In the Texas Community
Texas government mandates that private health insurers pay health care providers according to “usual and customary reimbursement” charges. But how can we ensure that patients are not victims of a situation outside their control? Lee Spangler, Vice President of Government Relations at Blue Cross and Blue Shield of Texas, expresses the need to ensure that patients are held harmless.
Continue the conversation with us and view Unusual Impact of UCR Charges Part 1.
You can also listen to this 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.
DAN: Texas government mandates that private health insurers pay health care providers according to usual and customary reimbursement charges. But there is an unusual impact that that has on Texans. How can we ensure that patients are not victims in a situation outside their control. Find out in this episode of Blue Promise. In the last episode we talked a lot about the challenges that usual and customary reimbursement charges pose. Let's start off by discussing what has been done so far to protect Texans. I'm here with my co-host Ross Blackstone.
ROSS:Thank you Dr. McCoy, we have Lee Spangler here he's Vice President of Government Relations for Blue Cross and Blue Shield of Texas, Lee thanks for being here.
LEE: Glad to be here.
ROSS: Okay. So, you office, we're literally right across the street from the capital you spend most of your time making yourself available for lawmakers to give them information that they need to make smart decisions about legislation impacting Texans. But they've already done a lot in this in this space regarding usual and customary reimbursement. Can you give us a little bit of history of what has been done in our state in this area.
LEE: Absolutely. This dispute this issue began at least 15 years ago. There have been a number of regulatory interventions that the first intervention was actually the Department of Insurance sending anesthesiologists cease and desist letters that they should not balance bill patients out of network. That actually came then came to the attention of the legislature. It was debated for one session. The next session, Representative Kelly Hancock introduced what we all know is the Texas mediation statute. Basically, it allows patients who have a balanced bill over a certain amount to have that out of network surprise Bill mediated between the patient the carrier and the provider. Yet all the parties together they have a teleconference. They try and sell a teleconference if that doesn't work then they go to mediation and ultimately they can end up in in district court. But really that's extremely rare that it ever gets that far.
ROSS: Just real briefly before we get too far ahead of ourselves just define what is a surprise bill for somebody who might not know.
LEE: So a surprise bill is a bill that you receive when as a patient or a consumer you go to a network hospital and you're somehow treated by an out of network provider and that could be in any circumstance or in an emergency circumstance where you're treated by an out of network provider. When you get billed after the carrier settles the claim and after the patient has paid their responsibility, that extra billing by the provider is a surprise bill.
ROSS: Also called a balance bill it's the remainder of your balance that the provider thinks that you owe and mediation, how would you define that?
LEE: Well mediation is it's, ah it's an informal method of bringing parties together to resolve a dispute go and in fact the law has a definition of what a mediation is and what its goals should be, which is basically to settle the claim.
DAN: OK so let me.. let me ask you a question, so that Bill was a successful piece of legislation. I mean Senator Hancock introduced that bill and I would argue that parts of it have been incredibly successful. What's going on? Well what happened?
LEE: Well what continues to happen is that delta that I've discussed previously keeps increasing, the delta between what the patient has paid, what we have settled the claim at and what the physician charges, it just keeps, the charges keep going up and the amount in controversy becomes larger and larger and so it's it's
LEE: Concerning consumers. I mean that truly they're bothered by the bills that they receive.
ROSS: So Dr. McCoy just to kind of put some numbers to that to help illustrate how it is a growing problem you know that that's addressed by these mediation right. So, the Texas Tribune recently reported that in 2013 the state of Texas had forty three requests for mediation. That was in 2013. In 2019 we expect to receive eight thousand. So that's from 43 to eight thousand in just five years. I think that clearly demonstrates that this is a growing problem.
DAN: So what else needs to be done to fix the problem.
LEE: Well Senator Kay Hancock has actually already filed legislation that provides his answer to that question. And basically it is… it's time to take the patient out of the mediation, take the patient out of the middle if you will and allow the carrier and the provider to mediate the settlement amongst themselves. In addition, Senator Hancock has proposed that the payment standards that TDI has put into place which has emboldened the charge.. charges that increase. That standard needs to be removed so he changes the standard and requires the carriers to pay a reasonable amount and of course it actually benefits us to pay a reasonable amount because one we make sure that the appropriate financial responsibilities placed on the shoulders of our members if we pay the correct amount. But it also means that if we do it appropriately, we'll have fewer mediations in general.
DAN: I guess the issue is that this legislation is in the session today doesn't mean it's going to pass although it seems like it's needed or something similar like that is needed but until then there are some things consumers could do to protect themselves. Right. You could try to stay in network that's going to do... that's going to help you because if you stay in network your insurance benefits are going to apply and I guess also ask a lot of questions whether or not you're going to be exposed to an out of network provider. I know that is an easy statement to say but it's hard right. Because you could have an emergency you could have a surgery and maybe you get exposed in the hospital to an anesthesiologist or possibly some other kind of testing that's not network. Is that fair?
LEE: That is fair. You do as much planning as you can and then on the back end when you do receive a bill from an out of network provider. Understand that if you're covered by a fully insured plan you have a form you do have a mechanism to try and reduce and bring that bill down to something that's much more reasonable and in line with what the market would otherwise demand. Maybe Senator Hancock's successful and the that won't have to be triggered by an enrollee or a member in the future but for right now as an enrollee that's what's available to you.
DAN: Well, Lee, thanks for being here and Ross thanks for being here. Thanks for joining us for this episode of Blue Promise here in Austin Texas. One of the biggest concerns here is that the patient is being held accountable for something that is out of their control. It sounds like the best legislative approach is ensuring that they are held harmless. Thanks for joining us for this episode of Blue Promise.
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