TMA assembled a group of physician leaders, the Balance Billing Task Force, to study the issue, reports Texas Medicine magazine. Among the causes TMA research found for why patients are increasingly weighed down with unexpected out-of-pocket costs: insurance companies selling plans with limited networks and high deductibles, plus notoriously inaccurate network directories.
Often the “surprise” in this billing is due partly to the health insurance companies’ failure to help their customers understand how their insurance coverage works. Several things are happening due to this lack of understanding:
- Patients might incorrectly assume the care they are receiving is covered by their policy;
- The insured patient might not yet have met his or her deductible, meaning he or she must pay more out of pocket before insurance benefits kick in; and
- The physician or health care provider treating the patient might not be in the network list for that patient’s health plan. In that situation, when patients receive care from a doctor not listed in their insurance plan’s network, the health insurance company can refuse to pay for some or all of that out-of-network medical care. As a result, the out-of-network physician may charge the insured patient for the remaining balance of the bill.
Some states are seeking to stop surprise bills by limiting physicians’ ability to bill patients for the balance owed in those situations, but TMA physician leaders say lawmakers must hold health insurers accountable for the larger problems of inadequate networks, policy limits, and other business practices.
“Nobody wants surprise bills. But the real problem is not balance billing. The real problem is narrow networks [health insurance networks with a limited choice of physicians and health care providers],” said Denton obstetrician-gynecologist Joseph Valenti, MD, Balance Billing Task Force member and former chair of TMA’s Council on Socioeconomics. “Patients are in the middle of this because it’s not made clear to them what they are purchasing.”
Health plans want to cut costs and increase profits. One way to accomplish this is to pay less for care, and one way to accomplish that is to have fewer doctors in the plan’s provider network, forcing more patients to receive out-of-network care. Then the patient is responsible for paying more of his or her medical bills, while the insurer pays less.
“The narrower [insurers] make these networks, the more they shift costs onto patients and doctors, and if regulators don't look at this, we are all in big trouble,” Dr. Valenti said.
It’s not for lack of trying on physicians’ part, TMA leaders say. For 61 percent of doctors who tried to join a plan’s network, the insurer essentially said no. (According to TMA and Texas physician surveys, 32 percent of those physicians received an unacceptable offer from the insurer, while 29 percent received no response at all.)
"We try hard to be in network,” said Keith A. Bourgeois, MD, chair of TMA’s Balance Billing Task Force. “The big dilemma is that sometimes being out of network is not a choice of the practice.” He said in those cases, the insurance company makes that choice; doctors receive “low-ball, take-it-or-leave-it offers” from health insurers, which are difficult for a business to accept (and doctors’ offices are businesses with overhead and employees just like any other business).
“I just renegotiated my lease, and the building expects a 3-percent rise every year,” said Dr. Bourgeois, a Houston ophthalmologist. “Many of the [insurance] contracts I hold are the same as they were 10 years ago.”
According to TMA research, only two insurers offer broad preferred provider organization (PPO) networks ¾ containing ample physicians for patients to see ¾ in Texas’ 2016 Affordable Care Act insurance marketplace, and both sell only regional coverage. In the 2015 health insurance marketplace, four health plans offered hundreds of PPO plans across the state.
TMA says it will support legislation to preserve physicians’ rights to bill for care they provide, while at the same time arming patients with more information to lessen the likelihood of receiving a surprise bill.
“Lawmakers want physicians to be a part of the solution. And we want the same things our patients want, which is transparency, not just from physicians but from all health plans and all health care providers, because our patients don't deserve to get a surprise bill,” said Beaumont anesthesiologist Ray Callas, MD, task force member and chair of TMA’s Council on Legislation.
Dr. Callas recently presented TMA’s new legislative recommendations to protect and inform patients to the Senate Committee on Business and Commerce, and the House Committee on Insurance. TMA recommends:
- Mandatory increase in state agency oversight of the adequacy of insurer networks, especially for insurers often brought to mediation by patients.
- Expanding the current mediation process to include all out-of-network physicians, other health care professionals, and vendors providing services at a facility. (The current mediation process pertains only to some out-of-network, hospital-based physicians. The current mediation threshold of a $500 balance after copayments, deductibles and coinsurance should be maintained.)
- Expansion of the current mediation process to apply to any out-of-network hospital, outpatient hospital, ambulatory surgical center, free-standing emergency medical facility or department, and ground ambulance services.
- Requiring that, prior to any preauthorized elective services, the insurer inform the patient about the network status of the facility-based physicians and others who may bill for services.
- Use of a standard form by physicians and providers to tell patients which physicians and providers might be involved in their care and how to contact them. Physicians and providers also should advise patients that it’s possible that another doctor or provider might treat the patient when unforeseen scheduling or staffing changes at the facility occur.
- Requiring insurers selling PPOs to include “a clear and conspicuous notice regarding the implications of using or receiving services from an out-of-network physician … and the potential for balance billing” on their websites, policy documents, and directories.
- Requiring insurance brokers and agents to educate consumers about the inherent limitations of the plans they buy, especially their out-of-pocket responsibilities for care provided both in and out of network.
TMA has also unveiled “Why Did I Get That Medical Bill?” to help explain to the public the root causes of unexpected medical bills.
“[Having narrow networks with too few doctors] is like buying a warranty on a car and finding out there’s only one shop in the entire [town] you can take your car to,” said Dr. Valenti.