Blue Buzz: How a New Law Could Affect Texas Health Care Providers

A new law limits when Texas health care providers can bill some patients. As a provider, you might be confused about your responsibilities under Senate Bill 1264. If you’re a health care provider yourself or you handle billing for a medical practice, you’re probably looking for more clarification. Watch this video for more information about the new surprise billing legislation.

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What's up docs? In this video we're
talking to Texas health care providers.

You might be confused about your responsibilities
under our state's new surprise bill and legislation.

Chances are - whether you're part of an insurance
network or not - you're going to want some clarification.

So, here's what you need to know.
There's a new law that limits when

Texas health care providers can bill some
patients. Providers should not send patients

a bill for amounts above the deductible,
copay or coinsurance for some services.

Sending a bill for more than these patient
share amounts is called "Balance Billing."

And limitations on balance billing
apply in three situations.

First, providers should not balance bill for
emergency services and supplies. Period.

Second, providers who practice at an in-network
facility but out-of-network themselves.

Well, they shouldn't be balance billing either.

For example, a patient has let's say
surgery at an in-network hospital

but the anesthesiologist who
treats them is out of network.

Lastly, an in-network doctor uses an out-
of-network provider for diagnostic imaging or lab work.

Well they shouldn't send a balance bill either.

For now, this law only applies to patients
with fully insured, state regulated plans

issued to groups and individuals
through HMOs, PPOs and EPOs.

You can tell by looking at a patient's
I.D. card. It applies to anyone with a

Blue Cross and Blue Shield of Texas
I.D. card that has the letters "TDI" printed on it.

Now other insurers might note these
plans with the letters "DOI" so keep that in mind.

There are a select few of employer-sponsored
plans that are covered by the law like the

Employees Retirement System of Texas or ERS
and the Teacher Retirement System of Texas or TRS.

But please note the law does not apply
to Medicare. And you can always call our

Provider Customer Service line to learn
whether or not your patient is covered by this new law.

So please don't hesitate.
For more information though

please check out our video on surprise
billing and get the full scoop on the law.

Now in some non-emergency situations
patients can still choose an out-of-network doctor

while getting care at an in-network facility.
If you're going to send a balance bill to a

patient covered by this new law,
the patient will need to agree to this waiver form

at least ten business days before the
procedure. The patient then has five business days

to change their mind and withdraw the
waiver. The waiver is not applicable

however in instances where a patient
does not have a choice of providers.

You can get a copy of this waiver form by
going to the Texas Department of Insurance website.

If Blue Cross and Blue Shield of Texas processes
one of your claims according to this new law,

you'll see it on the Provider Claim Summary
or the Electronic Remittance Advice that we

send you once the claim is finalized.
Now if you have questions about whether

a claim is subject to the law or
questions about the information that you see

simply call our Provider Customer Service
team. Now let's say you don't quite agree with

the payment amount that you receive
from the insurer. First, you'll want to follow

our normal appeal process. And if that
doesn't address your questions you can request

mediation or arbitration through the
Texas Department of Insurance's online portal.

This process is outlined on the same
provider claims summary that I mentioned earlier.

Now if you're managing a Blue Cross and
Blue Shield of Texas claim you must let us know

when you request either mediation
or arbitration through the TDI.

To do this, just send us an
e-mail at the address on the screen.

So what exactly happens when you
file one of these requests with the TDI?

Well, first we'll meet by phone
and try to reach an agreement.

And if the negotiation is successful, great!
We'll route a claim for adjustment and notify

the Texas Department of Insurance
that the issue is resolved. Case closed!

Now, if we can't come to an agreement,
then there are two different processes that

you might go through, depending
on what type of provider you are.

So, mediation is only available
to out-of-network facilities.

In this process, an independent third
party helps negotiate a resolution between

Blue Cross and Blue Shield
of Texas and the facility.

Now arbitration, contrary to mediation, is
only available to out-of-network providers

other than facilities. In this process, an
independent third-party reviews information submitted

by both sides and then makes a decision
about the reasonable amount to be paid for the claim.

Now there's a window of opportunity for when
a provider can submit a request for arbitration

and that's between 20 and 90 days after
receiving the very first claim payment.

If you have any questions, please just
call our Provider Customer Service line

and we'll be happy to help.
Now this is a new process for everyone

and that's what we have the trained staff
ready to provide directions for handling these requests.

But if you really want to avoid
all the hassle, join the network!

We're always looking for
high-quality providers across the state,

so simply visit our "Provider"section
of the website and apply to day.