A KVUE Defenders investigation uncovered a dramatic rise in Texas patients complaining about unexpected medical bills.
There has been a 1,000 percent increase in balanced billing complaints, according to Texas Department of Insurance.The number of complaints increased from 112 in 2012 to 1,334 in 2015.
Balanced billing typically happens when patients are told that a procedure is covered by their insurance, but later learn that it was not. They then get an unexpected bill in the mail to pay for the balance.
Lisa Beach is one of those patients.
A few years ago, the Buda resident thought she did everything she could to prevent an unexpected medical bill after back surgery. She called her doctor multiple times, months before her procedure, to make sure everything was covered by her insurance.
"And I asked again, and said, ‘Is there anyone else?’ And she said, ‘Nope, that’s it,'" Beach said.
Six months after the surgery, she got a bill in the mail for $1,050. Turns out, her doctor used special equipment during surgery not covered by her insurance and didn't tell her.
“And I’m like, ‘Why didn’t you mention this to me when I called you months ago?’” Beach said.
Stacey Pogue, a senior policy analyst at the Centers for Public Policy Priorities in Austin, said there isn't a law in place to help people like Beach.
“There’s nothing in the law to stop it,” Pogue said.
Last year, the bipartisan group conducted a study on balanced billing. It found, with some insurance companies, up to 50 percent of Texas hospitals in its network did not have one doctor on staff covered by patients’ insurance.
“So, there’s very little planning somebody can do in advance around an emergency that’s why we need good laws in place to protect consumers in emergencies,” Pogue said.
While state lawmakers have not been able to address the problem, federal lawmakers want to make balanced billing illegal.
U.S. House Representative Gene Green from Houston is one of 25 lawmakers supporting legislation called “End Surprising Billing Act”
“People shouldn’t have that surprise. There ought to be a way that they get notice, that there are no network doctors in that particularly facility. It’s happening in the Houston area and Austin, I know,” said Rep. Green.
Beach believes regulation is needed.
“This is what’s wrong with our healthcare system. This shouldn’t be happening,” Beach said.
The Texas Medical Association said the blame should fall more on the insurance companies than doctors.
“The consumer is no longer satisfied with the not-very-well-explained, varying levels of savings that insurance network products create, especially if that means a greater financial burden in emergencies. Yet, despite network shortcomings, consumers do not want to be left without the choice of managed care health plans that offer network benefits”, the TMA wrote in a 2015 report titled “The Truth About Balanced Billing.”
To learn more about the TMA's report, go here.
Healthcare advocates suspect the complaint numbers KVUE found should be much higher because most consumers don’t know they can turn to TDI for help.
Since 2012, the TDI has helped return more than $1.5 million dollars to consumers with balanced billing complaints.
TDI often helps Texas consumer with insurance billing issues. To learn more, call 800-252-3439.
There are two main ways TDI can help consumers:
- File a complaint. In 2015, TDI processed 69 confirmed balance billing complaints and helped recover $490,518 for Texas consumers.
- Request a mediation. In 2015, of the 1,039 requests for mediation, only 68 were unresolved and referred to the State Office of Administrative Hearings. 94 percent of mediations were successfully mediated at the first stage.
Mediation is available to most Texas consumers with health insurance, except for those on plans regulated at the federal level. While most consumers will have the “TDI/DOI” designation on their health insurance card (indicating state regulation by TDI/department of insurance), state workers insured through the Employee Retirement System of Texas may or may not have that designation but still qualify for mediation.
To learn more about what to do after you receive a surprise medical bill, watch this video:
