Surprise Billing Texas Medical Bills and Your Rights

If you live in Texas and receive a surprise medical bill, you're not alone. Many Texans have received unexpected medical bills for out-of-network care, and it's often due to a lack of transparency from healthcare providers.

Surprise billing in Texas can be caused by emergency care, non-emergency care, or even routine services like lab tests or imaging procedures.

In Texas, surprise billing is regulated by the Texas Insurance Code, which aims to protect consumers from unexpected medical expenses.

You have rights when it comes to surprise billing in Texas, and understanding them can help you navigate the process.

Surprise billing can happen unexpectedly, even in emergency situations, and it's not uncommon for patients to receive surprise medical bills.

You may be charged more for out-of-network services, and this amount might not count toward your plan's deductible or annual out-of-pocket limit.

Out-of-network providers can bill you for the difference between what your plan pays and the full amount charged for a service.

This is called "balance billing", and it's a common practice that can leave you with unexpected costs.

About 16 percent of Texans have state-regulated fully-insured insurance plans, which are regulated by the Texas Department of Insurance (TDI).

These plans are typically offered to state employees, public school teachers, and those who have insurance through the Affordable Care Act marketplace or private employers.

If you're unsure about the type of insurance you have, check your insurance card for a "TDI" or "DOI" designation, which signifies a health plan that is state-regulated.

Half of all Americans receive some sort of surprise medical billings, with the number one unforeseen charge coming from services provided by out-of-network physicians groups.

Surprise billing often happens when patients are treated at an out-of-network emergency care facility, but it can also occur when treated at an in-network facility by a provider that is not in the insurance provider's network.

Balance billing happens when you see a provider or visit a facility that isn't in your health plan's network, and they bill you for the difference between what your plan pays and the full amount charged for a service.

This can be costly, with the amount likely being more than in-network costs for the same service and might not count toward your plan's deductible or annual out-of-pocket limit.

Out-of-network providers may be allowed to bill you for this difference, which can be thousands of dollars depending on the procedure or service.

You might receive a surprise medical bill if you have an emergency or are treated at an in-network facility but by a provider that is not in the insurance provider's network.

It's not uncommon for patients to seek emergency care at an in-network facility, pay their insurance co-pay, and then later receive surprise medical bills because lab tests or imaging were provided by an out-of-network group.

In fact, research shows that half of all Americans receive some sort of surprise medical billings, with the number one unforeseen charge coming from services provided by out-of-network physicians groups.

At UTHealth Houston and UT Physicians, you're protected from balance billing in certain situations. You're protected from balance billing for emergency services, even if you receive care from an out-of-network provider or facility.

If you have an emergency medical condition and get emergency services, the most you'll be billed is your plan's in-network cost-sharing amount. This includes services you may get after you're in stable condition, unless you give written consent and give up your protections.

You can get services from an in-network hospital or ambulatory surgical center without worrying about balance billing for certain services. Emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services are covered, and the out-of-network providers can't balance bill you.

Some out-of-network providers may be at in-network facilities, but you're protected from balance billing for those services too. The out-of-network providers can't balance bill you, unless you give written consent and give up your protections.

You're not required to give up your protections from balance billing, and you also aren't required to get out-of-network care. You can choose a provider or facility in your plan's network.

Here are your protections when balance billing isn't allowed:

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. You can request this estimate by emailing [email protected] and including "Estimate Request" in the subject line.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

You're only responsible for paying your share of the cost, like copayments, coinsurance, and deductible, if balance billing isn't allowed.

Your health plan will pay any additional costs to out-of-network providers and facilities directly.

Here are the protections you have when balance billing isn't allowed:

As of January 1, 2020, Texans with state-regulated health plans are no longer stuck in the middle of billing disputes between health care providers and insurance companies.

The new law, SB1264, prevents health care providers from billing patients until a fair cost solution is reached with the insurance company.

This means patients won't receive multiple bills or threats of collection agency action if the bill balance isn't paid immediately.

However, patients are still responsible for all deductibles and co-pays as per their insurance plan.

In non-emergency situations, patients with state-regulated health plans can still receive balance billing if they intentionally receive care from out-of-network providers.

This can result in balance billing costs that are more than in-network costs for the same service and might not count toward the plan's deductible or annual out-of-pocket limit.

Surprise medical bills can be a huge financial burden, and it's essential to understand what they are and how they work.

Balance billing, also known as surprise billing, occurs when you're treated by an out-of-network provider, and they bill you for the difference between what your insurance pays and the full amount charged for a service.

You might be surprised to learn that even if you seek emergency care at an in-network facility, you can still receive surprise medical bills if lab tests or imaging are provided by an out-of-network group.

According to the University of Chicago research institute NORC, half of all Americans receive some sort of surprise medical billing, with out-of-network physician groups being the number one unforeseen charge.

Surprise billing can cost thousands of dollars, depending on the procedure or service, and might not even count toward your plan's deductible or annual out-of-pocket limit.

Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service, which is likely more than in-network costs for the same service.