People walk to and from the emergency room area at Parkland Memorial Hospital in Dallas. (2011 photo by G.J. McCarthy/Staff photographer)
A new report says many Texans with private health coverage are susceptible to a nasty surprise after a hospital stay — bills for thousands of dollars.
Consumer protections against “balance billing” are inadequate, despite a new regulation last year by the Texas Department of Insurance, said the report by the center-left think tank the Center for Public Policy Priorities.
Most Texans with private insurance are in Preferred Provider Organization policies, or PPO plans, the study says. Patients save money if they obtain treatments from providers within a specified network — those that have reached agreement on reimbursements and signed contracts with the insurer. But at hospitals, many doctors and labs are not “in network,” even though the hospital itself may be.
What that means is that for elective surgery, a patient may have checked to make sure his or her hospital was in network, but while there may receive services from an out of network anesthesiologist, pathologist and radiologist. They “balance bill” the patient because the PPO won’t pay much of their charge.
The study suggests a more common scenario is balance billing after a medical crisis. In such instances, of course, a patient and his or her loved ones don’t have time to check on whether any providers — hospital, doctors, labs — are in network. But very often the group practices of emergency physicians that work at in-network hospitals don’t have a contract with the three biggest insurers in Texas, the study says. Fifty-six percent of Texas hospitals that contract with Humana, for instance, lack any, in-network emergency room physicians, the report says.
Ouch. That could lead to a big unpaid bill.
“Imagine going out to eat and receiving separate bills from the restaurant, host, waiter, cook, and busboy, some … willing to negotiate discounts or accept coupons; … others … not,” it says.
Leticia Van de Putte, the Democratic Party's nominee for lieutenant governor, spoke at her party's state convention in June. (Ron Jenkins/Fort Worth Star-Telegram)
On Monday, the Senate State Affairs Committee heard testimony about balance billing.
Trey Berndt of AARP-Texas recounted how a Dallas area man suffered a stroke and then “almost had another stroke when he got home.”
Berndt explained that the man received bills for thousands of dollars from his emergency room doc and the non-hospital employees who administered his CT scan and MRI — all of whom were out of network in his insurance plan.
In July 2013, new “PPO network adequacy” rules issued by the state insurance department took effect. But the report says many gaps remain in the state’s protection of consumers.
At 23 Texas hospitals that contract with the three biggest PPO plans — UnitedHealthcare, Humana and Blue Cross Blue Shield — there are no emergency room doctors who are in those plans’ networks, the Center for Public Policy Priorities said after reviewing the most recent data submitted to the department.
Baylor University Medical Center in Dallas was one of the 23 hospitals, the center’s report said. At all of them, insured patients who visit the ER may later get an unpleasant balance billing surprise, it warned.
Baylor Health Care System officials did not immediately respond to a request for comment.
Sen. Leticia Van de Putte, a committee member and San Antonio Democrat who is running for lieutenant governor, said she’s not satisfied with current rules and laws.
“This isn’t working,” she said.
Van de Putte recalled how one provider listed on an insurance plan’s network had been dead two years. When she called to inform the insurer, an employee asked her how she knew the person was dead.
“Because I gave the eulogy,” she replied.