If you’ve received a surprise bill after a trip to an emergency room you thought would be covered by insurance, it’s a result of something called balanced billing.  Balance billing occurs when an insured patient receives care from a physician, hospital or other health care provider, who is not part of a patient’s health plan provider network. The out-of-network provider then bills the patient directly for the portion of medical expenses not covered by insurance, typically at a much higher rate.[1]

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Unbeknownst to many consumers, there is a process to contest these types of billing issues.  In 2017, Texas improved a law that established a mediation process for patients to resolve these types of disputes.

What does mediation mean?

“Mediation” means a process in which an impartial mediator facilitates and promotes agreement between the insurer offering a preferred provider benefit plan or the administrator and a facility-based provider or emergency care provider [physician] or the provider ’s [physician ’s] representative to settle a health benefit claim of an enrollee.[2]

A patient (or insurance enrollee) can request mediation if:

  1. The amount, after co-payments, deductibles, and co-insurances, that the patient is responsible for is over $500; or
  2. The claim (or the reason for the medical visit) was for emergency care or BY a preferred facility based provider (an in-network provider); unless the provider gives the patient a written disclosure explaining why and the patient signs a written acknowledgment of the disclosure.

Additionally…

The bill sent to the patient must also contain the following language: “This statement is a balance bill for out-of-network services that may be eligible for mediation. You may obtain more information at http://www.tdi.texas.gov/consumer/complfrm.html.”

If you are currently in this situation, you can fill about this form to request a mediation.

Once you’ve filled out the form, you can submit it by either:

  1. Emailing it to ConsumerProtection@tdi.texas.gov;
  2. Faxing it to 512-490-1007; or
  3. Mailing it to 333 Guadalupe, Austin, Texas 78701.

What happens next?

In an effort to settle the claim before mediation, all parties must participate in an informal settlement teleconference not later than the 30th day after the date on which the enrollee submits a request for mediation under this section unless otherwise agreed by all parties. The facility-based provider or emergency care provider and the insurer or administrator are equally responsible for scheduling the informal settlement teleconference.

If it does not settle over a teleconference, the mediation will be scheduled in the county where the health care or medical services were rendered. The patient is allowed to participate in the mediation but is not required.

Regardless of whether or not the patient participated in the mediation process or not, he/she has the right to appeal if not satisfied with the mediated agreement.

NOTE: Balance billing is totally prohibited for people with Medicaid (traditional Medicaid as well as Medicare patients with QMB Medicaid). Patients with Medicaid cannot be billed for any medical costs except prescription copays.

[1] https://www.healthcarelawinsights.com/2017/05/texas-governor-signs-legislation-expanding-balance-billing-mediation-and-other-protections/

[2] https://capitol.texas.gov/tlodocs/85R/billtext/pdf/SB00507I.pdf#navpanes=0