Dealing with a Surprise Bill after an Emergency Room Visit
05/14/19 – It has become common practice for emergency room physicians to be out-of-network. It has been estimated that one-half of all emergency room claims are out-of-network and one-in-three visits results in a “surprise bill.”  This situation has recently been brought to the forefront by the dispute between BlueCross BlueShield of Texas (BCBSTX) and Texas Medicine Resources (TMR), a group of emergency room physicians.
It was announced on April 15, 2019 that TMR doctors would no longer be in network with BCBSTX at any Texas Health Resources hospital emergency room.  Texas Health Resources Hospitals and their staff physicians are still in the BCBS PPO and HMO networks.
TMR is a group of emergency room physicians contracted with THR Facilities. TMR has issued a statement that they will not balance bill BCBSTX members who come to one of the Texas Health Resources emergency rooms. 
While this announcement caused widespread panic and concern from those enrolled in BCBS medical plans in North Texas, it is by no means anything new. TMR is currently out-of-network with other carriers such as Cigna.
What does this mean to the consumer?
If an enrolled member visits one of the emergency rooms staffed by TMR or other out-of-network physicians group, even though the emergency room is in an in-network facility, they will most likely receive a balance bill from the physician’s group. Receiving a bill from both the facility and the treating physician in an ER visit is nothing new. However, being billed above what the insurance carrier agrees to pay, is relatively new and results in what’s known as a “surprise bill” for the member.
Currently the Texas Department of Insurance (TDI) offers help to consumers who receive a surprise bill over $500. TDI will facilitate negotiations between the provider and the carrier to settle the outstanding balance. The consumer can apply for mediation by completing a form and submitting to TDI.
Due to the skyrocketing number of cases (4,500 in 2018) being sent to TDI in the last year, new legislation is being worked on at the state capital in Austin that will take the consumer out of the middle. The bill passed the Senate and now is being reviewed in the House.
Senate Bill 1264 would…: 
- Prohibit out-of-network providers from sending surprise bills when the patient does not have a real choice of provider (such as in an emergency room).
- Make patients responsible only for their applicable copays coinsurance and deductible amounts with no additional amounts due resulting from mediation between the out-of-network provider & health plan.
- Require health plans to pay out-of-network emergency care & facility-based providers reasonable or agreed to amounts and allow those providers to dispute payment amounts through binding mediation.
- Protect patients’ credit by prohibiting the issuance of a consumer debt report resulting from balance billing.
What can you do to help prevent receiving a surprise bill?
- Research ahead of time which facilities are in your plan’s network.
- Consider your options. Is it a true emergency? Other less costly options include the following:
- Urgent Care Services – treatment of minor emergencies, injuries and illnesses
- Onsite clinics – located in some pharmacies and some doctor’s offices
- Teladoc – treatment of minor illnesses are available over the phone and by video conferencing
- Nurse hotline – if you are uncertain of where you should seek treatment, registered nurses are available to answer your questions.
What to do if you receive a surprise bill? 
BCBSTX and TMR Updates
- Texas Health Resources facilities and their staff physicians are still in the BCBS PPO and HMO network. TMR is a group of emergency room physicians contracted with THR facilities. 
- TMR has stated they will not balance bill BCBSTX patients who come to one of the Texas Health Resources emergency rooms. 
- For more information from both sides of the debate, visit their respective websites.
Sources and References:
- https://ertruths.com/2019/04/the-er-doc-blue-cross-blue-shield-conflict-is-more-complicated-than-it-seems/ – ERTruths Article: The ER Doc-Blue Cross Blue Shield Conflict is More Complicated Than It Seems
- https://standingwithtexas.com/en/releases/release-58c6d444fc57722139a0ff161f0145b9-unreasonable-demands-lead-to-dfw-er-group-leaving-bcbstx-networks – Standing With Texas Article: Unreasonable Demands Lead to DFW ER Group Leaving BCBSTX Networks
- https://ertruths.com/2019/04/blue-cross-network-dispute-to-have-minimal-local-impact/ – ERTruths Article: Blue Cross Network Dispute to have Minimal Local Impact
- https://standingwithtexas.com/en/releases/release-6b6810f1516641fcf21d4e01a401413a-texas-health-plans-support-senate-bill-to-protect-texans-from-surprise-billing – Standing With Texas Article: Texas Health Plans Support Senate Bill to Protect Texans from Surprise Billing
- https://www.tdi.texas.gov/consumer/cpmmediation.html – Texas Department of Insurance: How to Get Help with a Surprise Bill from a Health Care Provider
- https://ertruths.com/tmr-and-bcbstx/ – ERTruths: Who is TMR
Posted by Morgan Rand in Blog