By Ashley Lopez, KUT Texas is now among more than a dozen states that have cracked down on the practice of surprise medical billing.
Texas Gov. Greg Abbott, a Republican, signed legislation Friday shielding patients from getting a huge bill when their insurance company and medical provider can’t agree on payment.
The bipartisan legislation removes patients from the middle of price disputes between a health insurance company and a hospital or other medical provider.
“We wanted to try to take the patients — get them out of the middle of it, because really it’s not their fight,” said Republican state Sen. Kelly Hancock, the bill’s author.
Under the new law, insurance companies and medical providers can enter into arbitration to negotiate a payment — and state officials would oversee that process.
Surprise medical billing typically happens when someone with health insurance goes to a hospital during an emergency and that hospital is out-of-network. It also occurs if a patient goes to an in-network hospital and their doctors or medical providers are not in-network. Sometimes insurance companies and medical providers won’t agree on what’s a fair price for that care and patients end up with a hefty medical bill.
Consumer advocates in the state have urged lawmakers to do more to help Texans saddled with surprise medical bills.
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Drew Calver is among the many Texans who have dealt with a surprise bill in the past few years. Calver, a high school history teacher in Austin, had a heart attack in 2017. He was rushed to the closest hospital by a friend that day, and doctors implanted stents to save his life.
Even though he had health insurance that paid the hospital more than $55,000 for his care, Calver ended up with a $109,000 bill. Calver and his wife, Erin, fought with the hospital and the insurance company for months with little success.
The Calvers eventually turned to the press. Last summer, he told his story to the “Bill of the Month” investigation from NPR and Kaiser Health News. “CBS This Morning” also covered the story. Shortly afterward, his bill was slashed to just $332. Erin Calver said she has seen her family’s story strike a chord.
“For whatever reason, people could relate to us — and be scared that maybe it could happen to them,” she said.
Drew Calver said he encounters many people who worry about the issue.
“The doctor that put my stents in — he either just had a baby or is about to have a baby — and he was saying that, ‘Yeah that could happen to me, too!’” Calver said.
In fact, getting a steep hospital bill is something many Americans call their biggest financial fear.
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“Polling shows us that the top household pocketbook concern for consumers is a surprise medical bill,” said Stacey Pogue with the Center for Public Policy Priorities, a think tank that analyzes health and economic issues in Texas. “And that’s actually pretty shocking that consumers will say they are more worried about their ability to afford a surprise medical bill than their health insurance premiums [and] their really high deductibles.”
Last year, a Kaiser Family Foundation poll found that 67% of people worry about unexpected medical bills — a larger share than those who say they worry about prescription drug costs or basic necessities such as rent, food and gas. (KHN is an editorially independent program of the foundation.)
Pogue said that’s a big reason why lawmakers in the state took the issue seriously and passed legislation that she said is now one of the strongest state protections she has seen.
“It is as strong or stronger than any of the protections in the country,” Pogue said.
In addition to Texas, neighboring states Colorado and New Mexico also passed legislation in 2019 to address the problem of surprise out-of-network bills. The Commonwealth Fund’s most recent report on the issue found about half of states offer some legal protections from surprise bills, but only six states had laws that provide “comprehensive” consumer protections similar to those just passed in Texas.
Texas’ new surprise bill law officially takes effect Sept. 1, 2020.
Hancock said the fight over who pays disputed bills will be back where it belongs: with insurance companies, leaving the hospitals, doctors and labs to focus on providing medical care.
“It was just time to get the patient out” of the middle of disputed bills, Hancock said.
Instead, when a hospital and insurer can’t agree on a price, the two parties will have to work it out — without ever billing the patient.
“There is still the ability to negotiate,” Hancock said. “You didn’t have government determining what the price was or determining what the settlement was.”
But not all Texans will be protected by the new law. The Texas law does not apply to people who work for large employers whose plans are regulated by the federal government. In Texas, federally regulated plans account for roughly 40% of the state’s health insurance market.
In fact, Drew Calver would have been exempt from the state’s protections because until recently he had a self-funded health plan regulated by the federal government. However, Drew is now part of wife Erin’s health plan, which will be subject to these new protections.
Pogue said people who have federally regulated health plans will be protected only if Congress acts. She predicted the state’s action will spur federal lawmakers.
“Texas passing a bill will really help on that front,” she said. “There were five states, I think, in 2019 that passed bills that fully protected consumers — and every nudge like that is going to help Congress move.”
Texas lawmakers passed separate legislation that could help Texans with federally regulated plans. Senate Bill 1037 prevents a surprise medical bill from affecting someone’s credit, regardless of what health insurance plan they have.
Congressional leaders have said they are working on coming up with a fix for people across the country with federally regulated plans. President Donald Trump also recently held an event at the White House, with Drew and Erin Calver standing by his side, announcing his administration’s support for banning surprise medical billing in the country.
During a U.S. House Ways and Means Health subcommittee meeting in May, members discussed ways to ban the practice of surprise medical billing.
The committee’s chairman, Austin Democrat Lloyd Doggett, said that “federal action is essential” to addressing the issue for many Americans with federally regulated plans. He said he plans to continue to push for legislation that will “finally offer some relief to patients.” However, no legislation has been passed, yet.
During his opening statements, Doggett said there is a bipartisan desire to shield patients from surprise bills, but “conflict remains over how to resolve insurer-provider disputes.”
This story is part of a partnership that includes KUT, NPR and Kaiser Health News.
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