Calling Surprise Billing by its Real Name—Surprise Under-coverage and Underpayment from Insurance Companies

By Okem Okpara

M.D., Member, Texas Association of Freestanding Emergency Centers (TAFEC)

Calling Surprise Billing by its Real Name—Surprise Under-coverage and Underpayment from Insurance Companies

By Okem Okpara, M.D., Member, Texas Association of Freestanding Emergency Centers (TAFEC)

“Surprise billing” must end. It’s a simple statement with a more complex solution ahead. In case you’re not familiar with the concept, “surprise billing” results when patients receive bills from their medical providers that they were expecting their insurance companies to cover. “Surprise billing” is really surprise under-coverage and underpayment from insurance companies.

While Texas-based physicians and medical staffs, facilities, legislators, and the general public are all adamant about confronting this multi-billion dollar challenge head-on, there’s one group that’s been much quieter about this growing phenomenon and its causes. The conspicuously absent voice is that of major health insurance corporations operating in our state.

While taking on record profits, these companies continue to raise rates on their policyholders, narrow the provider networks Texas consumers have access to, cause treatment delays because of their unnecessarily bureaucratic approval processes, and flat-out delay and often deny emergency treatment costs after-the-fact for necessary ER care.

Every day, Texans feel increasingly like drivers who are given directions in different languages at each and every new turn. How confusing is that! How can you get safely to where you’re going if the roadmap isn’t clear?

Fortunately, all across Texas and the United States, there is a movement to end the confusion wrought by misleading directions and underpayment of legitimate ER claims. People are fed up, and fortunately, our elected leaders are listening and actively working to change things for the better.

Texas’ freestanding ERs are squarely in favor of ending the “surprise billing” fiasco that has taken hold here. And thanks to the leadership of legislators such as Rep. Tom Oliverson (R-Houston), there is a bill this session that not only aims to create greater pricing transparency for ER patients in both hospitals and freestanding facilities, but one that could also help stem the tide of surprise under-coverage that has turned into a painful condition for thousands of Texans annually.

Some in the healthcare industry say that new legislative remedies won’t work for them. For freestanding ERs, our concern is not whether these legislative remedies work for us, it’s making sure they work for you, our patients. As an emergency physician who’s provided life-saving care to people in need for nearly 15 years and counting, my focus is on patient wellbeing, not the confusing games played by insurance giants. But I now see it as my duty to publicly challenge these wrongheaded efforts that often put profits ahead of patients.

What Texas consumers care about is that those charged to care for and protect them don’t steer them into danger. With a dedicated effort by some key legislators to administer a cure for the plight of surprise under-coverage, the question is: will the medicine take?

As the headline of a recent op-ed in these pages declared: “Patients should never be surprised by unexpected bills for out-of-network costs for emergency or unplanned health care services.” We couldn’t agree more. But what also needs to be said—and isn’t said enough is: when it comes to “surprise billing,” the culprit is clear. Health insurance corporations are playing unsettling games with consumers’ health and wallets.

Texans must have certainty that when they go to the ER for needed care—perhaps even life-saving care—that their visits will be properly covered by their insurance companies. Increasingly, that is not happening.

We have a responsibility to battle back against the consumer confusion being instigated by profit-hungry insurance corporations that benefit when you stay away from the ER. It’s worth noting that last year alone, the largest provider of healthcare policies in the state of Texas, spent “just 64 percent of their premiums…on medical care, resulting in almost $2.7 billion in gross profit.”

Whether you’re a cancer patient who has had your life-saving treatment denied by an insurer or an ER patient who had to endure the enormous cost of an ER visit that your health insurance company was obligated to cover, know this: Texas’ freestanding ERs stand with you in your fight against “surprise billing,” underpayment, delayed payment, and denied coverage.

First addressing the truth—that “surprise billing” is the direct result of under-coverage by insurers will help us to find a patient-centered solution.

And that’s why we’re working hard for policy changes in Austin that are in the best interest of our patients.

We’re committed to developing a roadmap for Texas patients that’s clear and straightforward, so that you can get exactly where you need to go without any more confusing directions or unwelcome surprises—and the reassurance that you’ll be taken care of when you arrive.