Major changes coming next month to benefit Texas patients

Several changes in the way Texas doctors practice medicine will take effect on Sept. 1 and some of them directly benefit patients.

The 85th Legislature addressed several medical and health care issues over its course, but among those bills signed into law scheduled to take effect Sept. 1, likely the most beneficial to patients are Senate Bills 507 and 680.

What made life hard for many patients were balances left on medical bills after insurance carriers refused to pay some, or in some cases all, of a claim.

Senate Bill 507 addressed the billing issue and while it's not a great fix, it's a start.

"We made some positive changes in the area of health care but we still have a long, long way to go," J.D. Sheffield, a Gatesville physician and state representative said Tuesday.

The problem came when patients discovered there were balances left on medical bills because their insurance wouldn't pay all of their claim.

What the bill did was expand a patient's ability to mediate their claims with the insurance companies and set new guidelines for mediation.

"Under (the) measure, mediation for balance billing will become available to more patients in a much wider array of care settings, giving them a much-needed recourse while preserving a physician's right to be paid for his or her services," Texas Medicine Magazine says.

According to the article published in Texas Medicine Magazine, "Senate Bill 507 expands the billing mediation process to all physicians and other out-of-network practitioners at certain in-network facilities to help reduce patients' issues when they receive a bill their health insurance will not pay.

"SB 507 also expands mediation to out-of-network emergency care," the article said.

And that's the key to the benefits, Sheffield said.

"The problem came when someone went to an emergency room to get treatment not realizing the emergency room doctors are on contract to the hospital and not employed by the hospital," Sheffield said.

"They'd get a bill from the hospital and then get another one, outside the network that would not be paid as part of the claim," Sheffield said.

The problem also exists with anesthesiologists, most of whom these days work for a group and not for a hospital.

But the real rub, attorneys say, could be with the arbitration process itself.

"It's better than what we have now but it's not good," Vic Feazell, a former McLennan County district attorney who’s now a personal injury lawyer with offices in both Waco and Austin, said.

"It's especially a problem when you're talking about a worker's compensation claim because those arbitrators work for the insurance companies they're representing in the mediation," Feazell said.

Waco attorney Steve Harrison seconded what Feazell said.

"If someone cannot take a case to the courtroom, then citizens are being denied their 7th Amendment right to a jury trial," Harrison said.

"The only level playing field in a dispute like that is the courtroom and that's the only place a party can expect fairness," Harrison said.

"It's not good, not good, Feazell said.

The second issue addressed was a new "step-therapy" protocol.

Senate Bill 680 allows physicians to override an insurance company's protocols when prescribing specific medications for a patient.

Sheffield, himself a primary care physician, said he's seen that very thing happen to his patients time and time again.

"(My nurse) will spend hours on the telephone arguing with insurance providers about the best medicine and this new bill will help with that," Sheffield said.

The Texas Medicine Magazine article says: "a physician's judgment on whether specific medication is working can more quickly override a health plan's efforts to cut costs through step therapy mandates."

Insurance companies routinely refuse to pay for medications ordered by doctors that would provide "the best" treatment and alter the ordered medication to a substitute that is on the insurance company's protocol.

Under the new rules a physician can override the insurance company and select the "best" medication without regard to the company's protocols.

If a patient's prescription medication is working, a health plan's step therapy protocols are no reason to switch the patient to another drug. That's the medicine-backed basis of Senator Hancock's Senate Bill 680, which also earned Governor Abbott's signature in late May.

A step therapy override allows a physician to continue prescribing an effective medication even if an insurer's step therapy plan calls for a change.

Under SB 680, a health plan generally has three days to determine whether to approve a physician override.

The current process can take as many as 53 days.

The bill also prevents patients from having to go through the step therapy process a second time if their coverage changes.

Another issue addressed was mental health care.

"We've fallen very short in providing mental health care for Texans but in this past session we allotted more funds for mental health and modified the law that calls for insurance companies to treat mental health care issues just like general health care issues," Sheffield said.