Why we need medical bills mediation
Obviously no one ever plans to be in a car accident or have any kind of medical emergency. He certainly doesn’t think he will be rushed to an expensive hospital and charged enormous amounts by the ambulance, hospital, ER doctors, radiologists, and specialists.
Most people don’t have the ability to pay these bills and assume they will be paid quickly by the at-fault driver’s liability company and his own health insurance plan.
But the injured person won’t know until months later which charges, if any, were paid — assuming he was insured and met his annual deductible. Many are not paid by the health insurance company because a provider was out of the plan’s network or the hospital was is in but the doctor was out of network so the physician’s bill has to be paid in full.
It’s like paying for an airplane flight and getting huge bills later for the pilot, flight attendants, and baggage handlers.
What the injured person doesn’t know — and certainly isn’t told — is that the ER can charge whatever it wants. A routine EKG is billed at anywhere from $18 to $317, which is 20 times the Medicare reimbursement rate.
And contrary to popular belief, the other driver’s insurance company does not pay the plaintiff’s medical expenses up front.
These balance bills add up quickly. They will be in the thousands — and even hundreds of thousands — of dollars.
An injury attorney tries to reduce these medical debts, as it is his job to make his client whole. (Read: Best ways to reduce huge medical bills)
But this is a difficult, time-consuming process that will be aided by this mediation process – especially if it is strengthened.
The severity of the problem
Even the Texas Medical Association refers to these “surprise medical bills that blindside patients” as “awfully persistent zombies.” The doctors’ organization promises to support badly needed legislation that will hold insurance companies more responsible for fairness in the billing process.
TMA believes that insurance companies have to disclose more information up front about which services will be not be covered and what medical services will cost an injured person.
State legislators know they still have a massive problem with surprise medical bills. How could they not? NPR and Kaiser Permanente write about it every month, including how an insured bicyclist who broke his hip was wiped out by his medical bills and an Austin school teacher owed $109,000 after he suffered a heart attack.
State Senator Kelly Hancock, a Republican from North Texas, sponsored 2017 legislation increasing the availability of mediation. Good news: new law will help injured Texans pay for medical care
But neither he or any one else appears to have filed any new bills advancing the mediation process this session.
How the process works
The injured person requests a mediation with the state. He participates in a telephone conference with the insurance company and provider within 30 days. The good news is that 90% of claims are resolved in this call.
The ones that are not worked out are sent to the Office of Administrative Hearings which holds a mediation within 180 days where most of the remaining disputes are worked out.
Texas deserves credit for being the first state to start medical bills mediations in 2009, but the program was weak and barely used.
Fortunately, the 2017 legislature made it easier for Texans to qualify and all out-of-network providers and the ubiquitous free-standing ERs were added as participants.
Before that happened, few people had heard about mediation and how the program works. But that number increased 100 times to over 4,500 last year. Requests are expected to double in 2019 and the system is backlogged. The TDI is hiring staff – including attorneys – to address the delays.
This process is very effective. Last year, the state agency received complaints regarding almost $9 million in bills and after the phone conference alone, insurance companies paid $1.6 million. And many of the remaining bills were written off or reduced as well.
Other states have much stronger programs. New York, for one, requires hospitals in advance to bargain with all out-of-network insurance companies and advise the patients what they will owe. Why doesn’t Texas do this? And while we are at it, cap all medical bills at a reasonable amount?
Even our doctors are crying out for help. The TMA writes on its website that “We Need to Make Texas Health Insurance Companies Put Patients Before Profit.”
Hopefully our state legislature now in session will solve this emergency of balance medical bills.