various specialties rarely, if ever, balance bill more than $500, the threshold for initiating Texas’ mediation model for patients in PPO plans to resolve out-of- network bills from certain facility-based physicians. On the other hand, health plan out-of-network payments are typically less than half of physicians’ charge for the service, across specialties. (See “Uneven Playing Field,” page 32–33.) Many surprise bills, Dr. Callas adds, don’t come from physicians at all and
are out of their control. Often, hospitals use outside companies to hire surgical assistants, occupational therapists, imaging technicians, or other professionals who bill separately for their services.
NETWORK CONFUSION FOR ALL A TMA white paper further details how health plans determine not only what rates to pay physicians but also how much of patients’ care they are willing to cover — referred to as maximum allowable amounts — versus paying the actual charge. In addition to confusing benefit structures, the paper also highlights
STATES THAT HAVE OR ARE PURSUING BALANCE BILLING RESTRICTIONS (IN RED)
Source: Consumer’s Union (
https://consumersunion.org/surprise-medical-bills/) May 2016 TEXAS MEDICINE 31
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