Tagged Texas

Texas Is Latest State To Attack Surprise Medical Bills

Texas is now among more than a dozen states that have cracked down on the practice of surprise medical billing.

Texas Gov. Greg Abbott, a Republican, signed legislation Friday shielding patients from getting a huge bill when their insurance company and medical provider can’t agree on payment.

The bipartisan legislation removes patients from the middle of price disputes between a health insurance company and a hospital or other medical provider.

“We wanted to try to take the patients — get them out of the middle of it, because really it’s not their fight,” said Republican state Sen. Kelly Hancock, the bill’s author.

Under the new law, insurance companies and medical providers can enter into arbitration to negotiate a payment — and state officials would oversee that process.

Surprise medical billing typically happens when someone with health insurance goes to a hospital during an emergency and that hospital is out-of-network. It also occurs if a patient goes to an in-network hospital and their doctors or medical providers are not in-network. Sometimes insurance companies and medical providers won’t agree on what’s a fair price for that care and patients end up with a hefty medical bill.

Consumer advocates in the state have urged lawmakers to do more to help Texans saddled with surprise medical bills.

Drew Calver is among the many Texans who have dealt with a surprise bill in the past few years. Calver, a high school history teacher in Austin, had a heart attack in 2017. He was rushed to the closest hospital by a friend that day, and doctors implanted stents to save his life.

Even though he had health insurance that paid the hospital more than $55,000 for his care, Calver ended up with a $109,000 bill. Calver and his wife, Erin, fought with the hospital and the insurance company for months with little success.

The Calvers eventually turned to the press. Last summer, he told his story to the “Bill of the Month” investigation from NPR and Kaiser Health News. “CBS This Morning” also covered the story. Shortly afterward, his bill was slashed to just $332. Erin Calver said she has seen her family’s story strike a chord.

“For whatever reason, people could relate to us — and be scared that maybe it could happen to them,” she said.

Drew Calver said he encounters many people who worry about the issue.

“The doctor that put my stents in — he either just had a baby or is about to have a baby — and he was saying that, ‘Yeah that could happen to me, too!’” Calver said.

In fact, getting a steep hospital bill is something many Americans call their biggest financial fear.

“Polling shows us that the top household pocketbook concern for consumers is a surprise medical bill,” said Stacey Pogue with the Center for Public Policy Priorities, a think tank that analyzes health and economic issues in Texas. “And that’s actually pretty shocking that consumers will say they are more worried about their ability to afford a surprise medical bill than their health insurance premiums [and] their really high deductibles.”

Last year, a Kaiser Family Foundation poll found that 67% of people worry about unexpected medical bills — a larger share than those who say they worry about prescription drug costs or basic necessities such as rent, food and gas. (KHN is an editorially independent program of the foundation.)

Pogue said that’s a big reason why lawmakers in the state took the issue seriously and passed legislation that she said is now one of the strongest state protections she has seen.

“It is as strong or stronger than any of the protections in the country,” Pogue said.

In addition to Texas, neighboring states Colorado and New Mexico also passed legislation in 2019 to address the problem of surprise out-of-network bills. The Commonwealth Fund’s most recent report on the issue found about half of states offer some legal protections from surprise bills, but only six states had laws that provide “comprehensive” consumer protections similar to those just passed in Texas.

Texas’ new surprise bill law officially takes effect Sept. 1, 2020.

Hancock said the fight over who pays disputed bills will be back where it belongs: with insurance companies, leaving the hospitals, doctors and labs to focus on providing medical care.

“It was just time to get the patient out” of the middle of disputed bills, Hancock said.

Instead, when a hospital and insurer can’t agree on a price, the two parties will have to work it out — without ever billing the patient.

“There is still the ability to negotiate,” Hancock said. “You didn’t have government determining what the price was or determining what the settlement was.”

But not all Texans will be protected by the new law. The Texas law does not apply to people who work for large employers whose plans are regulated by the federal government. In Texas, federally regulated plans account for roughly 40% of the state’s health insurance market.

In fact, Drew Calver would have been exempt from the state’s protections because until recently he had a self-funded health plan regulated by the federal government. However, Drew is now part of wife Erin’s health plan, which will be subject to these new protections.

Pogue said people who have federally regulated health plans will be protected only if Congress acts. She predicted the state’s action will spur federal lawmakers.

“Texas passing a bill will really help on that front,” she said. “There were five states, I think, in 2019 that passed bills that fully protected consumers — and every nudge like that is going to help Congress move.”

Texas lawmakers passed separate legislation that could help Texans with federally regulated plans. Senate Bill 1037 prevents a surprise medical bill from affecting someone’s credit, regardless of what health insurance plan they have.

Congressional leaders have said they are working on coming up with a fix for people across the country with federally regulated plans. President Donald Trump also recently held an event at the White House, with Drew and Erin Calver standing by his side, announcing his administration’s support for banning surprise medical billing in the country.

During a U.S. House Ways and Means Health subcommittee meeting in May, members discussed ways to ban the practice of surprise medical billing.

The committee’s chairman, Austin Democrat Lloyd Doggett, said that “federal action is essential” to addressing the issue for many Americans with federally regulated plans. He said he plans to continue to push for legislation that will “finally offer some relief to patients.” However, no legislation has been passed, yet.

During his opening statements, Doggett said there is a bipartisan desire to shield patients from surprise bills, but “conflict remains over how to resolve insurer-provider disputes.”

This story is part of a partnership that includes KUT, NPR and Kaiser Health News.

A Year After Spinal Surgery, A $94,031 Bill Feels Like A Back-Breaker

Spinal surgery made it possible for Liv Cannon to plant her first vegetable garden.

“It’s a lot of bending over and lifting the wheelbarrow and putting stakes in the ground,” the 26-year-old said as she surveyed the tomatillos, cherry tomatoes and eggplant growing in raised beds behind her house in Austin, Texas. “And none of that I could ever do before.”

For as long as she could remember, Cannon’s activities were limited by chronic pain and muscle weakness.

“There was a lot of pain in my legs, which I can now recognize as nerve pain,” she said. “There was a lot of pain in my back, which I thought was, you know, just something everybody lived with.”

Cannon saw many doctors over the years. But they couldn’t explain what was going on. She’d pretty much given up on finding an answer for her pain until her fiancé, Cole Chiumento, pushed her to try one more time.

“It never improved, it never got better,” Chiumento said. “That just didn’t sound right to me.”

So about two years ago, Cannon went to a specialist, who ordered a scan of her spine. A few days later, her phone rang.

“We found something on your MRI,” a voice said.

The images showed that Cannon had been born with diastematomyelia, a rare disorder related to spina bifida. It causes the spinal cord to split in two.

In Cannon’s case, the disorder also led to a tumor that trapped her spinal cord, causing it to stretch as she grew.

In December 2017, a neurosurgeon opened her spinal column and operated for several hours, freeing the cord.

“I think it was day three after my surgery I could feel the difference,” Cannon said. “There was just a pain that wasn’t there anymore.”

As she recovered, Cannon saw lots of huge medical bills go by. They were all covered by her insurance plan. Almost a year had passed since the operation.

Then a new bill came.

Cannon lived with chronic pain and debilitating muscle weakness until she was 24, when Cole Chiumento, who is now her fiancé, encouraged her to try once more to find a diagnosis. “Cole kept pushing me and saying, ‘This isn’t normal. This isn’t normal,’” Cannon says.(Julia Robinson for KHN)

Patient: Liv Cannon, 26, of Austin, Texas. At the time of her surgery, she was a graduate student insured with Blue Cross and Blue Shield of Texas through her job at the University of Texas.

Total bill: $94,031 for neuromonitoring services. The bill was submitted to Blue Cross and Blue Shield of Texas, which covered $815.69 of the amount and informed her she was responsible for the balance. The insurer covered all of Cannon’s other medical bills, which came to more than $100,000, including those from the hospital, surgeon and anesthesiologist.

Service provider: Traxx Medical Holdings LLC, an Austin company that provides neuromonitoring during spinal surgery. Neuromonitoring uses electrical signals to detect when a surgeon is causing damage to nerves.

Medical service: Cannon was born with a rare spinal condition that had caused chronic pain and muscle weakness since she was a child. In December 2017, she had successful spinal surgery to correct the problem. Her surgeon requested neuromonitoring during the operation.

What gives: Neuromonitoring made sense for the type of surgery Cannon had. The bill did not. Cannon should have been warned long before her surgery that the neuromonitoring company would be an out-of-network provider whose fees might not be covered by her insurer.

At first, she was baffled by the billing information Blue Cross sent her. “It was one of those things from the insurance company that says this is the amount we cover and this is the amount you might owe your provider,” she said, referring to her explanation of benefits.

The statement listed four separate charges from the day of her surgery. Each was described as a “diagnostic medical exam.” Together, they came to $94,031.

Blue Cross said the covered amount was $815.69 — minus a $750 deductible and $26.27 for coinsurance — and informed Cannon she might have to pay the balance: $93,991.58.

“I was shocked,” she said. Chiumento was outraged.

“As soon as I saw that, I thought it was a scam,” he said.

The charge came from Traxx Medical Holdings LLC, an Austin company. Traxx did not respond to emails, phone calls and a fax seeking comment on the charge.

The company’s website shows that Traxx provides a service called intra-operative neuromonitoring, which evaluates the function of nerves during surgery. The goal is to help a surgeon avoid causing permanent damage to the nervous system.

There is an ongoing debate about whether neuromonitoring is needed for all spinal surgery. But it is standard for a complicated operation like the one Cannon had, said Rich Vogel, president of the American Society of Neurophysiological Monitoring.

Cannon was diagnosed with diastematomyelia, a rare disorder related to spina bifida, and had surgery in December 2017 to correct the problem. Most of the cost of the surgery was covered by her insurance with Blue Cross and Blue Shield of Texas. But more than $93,000 for out-of-network neuromonitoring services was not.(Julia Robinson for KHN)

On the other hand, a $94,000 charge for the service can’t be justified, Vogel said.

“You’re not going to meet anybody who believes that a hundred thousand dollars or more is reasonable for neuromonitoring,” Vogel said.

Most neuromonitoring companies charge reasonable fees for a valuable service and are upfront about their ownership and financial arrangements, he said. But some companies are greedy and submit huge bills to an insurance company, hoping they won’t be challenged, he added.

Even worse, “some neuromonitoring groups charge excessive fees in order to gain business by paying the money back to surgeons,” Vogel said.

Last year, Vogel’s group published a position statement condemning these “kickback arrangements” and other unethical business practices.

It is unclear whether Traxx has any financial arrangements with surgeons. Cannon’s surgeon did not respond to requests for comment.

The size of the fee for Cannon’s monitoring was only part of the problem. The other part was that Traxx — unlike her hospital, doctor and anesthesiologist — had no contract with Blue Cross and Blue Shield of Texas. As an out-of-network provider, the company could set its fees and try to collect from Cannon any amount it didn’t get from her insurer.

Blue Cross and Blue Shield of Texas said it doesn’t comment on problems affecting individual members. But the insurer did offer a general statement by email about the problem:

“Unfortunately, non-contracted providers can expose our members to significantly greater out-of-pocket costs. These charges often have no connection to underlying market prices, costs or quality. If given the opportunity, we will try to negotiate with the provider to reduce the cost.”

One thing working against Cannon is that she is pretty sure that, just before surgery, she signed a paper that authorized the out-of-network neuromonitoring.

“It was 4:30 in the morning and you’re like, ‘OK, let’s get this over with,’” she recalled.

Getting consent in the hospital may be legal, but it’s not reasonable, said Dr. Arthur Garson Jr., who directs the Health Policy Institute at the Texas Medical Center in Houston.

For example, a patient might be having a heart attack, Garson said. “You got chest pain, you’re sweating, sick as you can be, and they hand you a piece of paper and they say, ‘Sign here.’”

The Texas Legislature passed a bill in May to protect patients from the sky-high bills this practice can produce. And Congress is considering similar legislation.

These are small steps in the right direction, Garson said.

“Asking the individual patient to make that decision even when they’re not sick I think is difficult,” he said, “and maybe we ought to think of some better way to do it.”

The Texas legislation is expected to take effect later this year but affects only bills that occur after it becomes law. So that $94,000 figure is never far from Cannon’s mind, even as she and Chiumento plan their wedding.

“Every time I go out and I collect the mail, I’m wondering, ‘Is this the day it’s going to show up and we’re going to have to deal with this?’” she said.

The threat of a $93,000-plus bill causes great anxiety for Cannon and Chiumento. The couple considered calling off their wedding in case they had to start paying off the medical debt. “I think about it every time I go to the mailbox,” Cannon says.(Julia Robinson for KHN)

The Takeaway: Neuromonitoring during complex surgery involving the spine can help prevent inadvertent damage. But monitoring may be unnecessary for lower-risk back operations, like spinal fusion.

It is odd that neuromonitoring is charged as a separate service, rather than part of the spine surgery. Cardiac monitoring is not charged separately during bypass surgery, for example.

When considering spine surgery, ask your doctor whether neuromonitoring will be part of the procedure. If so, will it be billed separately? Try to find out the name of the provider and get an estimate of the cost beforehand.

Check with your insurer to determine if the neuromonitoring provider is within your network and to make sure the estimated charge would be covered.

Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

KHN’s ‘What The Health’: Who Will Pay To Fix Problem Of Surprise Medical Bills?

Can’t see the audio player? Click here to listen on SoundCloud.

Congress is finally getting down to real work on legislation to end “surprise” medical bills, which patients get if they inadvertently receive care from an out-of-network health providers or use one in an emergency. But doctors, hospitals, insurers and other health care payers can’t seem to agree on who should pay more so patients can pay less.

Meanwhile, the fight over women’s reproductive rights continues in both Washington, D.C., and the states. This week, governors in three states — Vermont, Illinois and Maine — signed bills to make abortions easier to obtain. At the same time, the Democratic-led U.S. House of Representatives took up a spending bill for the Department of Health and Human Services that still includes the “Hyde Amendment,” which bans most federal abortion funding — despite the fact that most House Democrats oppose the restriction. House Democratic leaders fear that the fight to eliminate the restriction would jeopardize the rest of the spending bill in the GOP-controlled Senate and at the White House.

This week’s panelists are Julie Rovner from Kaiser Health News, Stephanie Armour of The Wall Street Journal, Alice Miranda Ollstein of Politico and Kimberly Leonard of the Washington Examiner.

Among the takeaways from this week’s podcast:

  • Republicans on Capitol Hill and at the White House are just as eager as Democrats are to settle on legislation that would keep consumers from getting surprise medical bills. It would provide a nice counterpoint during the upcoming campaign to Democrats’ charges that the GOP has been undermining health care with its opposition to the Affordable Care Act.
  • A federal judge in Texas has struck down the ACA’s provision that health plans must cover contraception. That is at odds with another judge in Pennsylvania who earlier this year blocked the Trump administration’s plans to loosen the birth control mandate.
  • State insurance regulators are raising concerns about health care sharing ministries, which offer plans that provide coverage for some medical expenses. But consumers often don’t realize that the plans may not cover many health costs, including those from preexisting conditions.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: The Washington Post’s “In Alabama — Where Lawmakers Banned Abortion for Rape Victims — Rapists’ Parental Rights Are Protected,” by Emily Wax-Thibodeaux

Alice Miranda Ollstein: The New York Times’ “Planned Parenthood to Host Women’s Health Forum for 2020 Democrats,” by Lisa Lerer

Stephanie Armour: NPR’s “You May Be Stressing Out Your Dog,” by Rebecca Hersher

Kimberly Leonard: Politico’s “Lost in Translation: Epic Goes to Denmark,” by Arthur Allen

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.