Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

Balance Billing Out-of-Network Patients in the ER


In early June, Texas Governor Greg Abbott signed a bill to help patients who receive an excessively high medical bill because a physician who treated them in the emergency room or in an unplanned surgical procedure is out of network.

Under the new law, which goes into effect on Sept. 1, healthcare consumers can seek mediation for balance billing of $500 or more. While the Texas Medical Association (TMA) originally opposed the legislation, they now support the legislation because of a key change made by the law’s sponsor, Rep. John Smithee.

“TMA appreciates that Representative Smithee and the members of the House supported a $500 mediation threshold in lieu of the $0 threshold which was in the bill as filed,” Dr. Tom Garcia, president of the organization, told the Lubbock Avalanche-Journal after final passage of SB 481. “This compromise amount addresses the concerns of the consumers as well as out-of-network facility-based physicians and assistant surgeons.”

Texas is one of several states attempting to curb balance billing by out-of-network physicians, particularly in emergency situations. According to a May Consumer Reports article, Consumers Union, the policy and advocacy arm of Consumer Reports, is working to pass legislation in other states, including California, Connecticut, and New Jersey. And a Kaiser Health News article highlighted a New York law that went into effect in March. Called “one of the broadest laws in the country concerning out-of-network bills,” the New York law sets new billing requirements on hospitals, doctors, and other medical providers resulting in most insured patients seeing their payments limited for services provided by out-of-network providers at in-network facilities.

While balance billing out-of-network patients is certainly not new, the fact that it continues after implementation of the Affordable Care Act (ACA) worries many consumer advocates. ACA proponents claimed that the law would help reduce the number of “medical” bankruptcies by capping out-of-pocket expenses and requiring coverage for emergency care. The ACA also prohibits insurers from charging higher copayments if members go to out-of-network hospitals for emergency services.

However, the ACA does not include charges from out-of-network providers in the annual out-of-pocket cap nor does it prohibit out-of-network emergency care providers from balance billing out-of-network patients.

Patients and consumer advocates say the practice of balance-billing is unfair. Insurance companies point the finger at providers, who are actually doing the balance-billing. And providers, who could be seen as the “bad guy” in this scenario, just want to be paid fairly (or even just paid) for their services.

So what should you do? Last October, we posted a list of six suggestions for when patients are out of network. All of those suggestions still apply. But as more and more states address the problem legislatively, here are a few more suggestions.

  1. Recognize the difficult position each party is in, particularly patients who often know the least about the insurance and billing process. Give your staff the tools to help patients interact with their insurance companies, including the Consumers Union’s new online Insurance Complaint Tool which provides information for each state about how to file complaints with and against insurance companies.
  2. Provide continuing education to your staff for assisting patients in the billing process. In many of the stories of balance billing that make national headlines, staff members often have misquoted billing procedures, failed to know which insurance plans are in-network, or used confusing language when describing office policies. If staff members are confused, then patients will be even more confused. In fact, in a recent Kaiser Family Foundation survey about health insurance terms and concepts, only four percent of responders answered all ten questions correctly.
  3. Know if and what your state is planning to do about balance billing and advocate for provider’s rights. (Kaiser Health Network regularly reports on out-of-network balance billing.) In both Texas and New York, two states who have recently passed legislation about balance billing, physicians involved in the legislative process were able to strike reasonable compromises to ensure they still are paid for their work.

— All rights reserved. For use or reprint in your blog, website, or publication, please contact us at cipromsmarketing@ciproms.com. Photo by GotCredit via Flickr used with permission under the Creative Commons License.


Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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