4 Dallas Medical Journal December 2018
Under the Dome
When the 86th legislative session gavels open
on Jan. 8, physicians will face new threats to their
practices and renewed challenges from sessions
past. The January DMJ will include a preview of the
session, but in the meantime, here’s a topic to whet
your appetite for the five months to come.
Although the House of Medicine does all it can to address
the factors that increase the odds of patients getting
blindsided by unexpected, costly medical bills, this issue
remains alive.
Over the summer, surprise billing came into public focus with the
story of an Austin man who received bills of nearly $109,000 for a
four-day hospital stay in 2017. After negative nationwide press, the
hospital knocked his bill down to some $300, but the conditions that
lead to such stories have not changed.
TMA again will tackle balance billing when the Legislature convenes
next month. TMA will push to hold insurers more accountable for
network adequacy while preserving a physician’s right to bill for services.
“Individuals need to know what they’re covered for,” says Arlo Weltge,
MD, a Houston emergency physician and vice speaker of TMA’s Board
of Trustees. “The insurance companies need to make clear what they
cover, and provide alternatives when issues need to be addressed.”
A big unwanted surprise
The passage of Senate Bill 507 marked one of medicine’s top
achievements during the 2017 session. The TMA-backed measure
opened the mediation process to more out-of-network practitioners
at in-network facilities. More than 90 percent of the billing disputes
that go to mediation — which can be used for bills totaling more than
$500 after copayments, deductible and coinsurance — are resolved in
the initial informal conference call. SB 507 also expanded mediation to
out-of-network emergency care.
But in August, the story of Austin teacher Drew Calver shined a
light on a problem that’s far from fixed.
He had a heart attack in April 2017, and a neighbor rushed him
to the emergency department at St. David’s Medical Center, which
was out-of-network under his school district health plan. Although
insurance picked up nearly $56,000 of the cost of his four-day
hospitalization, St. David’s billed him for the remaining $108,951. The
highest charges of the bill included nearly $43,000 for four stents and
almost $11,000 for room charges.
After the negative publicity the story generated, St. David’s lowered
Calver’s bill twice, settling on a balance of $332.29.
Houston emergency physician Jeremy Finkelstein, MD, says
patient education is key to addressing surprise bills. Even patients who
understand their option to mediate don’t always understand what they
can mediate, he says.
“We have patients who call up to do mediation with the Texas
Department of Insurance, and they’re calling about their deductible or
copay,” Dr. Finkelstein says.
A November 2016 study by PolicyGenius surveyed 2,000 health
Surprise
medical bills
insurance consumers. Just 4 percent correctly identified the terms
“deductible,” “copay,” “coinsurance,” and “out-of-pocket maximum.”
Insurer accountability
TMA lobbyist Clayton Stewart says Calver’s story shows that the
physician should not be the only one held accountable for surprise
bills.
“You’ve got the healthcare provider, you’ve got the facility (because
without the physician, the hospital is just an expensive hotel), and
you’ve got the insurer,” he says. “For several years, the finger has been
pointed at the physicians because they have the most direct contact
with the patient, and they should. But sometimes that brings negative
consequences.”
TMA’s legislative agenda on balance-billing for 2019 could include
advocating for:
• More frequently updated online network directories: Health plans
are required to update their directories monthly. A TMA-backed bill
during 2017 required health plans to update their directories daily,
and another required updates every two business days, but both bills
died.
• A data call by TDI to provide a full picture of network adequacy,
billing and related issues.
• PPO network adequacy examinations by TDI.
Cost transparency, or lack of, is one aspect of surprise billing that’s
largely up to the insurer, Stewart says. Although physicians can help
patients by telling them their out-of-network cash price up front,
the onus on finding what insurance covers ahead of time is up to the
patient and the health plan.
In 2019, TMA will again stress to lawmakers that narrow networks
are a large part of the problem.
“I know several people who run emergency room groups, and
insurers just won’t contract with them,” Dr. Finkelstein says. “Either
practices are too small, or they’re a single hospital group, or they’re in
a very competitive market, or the plans have made a deal with a larger
hospital in the area to squeeze other practices.”
Another aspect of surprise billing that Dr. Weltge says should be
included in the discussion is the resources and interventions available
to physicians that were “‘Star Wars’ sorts of things” 15 or 20 years ago.
Those high-tech, high-cost tests can save lives and rule out serious
illnesses.
“We don’t want to miss treatable diseases that give a lifetime deficit,”
he says. “We’re not dealing with, ‘Gee, I stubbed my toe and it’s sore
today.’ These are issues that, without the appropriate due diligence and
expectation, could cause individuals to lose their ability to speak, or
walk on their own, or to climb a flight of stairs.”
— Texas Medicine