Rep. Dustin Burrows (Dist. 83, Lubbock) introduced H.B. 307, which could significantly impact facilities and practitioners that provide services on an out-of-network basis. Specifically, for services other than emergency services, H.B. 307 requires that a facility or practitioner provide a patient with the amount, including facility fees, that:
(1) the patient’s health benefit plan will reimburse the facility or practitioner for the service, if the facility or practitioner is a participating provider under the patient’s health plan; or
(2) the facility or practitioner will charge for the service, if the facility or practitioner is not a participating provider under the patient’s health plan.
If a facility or practitioner is unable to quote a specific amount in compliance with the requirements above, due to an inability to predict the specific services the patient will need, the facility or practitioner must provide an estimate of the amounts. When an estimate is given, the facility or practitioner must disclose: (1) the incomplete nature of the estimate; and (2) that the facility or practitioner may be able to provide an updated estimate after obtaining more information.
Importantly, if a facility or practitioner fails to give a patient the required amount or estimate, the facility or practitioner cannot bill the patient or health plan for the services.
While these provisions would seem attractive to health plans based on an expectation that a patient presented with charge information for an out-of-network service may decide not to obtain the service, other provisions of H.B. 307 probably make it unlikely that H.B. 307 will be enacted, at least not without changes. In particular, the proposed legislation would also require a health plan to share savings with a beneficiary if a beneficiary obtains services at a cost lower than the average quoted price for the service. Health plans are likely to oppose such a cost-sharing mechanism due to the difficulties in implementing systems to assess actual and quoted costs and make payments to beneficiaries. The mechanism would also pose hurdles for facilities and practitioners because claim submissions would need to reflect the price agreed upon with a patient (if different than an applicable contract rate or charge master) so individual charge information would need to be entered for each claim where a negotiated price is used.