| Perspectives on Texas

I first became aware of the practice of “surprise medical billing” a few years ago when my patients began calling my office after receiving unexpected bills from physicians — usually following operations.

As a general practice doctor who acts as the primary care physician for my patients, I was as perplexed as they were. I presumed that when I referred a patient to a specialist who was in the patient’s insurance network, all care related to that referral would be considered “in network.”

I was surprised to learn, as were my patients, that just because the initial specialist was “in network” and the facility selected by the specialist was “in network,” it did not mean that other physicians involved, such as radiologists, anesthesiologists, pathologists, or assistant physicians, would necessarily be in network.

In fact, if those other physicians were “out of network,” they were free to charge my patients any amount. If the patient’s insurance would not pay the full amount, those physicians would expect the patient to pay the balance.

Surprise medical billing is more common with emergency medical care, when patients must rush to the nearest emergency rooms, where they have no ability to choose the doctors who treat them or confirm those doctors are part of their insurance networks.

The practice of surprise medical billing has become so prevalent that the Center for Public Policy Priorities estimates that some 250,000 Texans will get a surprise medical bill in a given two-year period. While patients can request mediation in these circumstances, the process is cumbersome and only about 4,000 of these affected Texans have managed to navigate the mediation system and get help. The state Legislature could improve the situation this session. The Texas Medical Association has studied this issue and proposed a number of recommendations to lawmakers.

Many factors affect surprise billing, but they ultimately break down to a difference of opinion as to a physician’s freedom to charge whatever he/she feels is appropriate and an insurance company’s determination of what they should pay for a given procedure. In practice, doctors generally charge higher rates and insurers generally pay lower rates; when they can’t agree, the patient gets a surprise bill. Since we live in a free society, it is reasonable to support both the physician and insurance company positions, but it seems unfair to place the patient financially in the middle of this difference of opinion between businesses.

As a primary care physician, when I refer a patient to a specialist, it is my responsibility to be sure I am sending that patient to an “in network” physician. For elective procedures, if the other physicians who care for that patient would take the same responsibility, surprise billing for non-emergency care would no longer be a problem. Unfortunately, even coordinating physicians cannot always know in advance which radiologist or anesthesiologist will provide services on a given day.

We need a comprehensive policy solution to address surprise bills; one that doesn’t push the costs off onto patients or require them to jump through hoops to get help. States like Florida, California and New York have passed bipartisan laws that protect patients from surprise bills while allowing doctors and insurers a way to figure out payments for out-of-network care.

Navigating the health care system is complicated. Even diligent patients who ask all of the right questions can get hit with surprising out-of-network medical bills.

We can’t afford to let doctors and insurers keep blaming each other for the problem while patients foot the bill.