Stronger together: Two patient protection bills are merged to end surprise medical billing in Texas

The quest to protect Texans against “shock” medical bills gained momentum Monday as two competing pieces of legislation merged to take aim at a business practice that can financially devastate unsuspecting patients.

“That’s why we’re here today, to show that House and Senate, Republicans and Democrats, have recognized the cries of our constituents,” said state Sen. Kelly Hancock, a Republican from suburban Fort Worth, as he unveiled the compromise measure in Austin.

The newly joined bill weaves together legislation sponsored by Hancock and state Rep. Trey Martinez Fischer, D- San Antonio, with that filed by Sen. John Whitmire, a Houston Democrat, and Rep. Tom Oliverson, R- Harris County. The compromise improves the chances of ultimately passing a law to remove patients from fights between insurance companies and health care providers — battles that currently leave patients footing the difference between what doctors or hospitals bill and what insurers pay.

The compromise could also soften opposition from the Texas Medical Association, the powerful doctor’s lobby that has fought similar measures in the past. The group has long contended inadequate insurance reimbursement and narrow networks, not doctors’ charges, are the cause of surprise bills. It also has said patient involvement in disputes is sometimes needed to pressure insurers for better coverage.

Dr. Douglas Curran, president of the Texas Medical Association, said on Monday his group was “cautiously optimistic” it could support the compromise bill. He cautioned, however, his group had not yet had a chance to fully study the legislation, and a “line by line” analysis was under way.

The Legislature is expected to vote on the new bill by the end of April. Gov. Greg Abbott has signaled he is supportive, Hancock said.

Decade-long battle

Hancock has fought for a decade against the system known as balance billing, where patients at their most vulnerable face tens of thousands of dollars in out-of-network medical bills even if they go to in-network facilities. On Feb. 28, he and Martinez Fischer introduced sweeping legislation that would stop doctors from balance billing in emergency rooms as well as when patients have no control over who treats them.

Five days later, Whitmire and Oliverson, introduced their own version.

In the merged bill, the state’s existing mediation system to settle billing disputes would be replaced with binding “baseball-style arbitration.”

The arbitration process would force providers and insurers to the table with their best and final offer. Arbiters would then determine the fairest amount, based on the evidence presented. Patients would only be responsible for the in-network rate for out-of-pocket costs, such as co-pays and deductibles.

“We’re just trying to get to some true, honest billing,” said Whitmire, who refers to the current practice as “shock billing.”

Hancock, whose original bill remained mostly intact, agreed to replace mediation with arbitration, saying it will help payments get closer to the actual value of care and punish anyone who games the system.

“If you low ball it, it will be held against you,” he said. “If you high ball your billed charge, it will also be held against you,” he said.

The new legislation also gives the attorney general the power to prosecute those who violate patient protections.

Still, the new law does not offer protection to all patients who feel wronged. Many health plans, including federally-regulated, self-funded plans offered by large employers, would remain ineligible. Hancock, however, has also introduced a separate measure that would allow self-funded plans to opt into the state system.

Health economists say Texas has one of the worst records for surprise billing in the nation with nearly double the rate of other states. A recent analysis by the Texas Association of Health Plans also shows that nearly two of three out-of-network emergency physician claims occurred at in-network hospitals.

Claims data has also found that out-of-network charges can be two to three times higher than in-network rates.

Consumer groups and health advocates have said 2019 could be the year that balance billing finally ends in Texas emergency rooms.

“Texas is on the precipice of finishing the job,” said Blake Hutson, associate state director of AARP Texas, which has battled against balance billing for its members for years. “At this point, any group opposed to this bill is simply uninterested in helping consumers.”