In my 10 years of experience working at a healthcare billing company in Houston, I’ve seen it all. Every tactic, strategy, and policy by insurance providers to deny a patient’s claim or reduce payment to healthcare providers across the state. And as the healthcare landscape changes, insurers appear to operate with less and less regulations and oversight. It’s a rigged system, and it’s Texas patients who pay the price.
Unfortunately, as time passes, it is becoming more difficult to interact with insurance companies. These days my company must fight tooth-and-nail over every single claim to ensure our customers are getting the coverage to which they are entitled – coverage outlined in their individual health plan. If we don’t, insurers will cut every corner and not hold up their end of the bargain.
Now more than ever, insurers are armed with tricks and schemes to avoid paying for emergency services at reasonable rates, and given the structure of our healthcare system, it is difficult for providers to combat them. I’ve had countless appeals to insurers regarding payment come back denied. Many of these insurance companies have their own patient advocacy departments where they tell customers the reason they must pay out-of-pocket is because the provider’s billed charges are so high, effectively diverting the focus away from their undercoverage and placing blame on the provider.
Something has to give. Even as providers attempt to negotiate in good faith with insurance, they are shut out. Someone other than healthcare providers must attempt to hold insurance companies accountable for providing coverage to patients.
One promising measure is HB 2449, filed by state Rep. Sergio Munoz Jr., D-Mission, relating to the assignment of health insurance benefits to a physician or health care provider. This bill would enable healthcare providers to initiate dispute resolution with the Texas Department of Insurance on behalf of their patients when it is evident a health plan has not met the legal requirement to pay at the usual and customary rate.
Recent healthcare trends indicate that problems will only get worse unless there is legislative or regulatory interference. Insurance companies are covering less for their enrollees and reimbursing providers less for services rendered at their facilities. Increasing deductibles allows insurers to shift costs to their enrollees, and without proper education, patients will be hit with surprise undercoverage and be left on the hook for large sums of money.
The proliferation of high deductible and junk health insurance plans demonstrate that Texans feel it is important to secure health insurance, but do not understand what is actually included with their coverage. Now, on top of fighting to protect our customers, we also must explain to them that the insurance companies are not being transparent and upfront about their coverage. Why is it that healthcare providers must also give patients an Insurance 101 lesson when they are not in the health insurance business at all?
A recent poll conducted by the American College of Emergency Physicians found that nine in 10 registered voters want to know how insurers calculate coverage for emergency care. Thankfully, state Rep. Greg Bonnen, R-Friendswood, recently filed HB 2077, which would require health insurance companies to report biannually to the Texas Department of Insurance explaining calculation of payment rates for out-of-network physicians and facilities.
Insurers are using the complexity of healthcare and insurance to prey upon patients, collecting monthly premiums while abandoning patients when they need coverage the most. Bills like those proposed by Reps. Bonnen and Munoz Jr. are good examples of steps the legislature can take to reign in insurance companies and protect Texas patients. But so much more must be done. We must demand fair coverage and ensure that insurance companies are held accountable to provide coverage to Texans who desperately need it.