By Aparna Zalani | CBS11 Special Projects Producer |

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BURLESON (CBSDFW.COM) – The only thing worse than Regina Bush’s dislocated elbow after a fall last year was the bill she received from Texas Health Huguley Hospital in Burleson.

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She thought she broke her arm and rushed to the ER. She knew the hospital was in-network on her insurance plan but turned out the ER physician who treated her wasn’t.

“I was shocked, I would never have expected to receive it because everything else was covered,” she recalled.

Her part of the bill: $789.

Carrolton resident Jennifer Broadway thought she was covered too. She went into Code ER – a free standing ER for blocked nasal passages. A long time allergy sufferer, knew she needed a steroid shot to clear the passages.

“I said ‘are you sure you are in network, because if you are not I am going across the street to Baylor,’ ” she remembered asking.

She thought she had asked all the right questions. She even asked the doctor the same question. “The doctor came in, I asked him ‘are you on my insurance,’ ” she said.

But then she got a bill for $652. In her case, the doctor was covered in her insurance plan but the ER facility was not.

Balance Billing

Devon Herrick is with National Center for Policy Analysis, a non-partisan research institute in Dallas. He said balance billing is when a physician does not have a pre-determined agreement on a price with the insurance company.

“They can bill you directly for the difference in what your insurance company is willing to pay versus what they are willing to charge,” Dr. Herrick told CBS 11 News.

Dr. Herrick said doctors complain about what insurance pays them, “doctors are saying insurance companies are low-balling us, offering us paltry fees,” he said. “The insurance companies saying we are trying to create narrow networks, best deal for all enrollees.”

That leaves patients like Regina and Jennifer caught in the middle.

Dr. Herrick said patients have to be their own advocates and ask for a list of everyone who is going to treat them. Patients can request physicians who are in-network at the facility. And, find out costs of procedures before hand, if you can. “What you don’t do is say do you accept my insurance? The appropriate term is “are you in my network?” he said.

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The Texas state legislature has given consumers right to request mediation from Texas Department of Insurance for certain out-of-network claims for bills over $500. It also requires physicians to tell patients of that right when sending a bill.

TDI has received over 4369 complaints on balance billing since 2013. Meanwhile, Both Jennifer and Regina called their insurance companies and treatment facilities to help mitigate the costs. When they got nowhere, they called Consumer Justice.

Help Is On Its Way

We put Regina in touch with the Texas department of insurance. It is working with her on a resolution. Texas Health Huguley Hospital physician’s group also offered to help after we contacted them.

They told CBS 11: “As Emergency Physicians we seek to offer excellent clinic care to all patients we have an opportunity to serve.
We understand that some patients face challenges when receiving a medical bill. We have an arrangement in place to help patients in this situation.  We encourage those patients to contact our office when they receive their bill for physician services.  We discount their bill to the maximum allowed and can set up a payment plan to assist them with unexpected out-of-pocket medical costs.  Now that we are aware that Ms. Bush is in this situation, we can make arrangements with her to reduce her medical bill and coordinate a payment schedule.
In accordance with HIPAA guidelines to protect patient privacy, any specific information about Ms. Bush’s medical bill can only be discussed directly with her.” – Huguley Emergency Physicians, LLP

Texas Health Hugely also responded: “We understand that going to the ER can be a confusing, stressful time for patients and their families. Once patients’ immediate medical needs have been assessed and treated, our patient services representative will work with them to help them understand the key things they need to know about billing and insurance reimbursement. We understand that this can feel like a very complex process under emotional circumstances. For example, physicians on the medical staff at hospitals may not be employed by the hospital and thus will bill patients for their professional services separately. In addition to the standard information we provide to patients, we’re working to constantly improve how we communicate with people about insurance coverage and all other aspects of their care.” – Texas Health Huguley Hospital

Code ER (where Jennifer Broadway went) said the breakdown in communication happened at their billing company. It was able to sort out the bill with Jennifer.

They sent CBS 11 a statement saying in part: “Our third party billing company is supposed to reach out to me anytime patients have problems with their bill and that did not occur with her and I am suspicious probably occurred for others. I would not have known if you had not contacted us.” – Dr Carrie de Moor, Code 3 ER

Click here to learn about the mediation process.

TDI can help patients with a PPO plan, and for claims for a medical service provided by an out-of-network, hospital-based physician (such as a radiologist, anesthesiologist, or emergency department physician).

If the mediation applies, it typically begins with a conference call our Consumer Protection Team sets-up between the insurance company and the healthcare provider, (the consumer may also be part of this call). Most cases are resolved with that informal call.

Click here to read more about the issue of surprise medical bill.

Call the  Consumer Protection Help Line at 1.800.252.3439 for help.

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