Insurance regulators will be a key focus for some Texas lawmakers as they prepare to take up balance billing again in 2017, according to The Texas Tribune.
The practice of balance billing refers to a physician's ability to bill patients for outstanding balances after the insurance company submits its portion of the bill. Out-of-network physicians, not bound by in-network rate agreements, have the ability to bill patients for the entire remaining balance.
Balance billing may occur when a patient receives a bill for an episode of care previously believed to be in-network and therefore covered by the insurance company, or when an insurance company contributes less money than expected for a medical service.
Physicians, insurance companies and patients have long argued over who is to blame for balance billing being an issue. Physicians have blamed health insurers, arguing that insurers' physician networks are too restricting, leaving patients stuck with out-of-network options and costs, according to the report. Under Texas law, health insurers must contract with a minimum number of physicians in a geographic area, the report notes.
Insurers, however, see the network adequacy claim as something that misleads or distracts from the issue.
Jamie Dudensing, CEO of the Texas Association of Health Plans, told The Texas Tribune that the state's requirements for physician access are "among some of the most stringent in the nation" in terms of ensuring payers contract with a certain number of physicians, and that balance billing is "rarely tied to issues with network adequacy."
But some Texas lawmakers have expressed concerns about how well the Texas Department of Insurance enforces state rules on network adequacy, and plan to look at the issue in the 2017 legislative session, according to the report.
Stacey Pogue, a senior policy analyst at the liberal Center for Public Policy Priorities, told The Texas Tribune she also hopes lawmakers will pass protections for consumers that require physicians, insurers and hospitals to provide up-front information about whether they'll be covered, and at what cost.
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