The Lone Star State is the newest member of the union to tackle the issue of balance, or surprise billing. Texas S.B. 1264 “protects patients from getting surprise-balance bills in medical situations when the patient does not have a choice who provides them with care,” according to Republican state Senator Kelly Hancock, who introduced the bill. Texas is far from alone in seeking a legislative pathway to protecting patients from surprise bills, as over half of the states have passed some sort of legislation trying to prevent them. Some, however, are far more comprehensive than others.|
Balance billing occurs when a patient is billed for medical costs insurance providers won’t pay after a dispute with a provider or providers. Patients generally receive these bills after they’re seen by an out-of-network provider at an in-network facility, information patients are not privy to until they get the bill. This practice of surprise billing is rampant throughout the United States. According to a study by the University of Chicago in August 2018, 57% of adults have been impacted by surprise billing. In Texas specifically, one in three emergency room admissions lead to a surprise bill. Due to the severity of this issue, balance billing legislation has recently received widespread bipartisan support.
Although the Trump Administration declared balance billing to be a top priority earlier this year, legislation has only been passed on the state level. Each state's legislation varies in both scope and intensity, and one of the primary components that separate Texas’ balance billing bills from the rest is the companion bill, S.B. 1530, which protects patients in self-insured plans. (About 60% of patients with employer-sponsored coverage have self-funded plans.) Unfortunately, the federal law ERISA limits the protections that state governments can provide to this crucial demographic. This challenge has led adamant proponents of surprise billing legislation to apply more pressure on the federal government to act.
Currently, Texas has infrastructure in place to handle balance billing that legislators believe to be inefficient. Under the current system, patients who receive a balance bill must request a formal mediation process by the Texas Department of Insurance (TDI). When the system was constructed in 2009, there were several qualifiers that prevented the majority of balance billing patients from being able to make a request, but bipartisan efforts removed some of those barriers in 2017. As positive of a change this was, it absolutely overwhelmed TDI; in 2013, TDI received only 43 requests compared to 4,519 in 2018, and the department expects an estimated 8,000 by the end of 2019. And even with this increase in requests, there have still been thousands of patients who had no idea this system was in place. Health care is a complex and confusing business, and Texas lawmakers who support these bills say patient should not have to face such a burden.
Both S.B. 1264 and S.B. 1530 have passed the Senate, and are very likely to pass the House. Under the new legislation, Texas would require providers and insurers to mediate disputes prior to sending the bills to patients. This method is meant to assist TDI with their backlog of mediation requests as well as ensure the patient does not have to undertake this daunting task themselves. TDI will address balance bills greater than $500 from any emergency provider as well as any out-of-network providers working at in-network facilities.
Click here to read NAHU’s compilation of surprise billing stories provided to the Senate HELP Committee for its hearing on surprise billing last month.