“Just because doctors have the right to balance bill for an out-of-network service doesn’t mean they necessarily do it, nor does it mean they are always successful in collection of a balance bill.”
In addition, health plans would no longer have to:
• Give patients information on the percentage and amount of out-of- network claims filed with a particular insurer;
• Designate the status of a preferred network that does not comply with network adequacy requirements as a “limited hospital care network”;
• File a network adequacy report when renewing a waiver from the require- ments; or
• Give certain information to selected physicians who must certify whether a waiver is warranted.
TMA officials also warn that certain changes may limit some of the original protections meant to give patients full credit for certain out-of-network expens- es toward their annual plan deductibles and out-of-pocket maximums if they have to go out of network for care. The newly proposed “Preferred and
information so they could make an in- formed choice and have less concern about unexpected bills. And both phy- sicians and insurers had to negotiate in good faith.
“Now we may have to spend more time and political capital on this, when we should be focusing on other im- portant issues affecting patients,” Dr. Hinchey said. TMA Vice President for Medical Eco-
nomics Lee Spangler added, “The lack of consensus is an inadequate rationale for the department to ask for the legislature to craft a solution, without first giving the previously adopted rules a chance to work. Former Com- missioner Geeslin understood that the legislature asked the department to develop a regula- tory mechanism that benefitted the consumer.”
Commissioner
William W. Hinchey, MD
Kitzman and her staff refused Texas
22 TEXAS MEDICINE March 2013
Medicine’s offers to comment for this story.
A complete 180 The new PPO rules retain some of the originally adopted network adequacy criteria that limit how far patients must travel for primary or specialty care and that establish basic payment criteria that track federal health reform rules for out- of-network services. For example, the Patient Protection and Affordable Care Act (PPACA) sets a floor for paying out- of-network emergency claims. But TMA officials point to the re- moval of key provisions they say tip the balance in favor of insurers by weaken- ing their responsibilities to contract with enough doctors and patients’ ability to assess their coverage. The newly proposed rules strip re-
quirements that PPOs notify patients and regulators when the number of in- network physicians and hospitals sub- stantially decreases and disclose in writ- ing basic network demographics, such as the number of preferred specialists in a given region.
Exclusive Provider Plans, Exclusive Pro- vider Benefit Plan Requirements” are available online at
www.tdi.texas.gov/ rules/2012/
parules.html.
TMA filed comments opposing the new rules, in conjunction with the Texas Society of Anesthesiologists, the Texas Society for Gastroenterology and Endos- copy, the American College of Obstetri- cians and Gynecologists, the Texas As- sociation of Obstetricians and Gynecolo- gists, the Texas Radiological Society, the Texas Orthopaedic Association, and the Texas Urological Society. The previously adopted network adequacy rules were the culmination of years of debate that began in 2005. (See “A Long History,” opposite page.) It started with a charge to the Senate Com- mittee on State Affairs to study network adequacy and balance-billing issues and led to the creation of the Health Net- work Adequacy Advisory Committee in 2007 under Senate Bill 1731. Those discussions took shape in 2009 when the legislature passed House Bill 2256. It required state insurance officials to adopt network adequacy standards that “ensure availability of, and accessi- bility to, a full range of contracted physi-
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