how errors in various health plan directories mislead patients to believe they are visiting an in-network physician group. (See “TMA Resources,” page 30.) A majority of Texas physicians already discuss their charges with patients
or help them estimate out-of-pocket costs, according to TMA’s survey. With help from a consumer research firm, the task force interviewed insured patients across Texas and discovered that’s exactly the kind of help they expect from their physicians because health plan products are so complex, and they find little to no help elsewhere. “They don’t blame you for the problem,” researcher Robin Rather told physi- cians at TMA’s 2016 Winter Conference, “but they want you to fix it.” Despite their best efforts, doctors are just as confused, says TMA Director of
Payment Advocacy Genevieve Davis. At the start of the ACA exchange in 2014, for instance, most health plans
touted the networks they offered were the same inside and outside of the mar- ketplace. That’s no longer the case, and certain network designs are so labyrin- thine or exclusive that “doctors and patients can’t even tell the network game anymore” to avoid out-of-network scenarios, Ms. Davis said. It got to be so confusing, Southwest Physician Associates (SPA) asked payers
to supply a list of the Dallas-based independent practice association’s members who are in network. “This year alone, 2016, networks have become so narrow and exclusive that it’s so hard even for practicing physicians to know what plans they are a member of. It really becomes a big problem, especially when you are referring out,” SPA President and pediatrician Christopher Abel, MD, said.
UNEVEN PLAYING FIELD One-quarter of physicians have
approached a plan with which they had no contract in an attempt to join its network, and of those, 29 percent received no response.
How frequently do you balance bill more than $500, the threshold for initiating Texas’ mediation model for resolving certain out-of-network bills?
Often 8%
No response 29%
Never 25%
Received a contract
39%
Received an unacceptable offer 32%
Sometimes 28%
Rarely 35%
Source: TMA 2014 and 2016 Texas Physician Surveys 32 TEXAS MEDICINE May 2016
All of the time 4%
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