October 7, 2015 —

New Study Reveals Out-of-Network Charges In Texas for Life Threatening Emergencies Among The Highest In The Nation

AUSTIN, TX – The Texas Association of Health Plans (TAHP) today issued the following statement regarding a new national study by America’s Health Insurance Plans (AHIP) that found Texans face exorbitant out-of-network medical bills. Data from the study shows that Texas has the 5th highest out-of-network provider charges for life-threatening emergency services in the country.

The study examines the extreme variation and cost of out-of-network medical bills across the country. The findings underscore the affordability challenges facing millions of Americans, particularly when patients face “surprise” bills from out-of-network doctors and clinicians. As TAHP has emphasized in the past, providers are not limited in what they can bill for out-of-network medical services and are often not required to be forthcoming with consumers about those charges before they are treated.

These medical bills typically have wide variation and in many instances have no connection to the actual cost of a service or negotiated prices. Inflated out-of-network medical billing is linked to the practice of “balance billing,” a growing occurrence in Texas and across the nation that occurs when consumers receive out-of-network care, often in an emergency, and later receive separate bills for charges in excess of what their insurance company already paid for their care. Often a surprise to the consumer, these medical bills can be hundreds of times what Medicare would reimburse for the same services.

The AHIP report confirms that balance billing and inflated out-of-network charges billed by providers are a growing problem in the U.S. but especially in Texas where consumers are receiving ER bills for high acuity care that are 650% higher than Medicare, which is more than 15% higher than the national average for this service.

“A growing coalition of health plans, members of the business community and consumers worked closely with legislators in the 84th Legislature to address the practice of balance billing, boost transparency for consumers, and provide them with greater tools to address inflated medical charges,” said Jamie Dudensing, CEO of TAHP and a former practicing nurse. “While important strides were made, there is more work to be done. A new national study underscores why that need is stronger than ever in Texas, where emergency care is resulting in exorbitant surprise medical bills for Texas consumers. We must do all we can to ensure Texans are better informed about the costs of care and have greater access to simple options like mediation to dispute unreasonable medical bills.”

The AHIP report, “Charges Billed by Out-of-Network Providers:  Implications for Affordability,” is the most comprehensive analysis to date on out-of-network medical charges based on FAIR Health’s private health insurance database of more than 18 million claims from all 50 states.

Other Texas-specific findings include:

  • Potential excess charges for cervical/thoracic spinal injections averaged more than 1,200 percent of the Medicare fee for the same procedure.
  • Patients that underwent brain MRIs saw potential charges averaging more than 1,000 percent of the Medicare fee.
  • Some patients seeking emergency care faced potential excess charges averaging more than 600 percent of the Medicare fee.
  • Ultrasonic guidance for biopsies also incurred excess charges averaging more than 500 percent of the Medicare fee.

To read more about TAHP’s efforts to increase transparency and access to the process of mediation to challenge balance billing charges, visit the following links:

The Texas Association of Health Plans

The Texas Association of Health Plans (TAHP) is the statewide trade association representing private health insurers, health maintenance organizations, and other related health care entities operating in Texas. Our members provide health and supplemental benefits to Texans through employer-sponsored coverage, the individual insurance market, and public programs such as Medicare and Medicaid. TAHP advocates for public and private health care solutions that improve the affordability, access and accountability of health care for many Texans. As the voice for health plans in Texas, TAHP strives to increase public awareness about our members’ services, health care delivery benefits and contributions to communities across Texas.