cians and health care providers.” It also gave patients recourse to resolve dis- putes with their health plans over out- of-network bills. The Texas Association of Health Plans, which also participated in the work- group, did not respond to Texas Medicine interview requests. Health plans argue that balance bills
largely are the result of physicians’ reluc- tance to contract with insurers. TMA’s 2012 Physician Survey results show otherwise: Seventy-five to 85 per- cent of physicians contract with at least one of the five major health plans in Tex- as. (See “Physician-Reported Contractual Relationships, page 24.) Of those who were not contracted but requested to join a network, 48 percent eventually signed a contract, 31 percent said they received an offer that was unacceptable, and 22 percent said the plans did not re- spond to their requests. Dr. Hinchey also pointed to a 2009
workgroup study that showed 90 per- cent of claims filed by facility-based spe- cialists in pathology, anesthesiology, ra- diology, and emergency care — services most often the subject of balance bills — were in network. The state’s five largest PPOs collected that data. “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,” Dr. Hinchey said.
He added that often health plans of- fer physicians payment rates well below the cost of providing care or change con- tract terms without giving doctors the opportunity to renegotiate. In approving adoption of the earlier rules, the insurance department under Mr. Geeslin concluded they were “neces- sary to assist [patients] and group con- tract holders to more accurately assess the risk of unanticipated balance bills,” and to “incentivize insurers to contract with adequate numbers of physicians and providers as a matter of competi- tion.” The department at the time also rejected health plans’ objections that potential administrative burdens war- ranted elimination of the earlier rules.
Commissioner Kitzman reversed course, however, and suspended imple- mentation of the former rules in De- cember 2011, just after the legislature authorized insurers to offer potentially more affordable, but more limited, EPO networks under House Bill 1772. She said the amendments were nec-
essary to align regulations for both PPO and EPO networks “to ensure consisten- cy within the market.” In doing so, TDI took out provisions
it suggested could mislead patients and lead to increased premiums. In the preamble to the newly pro-
posed regulations, TDI staff acknowl- edged concerns that the rules “relaxed requirements for insurers” and could “re- sult in less transparency for consumers.” But the department contends insurers
already have to make listings available to patients on their websites and regu- larly update them. And the new rules would still require health plans “to pay
A long history
2005 Senate Committee on State Affairs is charged to study reim- bursement of health care plans for out-of-network claims, ad- equacy of health plan networks, and balance billing.
2007 Senate Bill 1731 directs the Texas Department of Insurance (TDI) to work with an advisory committee and make recommenda- tions to the legislature.
2009
Health Network Adequacy Advisory Committee and TDI report to the legislature. House Bill 2256 requires TDI to write rules on network adequa- cy and allow patients to mediate out-of-network claims.
2011 Then TDI Commissioner Mike Geeslin adopts PPO network ad- equacy rule to be effective in May 2012. House Bill 1772 creates new “exclusive” provider organization (EPO) networks. Newly appointed TDI Commissioner Eleanor Kitzman suspends adopted PPO rule.
2012
TDI withdraws 2011 rules and proposes new regulations for both PPOs and EPOs, with anticipated adoption in early 2013.
March 2013 TEXAS MEDICINE 23
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