Blue Promise: Why are Texans Being Hit with Surprise Medical Bills?

Would you pay $3,000 to treat a cough? Many health care patients already have. Texans continue to face sticker shock like this after receiving surprise medical bills at freestanding emergency rooms. In this episode, BCBSTX's DSVP of Health Care Delivery, Shara McClure, offers her perspective on this trending topic in Texas. You can also listen to the complete discussion in podcast form on Apple Podcasts and SoundCloud.

Blue Promise is a podcast and online video blog that aims to address complicated health issues with candid conversations from subject matter experts. New editions are published regularly and are hosted by Dr. Dan McCoy, President of Blue Cross and Blue Shield of Texas, and his co-host, Ross Blackstone, Director of Strategic Influence.

Show Transcript




Would you pay three thousand dollars to treat a cough? Many health care patients already have. Texans continue to face sticker shock like after receiving medical bills at a free standing

emergency room.





Thanks for joining us for this edition of Blue Promise.  I'm Dr. Dan McCoy and I'm the President

of Blue Cross and Blue Shield of Texas.  I'm here with my co-host, Ross Blackstone.



Thank you, Dr. McCoy, we have DSVP of Health Care Delivery,  Shara McClure here with us.

Shara, we talked about this concept of surprise medical bills before here on Blue Promise but it's relevant to bring it up again because there's going to be some legislation coming up in the 2019 legislative session that relates to this.   So, we thought it would be helpful for our viewers and our listeners to kind of get a refresher and understand the issues that are going to be coming up

that could impact them eventually.  So maybe you know as we typically like to do here Blue Promise, kind of level that is get everybody on the same page.  If you could describe for us or define for us what is a surprise medical bill? Does it come in a box with a bow?





I’d be happy to, I know some of many surprises are good surprises but a surprise medical bill is not a surprise that you want to receive.  A surprise medical bill is when a medical provider, who wasn't in your insurance company's network, gives you a bill.  They might have led you to believe that they were in the network but they weren't.  And so, without a contract, a patient or a member isn't really protected from that surprise medical bill and they can get one.



How would someone get a surprise medical bill?



So let me share with you, Fort Worth Star Telegram recently reported about a woman who had a migraine went into a freestanding emergency room in Plano, was led to believe by the Center that they took her insurance but actually it was over five thousand dollars for that bill and then she received an eighteen-hundred-dollar bill in the mail later.



So that was a surprise?



It was a surprise, she didn't expect it.  She went in, she had insurance, she had a medical condition that she thought was appropriate to treat.  I would presume she had seen the advertisement from the local facility but yeah that eighteen-hundred-dollar bill was not a good surprise.



But insurance covered three thousand and then she was left with the remains.



So that's one where a person gets I guess to some degree deceived about whether or not somebody is in network or not but I guess it could happen with best intentions, right?

So, I've heard stories about people going in for surgery and getting a surprise bill and they may know that the hospitals in network and their doctor.  How does that happen?



Well when we go for surgery, we usually listen to what our physician tells us to do.  We usually look at our provider directories that our health plans offer to us and we have those online provider directories.  But it's a lot more challenging to know what every single physician

who's going to treat you is whether they're in the network or not and those include anesthesiologists, They can include pathologists, they could include surgical assistants, so, it's really important to do your homework before you receive an elective service, to know whether

all of those physicians are in the network or not.



And so, in that example you could go in for like your knee replacement right and you picked your hospital you pick your orthopedic surgeon to do your surgery but when you're like naked on the operating table, your anesthesiologist just might not be in a network.



They might not and so that's why it's important to ask those questions beforehand.



So, you'd get a surprise bill…



So, avoid a surprise bill, right?






Is there one type of provider that is more likely to give you a surprise medical bill?



So, from what we see the most likely types of providers that might bill, are emergency room physicians whether they practice at an out of network facility.  Of course, the freestanding emergency rooms also we see a lot of surprise billing from them and then probably the third most likely would be the anesthesiologists.



And so, the other thing on surprise bill, just kind of straight… keep them straight too.

It's not just necessarily the physician, right?  It could be a facility that could send you a surprise bill, is that true too?



It could really be any provider whether it's a physician or a facility…



Or a lab.



Absolutely a lab that doesn't participate in your health plan network.  So that's why it's so important to check that provider directory.



So, I want to ask you one quick question about surprise bills because sometimes there could

either be a problem whether or not, right?  So, I mean are we talking significant bills or are we talking just something like you know OK you know you thought this was going to be a hundred bucks and it turned out to be a hundred and ten dollars so you know you owe a little bit  more

than you thought.



It varies and so I mean I've seen statistics that over a quarter million Texans have received surprise bills fortunately in the last legislative session there was a law that passed that kind of set that threshold at 500 dollars for when a member or when a health plan covered enrollee

could actually go to mediation and so, they establish that if you receive something over five hundred dollars you actually have some recourse through the Texas Department of Insurance.



But that's really a sort of implies that it's not uncommon to be charged five hundred dollars more than you thought never for a procedure or is it?



Not uncommon at all. Previously that threshold was a thousand dollars and so it's actually protecting more Texans to lower it to 500 dollars.



I mentioned earlier that the Texas State legislature is looking to do something to address this

Is that because this is a unique problem for Texas or is this something that's happening across the country.   where do we fall in the spectrum compared to other States?



So, surprise billing is a national Issue but in Texas its particular issue and one of the biggest reasons is because Texas actually licenses freestanding emergency rooms.  Many states don't even recognize freestanding emergency room as a legitimate provider.



So, another thing that I've heard about surprise billing is that it's one thing to say have a different provider but patients are often surprised by what gets charged like the coding levels, Explain that to me a little bit.



So, let me just try to simplify so, if you go to the emergency room or if anyone goes to the emergency room there's certain coding levels let's say a scale from 1 to 5. So we'll call them levels 1 to 5 that mirror that scale one on …



One might be something really, really simple and five might be major trauma right”



Exactly…Exactly... So, 5 being the most severe one being the simplest. Well, over time we've seen what we would call up coding where something that previously was a very low level of acuity maybe a level one or level two now is moved to a level three, four and five and of course, that increases reimbursement or increases revenue for the hospitals or medical facilities and so of course the higher the level build the higher the price and the bigger the exposure for the surprise bill.



OK so I'm going to maybe over my skis a little bit, I'm going to ask you a question here. So, one of the challenges I think we have is the fact that if the person is not in network so in other words

you have this risk of getting a surprise bill there's really nobody policing that coding level, is that fair to say?



I mean there are general guidelines about that coding but they're not specific enough to match certain diseases to certain levels.



OK so I'm the layperson here, You're our expert Dr. McCoy.  You're a doctor, help me understand because this sounds like it's just a subjective decision that somebody might just say instead of a one let's make it a four.



Well it's actually goes something like this so that if you go to an in-network someone that SHARA has a contract with and that person say for instance you go in for a sore throat and it's a simple sore throat you get a prescription you go home but you get charged a level that would be the same as major trauma on the freeway which may shock you but I think that happens.  If they're contracted with us we get to look over that bill on behalf of that insured member, but in Shara’s story, if you go into a freestanding emergency room that's not in network, we don't have a contract with them, they're free to bill whatever they want, at whatever code they want

and although we can dispute it at the end of the day, it could be a significant surprise for the patient…

Is that fair?



Absolutely. That's just one more unregulated variable when going to a non- network provider



I mean to use your gift analogy, it's one thing to bring a small simple birthday gift but you could be delivering somebody a mortgage payment.



Right. And so you know we, like you said we would, Blue Cross could dispute it,  We'd pay a certain amount of what we consider to be fair and then go back to this this surprise bill.

Surprise! the member the patient is expected to cover the remainder of it That's what the problem is…



That's true and in the absence of the contract that protects that member that's what we're seeing…



So what can people do about it, I mean what can members and patients do about it and what can the state legislature do about it?



So, let me start with patients… let me start with members, I mean when we're having an emergency or we're not feeling well, or we have an injury that's a time of stress and that's what that's a time that it's hard to make a decision about where to go.  You just want to take care of your problem and you're not necessarily thinking about the dollars or thinking about what might happen later. 

So, as we think about…. being smart consumers and making those decisions about where we're going to receive care in the event of an emergency or an urgent event.  It's really a great idea to look at a resource that we have available that's called, so it's like smarter Texas dot com and it'll help you walk through some of those decisions that you'll be ready for, if you do have an emergency.


DAN: And also I think you there you can take advantage of the rules that have been


passed as related to mediation so mediation is a is a is something that


certainly in order in that regard and I would tell you to I think that that patients need to


be aggressive about disputing their charges if they think they've been overcharged or


you know over coded or charged

for major trauma for cold


They need to dispute it

They need to


They need a fight back to the system

a little bit because you know at


the end of the day it's

money out of their pocket


It's taking money out of their food and housing budget for their family


in particular a situation that they

may have had little or no control about


what was being charged


SHARA: I couldn't agree more and think of all the areas where we as consumers


we do dispute if we get.. if we get mis charged by a department store


or a grocery store or at a restaurant

we're smart… we're quick to dispute it


but I think we should be just as smart and just as careful consumers when we access it


DAN: it's a great analogy I think that the challenge that patients have, and you know


as a physician is the fact that the coding is complicated it's not clearly understood


If you go buy a dress at

a department store


you sort of know what

the value of that dress is


It probably even had a sticker on it

So, you know what it should have


been charged at and if you get the bill wrong when you get home and you have


protections like your credit card company that can step in and help to work that out


But in health care you're sick you're vulnerable you're often captive you don't


have anywhere else to go and

in fact the coating is very complicated


And so that complications kind of helps to trick people into believing that this is the


 appropriate charge when

in reality it's not


ROSS: So you know to your point it gets pretty complicated and we can advise


members and patients of some steps that they can do to help protect themselves but


t's important for them to know that

 they're not alone that their health insurer


Blue Cross Blue Shield of Texas if that is their health insurer we hope it is


that we're trying to do some things as well right we're working with the state


lawmakers to try and pass some laws

that will help protect them


Can you elaborate a

little bit on that Shara?



SHARA: I can so there are several

things that can be done


I mean first of all there could be fines there During the last legislative session there


were some transparency bills passed so that freestanding emergency rooms had to tell


the truth about whether they

were in a network or not


And so I think assigning fines to those for those freestanding emergency rooms that


aren't complying with the law that would that would be something that we would be


in favor of that would that would

help prohibiting the free standing


emergency rooms from using the

insurance companies logos


we've actually seen freestanding E.R. put insurance company logos on their


advertising which of course leads their patients to believe they're covered


when they're not in fact covered


DAN: Sounds like almost a deceptive

trade practice feels that way


SHARA: It feels that way


ROSS: I know we're also supporting the attorney general in giving him the authority


to pursue and penalize specifically freestanding emergency rooms who are


who are maybe not upholding the law and doing some of these bad practices right?


SHARA: Yeah like for egregious charges

So if we have a natural disaster or some


sort of state of emergency in the state

the attorney general can step in


and prevent price gouging


Why can't we expand that

to medical emergencies?



So, I think the take home message here is that I'm excited about where the legislature is leaning toward going down this path of protecting consumers and making sure that people that are

vulnerable these captive situations don't get price gouge but in the meantime, I think it's probably good for our patients to step up and make sure they ask a lot of questions like, what is this going to cost?  Are you really in-network?  Is my insurance going to pay for it?

Back to that dress analogy, go to your car you may look at your receipt and realize that you were overcharging to walk right back in a lot of times in health care, you get the surprise bill two to three weeks later, maybe even a month later.  It's disconnected, it's harder for you to figure out a way to solve it Is that fair?



I agree completely agree



Well Shara, thanks for being here today and thanks for joining us for this edition of Blue Promise


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