New Law Helps Patients with Bills for Out-of-Network Medical Care

Published 8:18 pm Thursday, September 10, 2015

Press Release

AUSTIN – A new state law gives more help to consumers facing high medical bills for out-of-network emergency or surgical services, a practice known as balance billing.

Senate Bill 481, which took effect this month, allows consumers to seek mediation through the Texas Department of Insurance for bills that exceed $500 and requires a physician to notify patients of that right when sending the bill.

“The practice of balance billing frequently leaves emergency care patients with medical bill sticker shock,” said Senator Kelly Hancock, author of the legislation. “During a stressful life event like an emergency room visit or surgical procedure, patients shouldn’t have to worry about surprise, bank-breaking bills. This law lowers the mediation threshold and gives more Texans recourse.”

Senators Juan “Chuy” Hinojosa and Royce West co-authored the legislation.

Balance billing occurs when a physician bills patients for medical expenses not covered by the patient’s insurance. The new law applies when patients go to an in-network hospital or facility, but later get a bill from a physician who does not have a contract with their health plan.

“We want to increase transparency and create more avenues of assistance for consumers facing high out-of-pocket costs for medical services,” said Rep. John Smithee, who sponsored the legislation in the Texas House. “The Department of Insurance is able to resolve many of these cases with just a phone call between the insurer and the physician.”

The 2009 Legislature created a mediation process to help consumers with bills exceeding $1,000. The new law lowers the threshold to qualify for mediation to $500, requires bills to have a “conspicuous, plain language explanation” of the consumer’s right to mediation, and adds assistant surgeons to the list of physicians who must comply with the law.

“These protections are working,” Insurance Commissioner David Mattax said. “In 2014, we helped lower the bills for more than 500 patients by almost $455,000.”

For information about filing an insurance-related complaint, call TDI’s Consumer Help Line at 800-252-3439 between 8 a.m. and 5 p.m., Central time, Monday-Friday.