until every involved party comes to the table and works together to find reasonable solutions.
This includes providers, insurers, hospitals and government leaders.
One important solution is under consideration in the 84th Legislature.
Legislation authored by state Sen. Kelly Hancock, R-North Richland Hills, and state Rep. John Smithee, R-Amarillo, would expand the use of mediation — already being successfully and efficiently used in Texas — to ensure consumers are billed the fair amount for the care they received and that physicians are reimbursed accordingly and in a timely fashion.
The Texas Association of Health Plans is part of a growing coalition, including the Texas Association of Business and others, who believe providing consumers with greater access to mediation is essential to tackling the practice of balance billing.
Expanding mediation will bring a higher degree of fairness to the situation and, ultimately, better protect Texans from surprise debt.
Jamie Dudensing is CEO of the Texas Association of Health Plans.