Over the past few months, the Texas Association of Health Plans (TAHP) has distributed flyers and held a tutorial for legislative staff on balance billing. The Texas Medical Association reviewed TAHP's materials and found its assertions neither accurate nor addressing the real reasons patients incur additional costs for out-of-network medical services.
TMA believes it is time to set the record straight. We developed a fact sheet outlining our response and distributed these to legislators and their staff last week. TMA expressed to lawmakers that the reasons a physician may bill a patient for an out-of-network medical service include these:
- The patient's health plan benefits do not cover the medical care,
- A physician who did not have a contract with the health plan provided the patient's medical care,
- The patient has not met the annual deductible amount or paid the coinsurance portion, or
- Most important, the patient's health plan single-handedly determines what it is willing to pay for the out-of-network care. In many cases, health plans arbitrarily use inaccurate data to establish their payment.