TX Lawmakers Might Revamp “Surprise Medical Bill” Mediation

by Mark Richardson

AUSTIN, Texas – It can be a major setback for Texas health care consumers: a surprise bill for thousands of dollars from a doctor who isn’t in your insurance company’s network. Texas lawmakers approved a mediation plan in 2015 to allow patients to negotiate those bills, but health care advocates say it’s so complex that too few consumers are using it.

According to Stacey Pogue, senior policy analyst with the Center for Public Policy Priorities, under the current payment system, a medical procedure can become a Catch-22 for the patient.

“Say, a colonoscopy – they often find out if their doctor is in-network and the facility is in-network,” Pogue said. “But they don’t know to ask – or they can’t get good information on – whether the anesthesiologist is going to be in-network; if they have a biopsy and it goes to a lab, if that pathologist in network.”

Pogue said patients, particularly during emergencies, are rarely informed that they may be treated by an out-of-network provider, and those bills must be paid in addition to any deductibles or co-pays. She said Texas legislators are looking at several ways to address the problem, simplify the process and make it easier to arbitrate the bill.

Surprise bills have become a hot potato the health care system doesn’t want to deal with, Pogue said.

“Insurance companies, as you can imagine, and doctors don’t agree on who should pick up the tab. Today, they just push it off on patients because they can,” she said. “And so, if the Legislature says ‘No, you can’t push that cost off on a patient,’ what these other agencies care about is who has to pick up that cost. And that’s the complicating factor.”

Since 2015, about 250,000 Texans who received out-of-network bills were eligible for mediation, Pogue said, but fewer than 4,000 have taken advantage of it.

“Hopefully, it’ll also help consumers know about the program, because that’s one of the biggest barriers is that they created this program to help consumers, but they don’t know about it,” she said. “It does require that there’s a notice that’s put on your medical bill that you have a right to mediation.”

Pogue said she’s confident that the Legislature will act on surprise medical bills this session. She said the issue has bipartisan support in both the House and Senate.

A report, written by Pogue, on the issue of surprise out-of-network medical bills is available here.