In 2007, Senate Bill 1731 was enacted into law.  This law requires health plans to notify enrollees in advance of services that facility-based physicians may not be contracted with the health plans and that the patient may billed for the amount not paid by the health plan.  This law also requires that hospitals and physicians must notify patients that they may be billed for “out of network” services, even if the hospital is contracted with the health plan.

Rep. Smithee feels that more should be done to remedy the “balance-billing” and “network adequacy” problem.  He is advocating that insurance companies make greater efforts to include hospital-based physicians in their networks and that contracted hospitals also make greater efforts to insure that at least “some” of their hospital-based physicians are contracted with any health plan with which the hospital is contracted.. He feels that responsibility for resolving the problem must be a “shared” obligation of health plans, patients and physicians.

SB1731 also directed the Texas Dept. of Insurance to collect data on health plan reimbursements and to also create a Task Force to study network adequacy issues.  This Task Force held its initial meeting in Dec., 2007 to bring the stakeholders together to discuss both network adequacy and balance billing.  Dianne Longley, Director of Special Projects for the TDI Life, Health and Licensing Division stated that the first mission of the task force is to determine what data is needed and what data is missing. Ms. Langley says that TDI wants to obtain a variety of data, such as the percentage of claims filed “out of network” and the “actual number of patients being balance billed by physicians”.  Another problem is that there is no universally accepted definition of “network adequacy”. In December, 2008, the Task Force will submit data and their recommendations to the legislature.  In all likelihood, the TMA will advocate for increased authority for the TDI to regulate “network adequacy” and for TDI to require increased “transparency” of health plans in terms of their “loss-ratios”, i.e. the percentage of each premium dollar that actually goes to pay healthcare providers.