Prevent Balance Billing with Real-Time at the Point of Care Solutions

Research done by Analyst Stacey Pogue of the Center for Public Policy Priorities found that more than 300 Texas hospitals did not have a single emergency physician who was in-network with at least one of three major carriers.


Texas patients are significantly more exposed to “surprise billing” than other states due to the lack of a comprehensive system for shielding patients from contract disputes between insurers and providers. That is why network adequacy standards need to be enforced to bring pressure during contract negotiations between insurers and providers to include physician groups in networks to assist in solving the problem.  

Even though some patients are proactive and ask the right questions when receiving services at an emergency room, they still receive surprise out-of-network medical bills.  In addition, patients are essentially “blind” when they are undergoing surgery. Ancillary services from providers such as pathologists and radiologists may be required during surgery without prior patient knowledge.   

Balance billing occurs when a patient receives care at an in-network facility but the specialists that that treated him were not contracted with their insurer so the patient ends up with surprise bills with out of network deductibles and copayments.  The patient was not aware of this because his insurer did not provide complete information about any contract disputes to allow the patient to take an informed decision.



Texas Expands Bill Balancing Protection


In order to protect patients and promote goodwill among all of the parties while still controlling health care costs,  on May 23, 2017 Texas Governor Greg Abbott signed Senate Bill (SB) 507, expanding the current law dealing with “balance billing.” The law which took effect on September 1, 2017, could help patients reduce unexpected out-of-pocket costs while preserving physicians’ right to balance bill when appropriate.


The law also requires bills for out-of-network care to come with an understandable summary of patient mediation rights. Additionally, the law allows mediation for emergent care balance bills over $500 at any healthcare facility, whether in or out of network. 


Patients that choose to resource to mediation must overcome several hurdles before doing so. They must decode their medical bills and they must have knowledge about the law’s provisions to be able to resolve their high out of network patient financial responsibility.


Although insurers may choose to protect their enrollees from some balance billing cases, there are no federal protections that explicitly prohibit this practice. In some states such as California (Assembly Bill 72 effective July 2017), the insurer is required to offer the out of network provider the in-network average payment amount for that geographic region as determined by the state department of insurance.  The providers are regulatorily obligated to accept the proposed in-network amount or dispute it via a mediation system. The patient would only be liable for any in-network financial responsibility per their coverage plan.


Around the same time in 2017 among several significant actions, Texas House Bill 3276 was passed to help consumers contend with the billing practices of freestanding emergency rooms. This House Bill would require a freestanding ER to disclose which health benefit plan’s provider network it’s in or to make clear to patients that it is not a participating provider in any such network.



Surprise Billing is a National Concern

Faced with this persistent national problem, the Commonwealth Fund conducted a study that provides an overview of available protections state by state.


The research results showed that only 21 states have direct protections laid out in statute or regulations for consumers to prevent them from balance billing by an out-of-network provider for care delivered in an emergency department or in-network hospital. Additionally, the study shows that only six out of those states have a comprehensive approach to safeguard consumers.





The same study also found that six states have comprehensive protections against balance billing. These six states incorporate a comprehensive approach by:

  • Extending protections to both ED and in-network hospital settings.
  • Applying laws to both HMOs and PPOs
  • Protecting consumers both by holding them harmless from extra provider charges and prohibiting providers from balance billing 
  • Adopting adequate payment standards or dispute resolution processes to resolve payment disputes between providers and insurers (Exhibit 2).


To quote a clear precedent of transparency, the state of North Carolina Senate passed SB 629 to protect consumers. SB 629 (Health Care Services Billing Transparency) states that if an insurer determines an in-network provider is not able to meet the needs of the insured or is not available to the insured without unreasonable delay, the insurer will pay for any out-of-network services provided using a new benchmark outlined in this bill unless the provider and the insurer create another agreement.


Jamie Dudensing, CEO of the Texas Association of Health Plans (TAHP), who has more than a decade of engagement in health care and appropriations policy is committed to making life better for Texans by campaigning to end the balance billing issue.


Ms. Dudensing has continued to advocate for this problem at the TAHP 2018 Managed Care Conference held in Houston this month and was an active participant during the series of panels that went on for three consecutive days. Surprise billing came up multiple times taking a prominent place in those panels.


There is a remedy to help all stakeholders avoid balance billing. Conexia offers Real-time at the point of care software solutions. With the implementation of the real-time at the point of care solutions, when patients are at the facility to receive the attention they can be made aware of their financial responsibility and the payment methodologies available to make an informed decision regarding the implications of the treatments they should receive.


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