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2023 Legislative Preview: TMA's Top 10 Priorities
Goal: Enhance enforcement of and accountability under state network adequacy laws and protect Texas’ surprise-billing law
Impact: Texas has some of the strongest network adequacy rules in the country. Yet the Texas Medical Association continues to receive reports of health plans exploiting regulatory loopholes and offering plans that do not provide patients access to a sufficient panel of in-network physicians, says TMA lobbyist Ben Wright.
TMA experts stress that effective surprise-billing legislation is intimately tied up with effective network adequacy. The Council on Legislation has formed a task force on the issue to protect the state’s surprise-billing provisions and to advocate for stronger network adequacy enforcement by the Texas Department of Insurance (TDI).
State Rep. Tom Oliverson, MD (R-Cypress), anticipates health plans will buck at TMA’s advocacy because they stand to benefit from skewed arbitration provisions in the rules implementing the federal law, as those rules currently stand. (TMA is challenging some of the federal rule provisions in court.)
In both the federal and the state surprise-billing frameworks, an arbitrator ultimately picks either the physician’s proposed payment or the health plan’s. Unlike the federal provisions, however, Texas Senate Bill 1264 – which Representative Oliverson sponsored in the House in 2021 as then-chair of its insurance committee – expressly requires an arbitrator to take into account the 80th percentile of physicians’ billed charges as one of the factors in deciding a surprise medical bill dispute.
Unfair arbitration rules disincentivize health plans from providing adequate networks because they expect to prevail in any surprise-billing dispute, TMA experts say.
And without adequate networks, health plans cannot keep their promise of adequate health care coverage, says Tilden Childs, MD, chair of TMA’s Council on Legislation, hence the need for more accountability. “Just saying you have coverage doesn’t mean anything unless you can really offer services that are supposed to be there,” he said.
Representative Oliverson agrees stronger TDI enforcement is paramount.
“You can’t sell a defective product like a car,” he said. “I don’t know why an insurance company would be allowed to offer an insurance plan to new enrollees that they knew had a defective network.”