Medical billing isn’t as simple and straightforward as some might assume. There are so many factors to consider, from choosing the right codes to drafting an error-free claim to staying updated on all medical billing laws and regulations.
That’s because if there’s even one small issue, the health insurer or payer could refuse to reimburse the healthcare practitioner for the services provided. This not only puts the healthcare provider and practice in a tough spot but also becomes a source of stress for the patient.
And one of the sources of stress for patients has been surprise medical bills. However, people in Texas can rejoice because a new surprise billing law saves them from this trouble. Keep reading to find out everything you need to know about Texas’ surprise billing law.
WHAT IS THIS SURPRISE BILLING LAW ALL ABOUT?
Texas’ new law, Senate Bill 1264, aims at protecting patients from surprise medical bills. The bill was passed early this year and has been praised by many people as a big step towards patient billing protection and more efficient healthcare services. Here’s why it was so necessary.
Initially, what used to happen was that patients would go to a healthcare provider that was within their network. They would avail all the services they needed, and unknowingly, those services sometimes might include services from out-of-network practitioners as well. In-network practitioners have an agreement with the insurance company, and they provide medical services at discounted rates.
In comparison, out-of-network practitioners don’t have any such agreement, and therefore, they tend to cost more. When the healthcare practice would send the medical bill to insurers for those services, they would only reimburse the practice for those services rendered by the professionals who are part of the network. They would partly or completely refuse the payment for the out-of-network healthcare services.
However, the practice still needs to be compensated for those services so they would send those balance bills to the patient, for whom it would be a complete surprise, and hence the term surprise medical bills. Receiving such surprise medical bills can be stressful for the patients and affect the revenue cycles of healthcare practices as well.
That’s why Texas’ surprise billing law is so important. According to this Senate Bill, any time there seems to be a dispute between the healthcare practice and the insurance company over compensation, the healthcare provider has to negotiate the payment with the insurance company themselves or through an arbitration process.
They can not bring in the patients in the middle of the dispute and must solve the whole matter amongst themselves. This saves patients from getting surprise medical bills for unknowingly using out-of-network healthcare services.
WHO DOES IT APPLY TO?
While this surprise billing law is great for some patients, not everyone is necessarily happy with it. This is because this law doesn’t apply to everyone, at least not yet. As of now, the law is only applicable to those patients who fulfill any one of the following criteria:
- Their health insurance card has “TDI” or “DOI” imprinted on it.
- Their medical insurance is covered by Employee Retirement System (ERS)
- Their medical insurance is covered by Teachers Retirement System (TRS)
Basically, it applies to those Texans who are under a state-regulated health plan. This usually includes state employees, public school teachers, people who have bought their health insurance plans through the Affordable Care Act market, and a few people whose insurance is covered by private employers.
This law does not apply to people who have any other health insurance plan, Medicate, are on the Federal Employee Plan, or are under any other health plan issued outside of Texas. If you are unsure whether a certain patient comes under the surprise billing law or not, the best way to find out is to contact their insurance provider directly and ask them.
WHICH SERVICES ARE COVERED UNDER THIS LAW?
Under this law, patients can safely avail all services provided at their in-network healthcare practices, whether those services are performed by in-network or out-of-network professionals. These healthcare practices include hospitals, ambulatory surgical centers, birthing centers, and free-standing emergency medical care organizations.
Services applicable under this law also include any out-of-network laboratory services or diagnostic imaging that are part of or connected to another service from an in-network professional’s service. More importantly, this law covers any emergency services provided by out-of-network professionals.
This means that any time a patient avails any of these medical services and the insurance company raises a dispute over the amount payable, the healthcare practice, insurance company, and medical billing company are forbidden from sending any surprise medical bills to the patient or involving them in the dispute in any way. Instead, the practice and payer must negotiate and solve the dispute themselves or through arbitration.
WHEN DOES THIS LAW NOT APPLY?
There are cases when this surprise billing law does not apply to patients. If a patient knowingly and intentionally approaches an out-of-network healthcare provider in case of a non-emergency situation, they can be billed for the balance amount pending.
However, before that, they need to sign the Balance Billing Waiver form, which basically means that they relinquish the protection from the surprise billing law. In those cases, any remaining amount which the insurance company refuses to pay will have to be paid by the patient only.
Surprise medical bills are definitely a big concern, especially during current times. According to one poll, around two-thirds of Americans showed deep concerns regarding their inability to pay off unexpected medical expenses such as surprise medical bills.
The current pandemic situation has only worsened such concerns as patients are often forced to deal with out-of-network physicians due to staff shortages and other reasons. That’s why federal and state efforts to launch legislation to protect patients from such bills are extremely important, and it seems like Texas is on the right path.
If you need help with your medical billing, payment, and collection, get in touch with us for our full line up of medical billing services. We help take away from your work load when it comes to payments and documentation, so you have more time to devote to patient care.