TAHP_CompleteCoverage_Newsletter_0515-1Texas Legislators Seek To Remedy Unexpected Medical ChargesCapitol_April2015_Newsletter

What is Balance Billing?

When Texans find themselves in the middle of an emergency medical situation, the first thing on their minds is getting the care and treatment they need in the fastest way possible. Perhaps the last thing they’re questioning is the network status of the physician who is caring for them at the emergency room. 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 get home.

Due to a growing practice known as “balance billing,” more and more Texas patients are getting hit with outsize bills for care they received and 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 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.

While 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, 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 who mercilessly hound patients for payment.

Consumers Shouldn’t Shoulder Burden of Balance Billing

While 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, 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.

Solution: Expanded Use of Mediation

One important solution is currently under consideration in the 84th Legislature. Legislation authored by Texas Sen. Kelly Hancock, R-North Richland Hills, SB 481 (passed by the Senate Thursday) and State Rep. John Smithee, R-Amarillo, HB 1638 and HB 3133, would expand the use of mediation—already being successfully and efficiently utilized 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 its use will bring a higher degree of fairness to the situation and, ultimately, better protect Texans from surprise debt.

Additional Balance Billing Resources

Did You Know?

  • Economists and advocates estimate that consumers routinely pay almost $1 billion a year due to balance billing.
  • 8% of hospitals that contract with the three largest insurers in Texas have NO ER physician groups that are in-network (CPPP).
  • The percentage of in-network hospitals in Texas with no in-network emergency room physicians can range as high as 56% (CPPP).

Balance Billing 101
TAHP Supports 481
TAHP Guest Column: Healthcare billing practice causes unpleasant surprises
TAB Guest Column: ‘Balance Bill Shock’ Can Put You Back in the Hospital


healthyworkplace.170939Scott & White Health Plan Ranked 7th Healthiest Employer in North Texas

The largest not-for-profit health care system in Texas, and one of the largest in the United States, Baylor Scott & White Health, which includes Scott & White Health Plan, was recently ranked the 7th “Healthiest Employer” in North Texas by the Dallas Business Journal.  The system’s innovative wellness program, Thrive, is based on five pillars — weight loss, fitness, nutrition, stress management and tobacco cessation.

Results have been staggering, with almost 50,000 pounds lost; over 20,000 engaged employees and their families; 45 percent eliminated Metabolic Syndrome; 10 percent increase to low- risk population; 7.8 percent decrease in medium-risk population, 2.2 percent decrease in high-risk population and a 95 percent satisfaction rate.

Thrive has grown from a “nice-to-have” employee wellness program to a foundational piece of the organization’s health and wellness culture, cultivating healthy lifestyles for employees and patients alike. The cultural effects the Thrive program has created are reflected in the ability of Baylor Scott & White Health to attract and retain the best and brightest and have engaged leaders and employees who champion the health and wellness in their community. Creating a mission to “… serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing …” has set an example for North Texas and beyond.

FirstCare Earns Three-Year NCQA Accreditation


TAHP Member FirstCare Health Plans announced in late March it has earned three-year Accreditation status from the National Committee for Quality Assurance (NCQA), the industry’s most meticulous, comprehensive, and transparent health care accreditation program. NCQA accreditation provides consumers and businesses with an unbiased, third-party review to verify, score and publicly report health plan performance.

FirstCare President and CEO Darnell Dent said, “This accreditation confirms that FirstCare is fulfilling our commitment to quality for our members. It is an honor to be recognized for our hard work and dedication towards providing Texans with access to quality care and remaining strong in our belief that our communities should be healthy.”


ADA.171156_smallMerck Announces Educational Campaign with American Diabetes Association

TAHP Affiliate Member Merck has announced a collaboration with the American Diabetes Association that seeks to educate adults with diabetes about their increased risk for other potentially serious health problems, such as pneumococcal pneumonia, influenza (flu) and hepatitis B. The program aims to encourage individuals with Type 1 or Type 2 diabetes to communicate with their health care professionals about their increased levels of risk for these infections.

Merck’s medical director, Dr. Mel Kohn, M.P.H., said, “It is important for health care providers to help their diabetic patients understand their increased risk for infections, and to discuss the best approach to managing this increased risk. For example, adults with diabetes are three times more likely to develop pneumococcal pneumonia compared to adults without diabetes.”

According to the Centers for Disease Control and Prevention (CDC), 29.1 million people, or 9.3%, of the U.S. population have diabetes (it is estimated that of this population, 21 million people are diagnosed and 8.1 million people remain undiagnosed). Each year, 1.7 million new cases of diabetes are diagnosed in people aged 20 years and older.

The Merck/ADA program will help disseminate important information to the diabetes community about how to stay up to date on medical appointments, be aware of risk factors, and how to minimize additional complications.

bday-cake_smallApril Legislative Birthdays

4/4         Rep. John Raney
4/5         Rep. Larry Phillips
4/7         Rep. Alma Allen
4/7         Sen. Rodney Ellis
4/8        Rep. Byron Cook
4/9         Rep. Allen Fletcher
4/11       Rep. Matt Rinaldi
4/20       Rep. Jodie Laubenberg
4/21        Rep. Helen Giddings
4/23       Rep. Cesar Blanco & Rep. Andrew Murr
4/26       Rep. Myra Crownover
4/27       Rep. Rick Galindo
4/29       Rep. Rodney Anderson