New Report Shows Only a Tiny Fraction of Texas Patients Helped with Surprise Bills

Stacey Pogue

Today, we released a new report, video, and fact sheets on surprise medical bills. Surprise medical bills happen when insurers and doctors or other health care providers–fighting over prices– jointly pass the buck to a patient, who received out-of-network health care unknowingly.

Surprise billing is especially common in an emergency–when sick or injured patients must rush to the nearest emergency room and have no ability to choose the doctors who treat them.  Our new report shows that Texas patients are routinely treated by out-of-network doctors at in-network hospital ERs. A staggering share of Texas hospitals do not have even a single in-network emergency room physician for one or more insurers that covering the hospital, guaranteeing that emergency treatment will be performed by out-of-network doctors for many patients.

The Texas Legislature, long frustrated by surprise billing, developed a “mediation” system for surprise bills in 2009.  Mediation is something of a misnomer.  Most price disputes are settled through a simple phone call between the doctor’s office and insurer.  When patients are able to access this system, it works well and saves them money.

Unfortunately, our new report shows that only a very small fraction of Texans patients who get surprise bills have managed to initiate mediation.  While about 250,000 Texans who have a mediation-eligible health plan will get a surprise, out-of-network medical bill in a two-year period, fewer than 4,000 Texas patients have ever used mediation.

The steps required to initiate mediation are simply too difficult for many patients. Before an insurer and doctor have to pick up the phone to talk, patients must first decode complicated medical bills, determine if a bill is eligible, know about their mediation rights, and apply for mediation – all while dealing with the aftermath of a medical emergency or hospitalization.  Patients who are able to clear these initial hurdles may still be stymied by legal loopholes that make many surprise bills ineligible for mediation under current Texas law.

It doesn’t have to be this hard for patients.  Several other states address surprise bills without making patients jump over all these hurdles.

Bills have already been filed this session to close some of the loopholes that keep patients from taking certain surprise bills to mediation.  We’ll take a closer look at those bills in a future post.

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