TAFEC Resolution Adopted January 25th, 2017

TDI HEALTH INSURANCE  OVERSIGHT AND ENFORCEMENT

WHEREAS, the Texas Association of Freestanding Emergency Centers (TAFEC) is comprised of 220 full-service emergency medical care centers located in over 100 communities in all regions of Texas; and

WHEREAS, each freestanding emergency medical care center is regulated under Chapter 254, Texas Health and Safety Code, and Title 25, Chapter 131, Texas Administrative Code; and

WHEREAS, TAFEC members offer patients in need of emergency medical care treatment around-the-clock provided by physicians who are experts in Emergency Medicine using state-of-the-art diagnostic and treatment tools; and

WHEREAS, TAFEC members meet their social and legal obligations to provide treatment to each patient who needs emergency care, regardless of the patient’s ability to pay, and TAFEC members provide millions of dollars in uncompensated care annually; and

WHEREAS, insured patients who need emergency medical care often have no choice but to obtain emergency care in a facility that has been excluded from their insurers’ preferred provider networks; and

WHEREAS, in 2009, the Health Network Adequacy Committee established by Senate Bill 1731, 80th Legislature, Regular Session (2007), reported that reimbursements by insurers to out-of-network providers for the same services were wildly variable and that payments were so low that “in some cases could make the out-of-network benefits effectively unavailable”; and

WHEREAS, the Legislature has attempted to protect insured emergency care patients by requiring insurers to maintain adequate networks of medical care providers to reduce the amount of out-of-network services their customers must obtain; and

WHEREAS, the Legislature and the Texas Department of Insurance (TDI) have also attempted to protect emergency care patients who must obtain care from out-of-network providers by requiring insurers to pay for those services at the “usual, customary and reasonable” rate paid to in-network providers; and

WHEREAS, in 2013, TDI adopted rules intended to strengthen enforcement of its network adequacy rules, but insurers continue to reject some providers from participation in their networks, frequently by offering unrealistic reimbursement rates to prospective providers; and

WHEREAS, in 2013, TDI adopted rules to enforce the “usual and customary” requirement, but the agency did not define the term and allowed each insurer to establish its own methods for determining what constitutes a usual and customary rate; and

WHEREAS, TDI has surveyed Texas insurers regarding payment rates for a variety of medical services provided by in-network and out-of-network providers but the data requested did not cover all emergency care reimbursement codes or types of services; and

WHEREAS, the failure to enforce network adequacy and payment of usual and customary charges has forced providers to bill patients for services provided to them in usually unpredictable emergency situations, causing patients to be caught in the middle between insurers and providers, and leading to hundreds of complaints of insurer misconduct and use of time-consuming alternative dispute resolution processes through TDI and the State Office of Administrative Hearings; and

WHEREAS, although the Legislature and TDI have attempted to limit balance billing, those efforts have been thwarted by the absence of a reliable, comprehensive source of health care reimbursement information available to the public and providers; now, therefore, be it

RESOLVED, that TAFEC requests TDI to perform and publish the results of surveys of insurers to obtain the data needed for patients and providers to have certainty regarding what constitutes the usual and customary reimbursement for all reimbursement codes for emergency room procedures and treatment events across all regions of the state; and, be it further

RESOLVED, that TAFEC requests the Legislature to ensure that TDI has the directive, authority and resources to gather, update, maintain and publish the data controlled by insurers that are necessary to provide the public and health care providers with a reliable and comprehensive source of health care reimbursement information in order to enforce the usual and customary health care reimbursement requirement of current law.

ADOPTED
January 25th, 2017

 

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