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PRESIDENT’S
MESSAGE
“Balance Billing”
Understanding the real issues,
both for the physicians and the patients
By Dr. Jayesh Shah, 2016 BCMS President
Recently, at the legislative committee meeting at the Bexar The following information is from the TMA web-
County Medical Society headquarters, there was a spirited discus- site https://www.texmed.org/surprise/:
sion in relation to balance billing. The Texas Medical Association • Mandatory increases in state agency oversight of the adequacy
did extensive work last year to find out the best practices for Texas
physicians and patients on the subject of balance billing and as a of insurer networks.
result TMA’s socioeconomic committee came back with a consen-
sus presentation. • Expand the current $500 balance bill threshold for mediation
to include all out-of-network physicians, other health care pro-
Health insurance companies are beginning to narrow their net- fessionals, facilities, and vendors.
works and are setting limits on payments for services for out-of-
network providers because of patients receiving unexpected medical • Prior to any preauthorized elective services, require the insurer
bills. Physicians are concerned for their patients, some who earn to inform the patient “about the network status of the facility-
less than $10 per hour and end up with a bill for thousands of dol- based physicians and others who may participate in their care
lars after a visit to an emergency room. Patients are often surprised and bill for services.”
with the size of their bills that it causes undue hardship on them.
• Similarly, physicians and providers should use a standard form
Physicians believe that patients have a right to be educated on to tell patients which physicians and providers who may be in-
narrow networks before they sign up and start paying premiums to volved in their care “typically practice in the facility where the
these insurance companies. planned services will occur.”
TMA research clearly shows that narrow networks and other in- • Require insurers selling PPOs to include “a clear and conspic-
surance practices are bearing down on patients in the form of un- uous notice regarding the implications of using or receiving
expected, out-of-network balance bills. How can this be a physician services from an out-of-network physician and the potential for
billing problem? balance billing” on their websites, policy documents, and di-
rectories.
In a recent TMA survey, about one-in-four physicians said they
tried to join a network and, surprisingly, 29 percent received no • Require insurance brokers and agents to educate consumers on
answer to their request, 32 percent got a payment offer that was the inherent limitations of the plans they buy, especially their
too low for them to accept, and only 39 percent received a contract out-of-pocket responsibilities for care provided both in and out
to join the network. So how can this be a physician billing problem? of network.
A 2014 survey of Texas physicians found that 61 percent of What can you do?
physicians found they were listed as being in a network when really • TMA is asking the county medical societies to make contact
they were not, and 56 percent of physicians found instances where
they were not listed in a plan when they should have been listed. with their legislators on this issue prior to September 30.
So who is responsible for inaccurate directories that mislead patients
when are ready to buy particular insurance products? • Physicians should know and read all the terms of their contracts
with insurance companies.
In both 2014 and 2015 HMO report cards, the Office of Public
Insurance Counsel (OPIC) found a growing number of consumer • Educate your patients about the real issue. TMA has developed
complaints about insurance companies’ “failure to properly disclose educational materials for patients that can be printed from the
provider networks” and “improperly expecting additional payment.” following link-https://www.texmed.org/surprise/.
Appearing before House and Senate committees, the Chair of Regards, Dr. Jayesh Shah
the TMA Council on Legislation, Ray Callas, MD, laid out medi-
cine’s solution for the surprise bill problem.
8 San Antonio Medicine • September 2016
