“If I’m being told by the insurance company that I’m in network, and it turns out I’m not, why should I take the financial hit for that?”
TDI, too, is hearing from consumers seeking help in navigating networks,
discerning costs, and finding doctors. The calls parallel a rise in complaints to TDI about balance bills. Officials stopped short of linking the two trends, but given the growing interest in network issues from consumers, as well as lawmak- ers, TDI told Texas Medicine it will more closely track such inquiries.
VALUE PROPOSITION Health plans declined Texas Medicine interview requests, but through state- ments say their products meet state and federal access-to-care requirements and provide exactly what consumers want: a balance of affordability and choice. “Creating focused or tailored networks forwards our commitment to provide
the right care at the right time, in the right place … [and] we strive to educate and engage consumers and physicians on the value of coordinated care to reduce waste or redundancy, improve health care results, and lower out-of-[pocket] expenses for patients,” reads a BCBSTX statement. On the other hand, officials say, “One of the biggest drivers of unplanned costs is out-of-network care. We negotiate rates with contracted providers so that we can predict and better man- age what the costs of care will be.” BCBSTX points to a September 2015 report by America’s Health Insurance
Plans (AHIP), tma.tips/AHIPBalanceBillingReport, that blames some of those expenses on “exorbitant charges” for a range of out-of-network services pro- vided by hospitals, physicians, and others, when compared with Medicare pay- ments for the same treatments. “These exorbitant charges underscore the value of health plans’ provider net-
works. Health plans develop provider networks to improve quality and make health care more affordable for consumers,” states an AHIP press release. “By selectively contracting with credentialed providers, health plans ensure con- sumers have access to a wide-range of providers and clinicians, and patients see measurable savings when they visit contracted providers. Yet when providers choose not to participate in a health plan’s network or do not meet requirements for participation, consumers have little protection against physicians who ‘bal- ance bill’ or charge the cost difference for a particular service.” TMA vigorously disputed that AHIP report. “This so-called report is nothing
more than a desperate smoke screen to divert attention from the real problem,” Dr. Garcia said. “The health insurance industry games the system to keep more of patients’ premium dollars by forcing patients to seek care out of network. Then they have the gall to criticize what some doctors bill for that care.” Aetna officials also tell Texas Medicine balance billing “can happen for a va-
riety of reasons. In some cases, physician groups want to have an exclusive con- tract with a hospital and remain out of network for plans. In others, an account- able care organization run by a health system is operating a narrow network for a specific employer. Regardless of the specific circumstances, balance billing can result in unforeseen medical bills.” Aetna and BCBSTX say they have taken steps to protect consumers from “un-
expected and egregious medical bills” by educating members on their plans and cost differences between in- and out-of-network care; enhancing provider di- rectories; and creating “cost transparency tools” that show doctor- and facility- specific information on health care costs and quality. “We recognize that there can be confusion when networks change, and as a
result we are working to simplify the process” and solicit ongoing input from TMA, Aetna representatives said. In addition to insurers providing consumers with transparency tools, AHIP
advocates “greater transparency from providers” and “strengthening financial protections for consumers by imposing limits on balance billing.”
34 TEXAS MEDICINE May 2016
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