In early 2009, I underwent a medical procedure. I had spoken with the doctor and hospital regarding how much I will need to pay and how much my health insurance would pay for the procedure. I was given the amounts. A couple of months after the procedure, I received a bill from an anesthesiologist for several thousand dollars. I was of course surprised and disappointed-this anesthesiologist was not covered under my health insurance plan and I was stuck paying this bill. This is called balance billing.
Balance billing occurs when a doctor bills a patient for the difference between what the doctor charges for a service and what health insurance pays the doctor for the service. When a doctor is not within the health insurance plan, there is not a set payment rate that the doctor has agreed to accept from the health insurance plan so the health insurance plan can pay what it believes is appropriate and the patient is billed for the difference. In other words, the health insurance plan is under little obligation to pay, leaving the patient with the bill.
Fortunately, after my procedure, on June 19, 2009, the Texas Legislature passed into law Texas House Bill 2256 and became effective immediately. Under this law, patients with medical debt exceeding $1,000 can elect to have a mediator decide what they owe, provided the medical service was conducted by a physician in a hospital covered under the patient’s insurance. If a patient requests mediation, a mediator agreed upon by all parties (or appointed by the chief administrative law judge by random assignment) would conduct the mediation. Each party would have an opportunity to state their position. The mediation would consider three issues. First, whether the amount charged by the facility-based physician was excessive. Second, whether the amount paid by the insurer for the service was the usual and customary rate (UCR) or unreasonably low. Third, whether the amount for which the enrolled is to be responsible is excessive.
Therefore, if you have been balanced billed, consider HB 2256 as you now have the option to mediate.