Balance billing occurs when doctors, hospitals, or other health care providers who are not contracted with a patient’s HMO or preferred provider benefit plan (PPO) bill the patient for the difference between the amount the health plan pays and the amount the provider believes to be the adequate cost of a service.
For example, a patient may visit the emergency room at a hospital that is contracted with her health plan, but the emergency room doctor who treats her is not contracted with that health plan. The emergency room doctor and the hospital each bill $1,000 for their services, and the health plan pays them each $400. The hospital, which is contracted with the patient’s health plan, may bill the patient only for the copayments, deductibles, and coinsurance amounts under her plan. It may not bill the patient for the additional amount not paid by her health plan. However, the emergency room doctor, who is not contracted with the patient’s health plan, may bill her for the $600 that her health plan didn’t pay, as well as any copayments, deductibles, and coinsurance that she owes.
Texas law gives patients the right to request, in advance, estimates of charges from providers and facilities and estimated payments from health plans. Doctors, other providers, and health plans have 10 days to give patients the estimates, so they won’t be able to get them in advance in cases of emergencies. Some providers and health plans also have cost information on their websites.
Texas law does not give consumers many rights when they are surprised by a “balance billing.” However, in some cases, patients can require providers and carriers to attend mediation to try to work out the claim. For details on how to determine if you’re eligible for mediation, visit www.tdi.texas.gov/consumer/cpmmediation.htm.