TAFEC Balance Billing

Is it ‘Balance Billing’ or ‘Predatory Underpayment’?

For too long Texas health insurance providers have controlled the healthcare narrative, attempting to vilify healthcare providers while they slowly reduce coverage for consumers and shrink their networks. On one issue in particular, balance billing, health insurance providers have been unchecked by regulation, and Texas consumers are paying the price.
TAFEC defines balance billing below:

“Balance billing is a direct consequence of insurance companies failing to pay healthcare facilities anything close to reasonable amounts. When facilities are reimbursed an unusually low percentage of billed charges, they may seek to collect the remaining balance from patients.”

As emergency care providers, we believe a more appropriate term for balance billing is “predatory underpayment,” something that ultimately hurts consumers and the healthcare system overall.

Predatory Underpayment

Because there is no established industry standard for reimbursing healthcare providers, health plans are lowering freestanding emergency center reimbursement rates to unacceptable levels. As a result of the insurance provider’s predatory underpayment, a freestanding emergency center’s only option may be to seek reimbursement for their services from the patient.
Health plans then try to pin these bills on medical care providers, arguing that FECs are increasing the cost of healthcare by remaining out-of-network. But if health insurance providers are obeying Texas law and using the nationally accepted “prudent layperson” standard, a law enacted to protect consumers seeking emergency care, then emergency room visits where a patient believes his or her life is in danger should be billed at the in-network rate. Somehow this provision is overlooked and rarely enforced, allowing insurance providers to illegally bill consumers at the out-of-network rate for emergency care received at an FEC facility.

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