a concerning Connecticut law that labels balance billing as a deceptive trade practice. (See the map on page 31.) In Texas, renewed attention stems in part from interim charges state leaders
issued to the House Insurance and Senate Business and Commerce committees to examine whether existing laws dating back to 2007 are working to encourage transparency and adequacy of health plan networks and “protect consumers from the negative impacts of disputes over out-of-network services.” The issue is in the national spotlight with the proliferation of high-deductible and narrow- network plans sold in the Accountable Care Act insurance marketplace meant to keep premium costs down. TMA is no longer optimistic, however, about 2017 federal rules that backped-
al on more stringent requirements in earlier drafts to tackle ACA plan shortfalls. Similarly, TMA officials warn that new model network adequacy legislation ad- opted by the National Association of Insurance Commissioners (NAIC) — an organization of states’ chief insurance regulators — does little in the realm of insurance regulation. The template, which garnered widespread support from the health insurance industry and could influence future Centers for Medicare & Medicaid Services (CMS) rules, largely leaves network standards up to indi- vidual states while restricting physicians’ ability to balance bill. “Make no mistake, balance billing will be one of the first things on the [Texas] legislative agenda when the gavel strikes in 2017,” then-TMA President Tom Garcia, MD, told physicians at TMA’s Winter Conference in January. As this article went to press, TMA’s Board of Trustees approved the Task
Force on Balance Billing’s recommendations for possible new TMA policy and advocacy solutions to be considered by the House of Delegates at TexMed 2016, April 29–30 in Dallas. At the top of the list: “Ardently pursue legislative goals [that] seek to hold insurers accountable for their actions.” “Lawmakers want physicians to be a part of the solution. And we want the
same things our patients want, which is transparency, not just from physicians but from all health plans and all health care providers, because our patients don’t deserve to get a surprise bill,” said Beaumont anesthesiologist Ray Callas, MD, task force member and chair of TMA’s Council on Legislation. Until now, much of the debate focused largely on emergency care because patients don’t always have a choice of where to turn for treatment and because emergency care can be more expensive than routine, nonurgent services. But Dr. Bourgeois cautions recent efforts more broadly target any out-of-network physician providing services at an in-network facility. The End Surprise Billing Act of 2015, filed by Texas’ own U.S. Rep. Lloyd
Doggett, a Democrat, would prohibit balance billing by physicians of any spe- cialty who have privileges at a network hospital but do not contract with the same insurer. Democratic presidential candidate Hillary Clinton’s plan for lowering out-of-pocket costs would require that patients “pay no more than in- network cost-sharing for any care received in a hospital in their plan’s networks and for any emergency services in a true emergency. Americans should never be surprised by an unexpected medical bill, especially in moments when health is their greatest concern,” states a Sept. 9, 2015, factsheet from her campaign website. Read the factsheet at tma.tips/ClintonBalanceBilling.
NARROW NETWORKS ON THE RISE The mounting pressure on health plans to keep their premiums affordable has brought on a proliferation of narrow networks, Dr. Valenti says. But he cautions prohibiting balance billing or removing the patient from the process would only further encourage insurers to shirk their responsibility to ensure adequate ac- cess and contract in good faith. And much like the megamergers of some of the
May 2016 TEXAS MEDICINE 29
confusing for patients, and it’s very confusing
“It’s very for doctors.”
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