A growing number of Texans are turning to a little-known state mediation program to deal with surprise hospital bills. However, the program is likely only addressing a fraction of the surprise medical bills Texans receive in the mail every year.
The Texas Department of Insurance program is meant to intervene when Texans are stuck with a bill after their insurance provider and hospital can鈥檛 agree on a fair price for services 鈥� usually after an emergency. The practice is known as balance billing. The state only intervenes, though, after patients file a complaint with the agency.
The program, historically, had many loopholes and few consumers qualified for help. It was expanded during the last legislative session, though, and more patients have been filing complaints. In 2014, the department was asked to mediate 686 medical bills. During the 2018 fiscal year, it received 4,445 bills.
Brad Buckingham said he had to deal with a surprise medical bill after a bicycle accident in 2016. The Austin dentist was on a ride with friends when he crossed some train tracks at an angle to avoid a pile up. His wheel slipped out from under him and he landed hard on his left hip.
鈥淎ll I could do was scream,鈥� he said. 鈥淚 couldn鈥檛 even make words.鈥�
His friends called an ambulance, and Buckingham was taken to the nearest hospital: St. David鈥檚 in South Austin.
鈥淚 specifically remember I gave them my health insurance information in the ambulance,鈥� he said. 鈥淎nd they put me in the ER and from the ER they took my insurance information, again.鈥�
Buckingham had insurance through Baylor Scott & White Health, which he bought through the Affordable Care Act marketplace. St. David鈥檚 was out of network for his plan, but no one told him at first.
Buckingham had broken his hip, and doctors took him into surgery the same day.
鈥淭hey held me in the hospital for three days just for recovery and never told me I was out of network until the time of my discharge,鈥� he said.
A few weeks later, Buckingham got a bill for $71,543.
The total bill was $75,346. Baylor Scott & White, which left the ACA marketplace the following year, paid only about $3,812.
Buckingham said when he first saw the bill, he thought it was a mistake. He called the hospital and the insurer to sort it out. But after weeks of inquiring about it, there was no resolution.
Both sides insisted it was his responsibility.
鈥淚鈥檓 sitting there thinking to myself that there is no way 鈥� there is no way this is right,鈥� he said.
Baylor Scott & White said it could not discuss Buckingham鈥檚 bill 鈥渄ue to confidentiality requirements."
After Buckingham signed releases, St. David鈥檚 released a statement saying he was not balanced billed. It also blamed the large bill on his 鈥渉igh deductible plan.鈥�
鈥淸Those plans] may be attractive to some people because they cost less,鈥� St. David鈥檚 said, "though they place more financial responsibility on the patient."
Buckingham said his policy had a deductible of $5,000 for in-network care and $10,000 for out of network. He said he still doesn鈥檛 know what happened.
鈥淵ou know, whenever I tell my story to anybody they kind of agree 鈥� like, 'Oh my gosh, this is ridiculous,鈥欌�� he said. 鈥淏ut then when you talk to the people that have any control over it, it鈥檚 the exact opposite. It's: 鈥榊ou owe it, we don鈥檛.鈥欌��
Buckingham didn't know where to turn, so he got a lawyer to help lower his bill. He said he owes only a couple thousand dollars now, but he is still frustrated that all this happened.
It's a situation anyone can find themselves in.
Stacey Pogue, a senior policy analyst with the Center for Public Policy Priorities, has been looking into balance billing for years. She said whether you get a surprise bill after a trip to the ER is a total crapshoot.
鈥淚t鈥檚 a total roll of the dice,鈥� she said. 鈥淭he medical emergency that鈥檚 going to send you to the hospital where you could get a surprise bill 鈥� is that emergency room going to be in or out of network?鈥�
Pogue said the Texas Department of Insurance's mediation program has been around for a while to help people in these situations. It forces an insurance company and the hospital or medical provider to negotiate a fair price for services. She said 90 percent of the time those negotiations happen over the phone.
From 2017 to 2018, the number of bills sent to the program more than doubled 鈥� from 2,063 to 4,445. Pogue said there are two big reasons for that.
鈥淥ne is just increased awareness,鈥� she said. 鈥淭here is constant media attention now to surprise medical bills, because the stories are so shocking, right. We see them covered more, so people are more aware that when they get one they could do something about it.鈥�
The second reason is because in 2017, the Texas Legislature opened the mediation program up to more people, including teachers.
Stacey Shapiro, a first-grade teacher in Austin, also received a surprise bill from St. David鈥檚 after she landed in the emergency room last March.
The marathon runner said she woke up one Saturday for an early run and wasn't feeling well.
鈥淚 just felt so sick, I wasn鈥檛 sure if I was going to throw up,鈥� she said.
In the bathroom, things got worse: 鈥淎ll of a sudden the whole room started spinning. ... I started sweating, sweating like buckets,鈥� she said. 鈥淚t was terrible, and then all I remember is that my ears started popping, my vision got blurred and then the next thing I knew, I had passed out.鈥�
Shapiro鈥檚 boyfriend heard her hit the floor. He found her passed out, with her eyes open and hardly breathing. He took her to St. David鈥檚, which was the closest hospital.
Shapiro said she was taken care of in a few hours. Hospital staff gave her fluids and anti-nausea medication. Doctors found she had a huge change in her blood pressure that was likely due to her hypoglycemia, or low blood sugar.
Two months later, a $6,720 bill came in the mail.
Like many teachers in Austin, Shapiro gets her health insurance from Aetna.
In a statement, the insurer said Austin ISD employees use the Seton Accountable Care network, a plan that St. David鈥檚 parent company, HCA, doesn't participate in.
鈥淯nfortunately HCA is not currently accepting payments through Aetna鈥檚 NAP program, which provides set payment fees for non-participating providers. This has resulted in Ms. Shapiro being balance billed for her emergency room visit,鈥� Aetna said in a statement.
Shapiro said Aetna told her to pay only her deductible ($1,275), which she did right away. But St. David鈥檚 kept sending bills for the rest of the balance.
鈥淚 guess I just thought that it was going to go away,鈥� she said.
But it didn鈥檛. As a public school teacher, she said, $5,000 would have been a huge blow.
Shapiro applied for financial aid, but St. David's said she didn鈥檛 qualify. She said she felt like she was out of options 鈥� until a friend told her about the state's mediation program.
Aetna and St. David's had a scheduled mediation call, but before it took place, KUT asked St. David鈥檚 for a comment on the situation. Shortly after, Shapiro said St. David鈥檚 told her she no longer owed anything.
St. David鈥檚 said Shapiro had 鈥渁lready satisfied her financial obligation.鈥� It also denied that she was balance billed to begin with.
Shapiro said the whole thing has been exhausting.
鈥淚t鈥檚 just very frustrating because this has been very time consuming,鈥� she said.
That's why Pogue has been arguing that the state needs to find ways to get involved.
She said the current mediation process is pretty good, but not enough people know it鈥檚 an option.
鈥淏ecause first, the instructions for how to do it are on your medical bill and your explanation of benefits 鈥� the most indecipherable documents you are going to get,鈥� she said.
Pogue said even when people understand they have a right to mediation, they might get scared off by the concept and think they need a lawyer.
But when people use the program, it tends to work.
According to the state insurance agency, in the 2018 fiscal year the complaints amounted to $9.7 million worth of medical bills. By the time all those teleconferences were finished, the charges were negotiated down to $1.3 million.
Pogue said she can just imagine someone going through the process say, 鈥淲hy didn鈥檛 this happen at the first place? How come I had to, while recovering from an emergency, decipher medical bills, fill out paperwork with the state department of insurance, jump through all these hoops, when all that needed to happen was a phone call?鈥�
Ideally, she said, a solution to surprise medical bills would remove consumers from this confusing web altogether.
Pogue said states like New York, California and Florida have systems that make things easier for consumers and she thinks Texas should do that, too.
In the meantime, she said, more people here should take advantage of what's already in place.
The number of people who seek mediation is "tiny compared to the number of people who get surprise bills,鈥� she said, "so, there is a ton of work to be done."
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