Over the last week, North Texas residents have found themselves caught in the middle of a corporate struggle between the largest private health insurance company in the state and a group of emergency room physicians that could result in higher emergency room bills.

News broke last week that Blue Cross Blue Shield of Texas was dropping coverage with physicians staffing 14 area hospitals, including Texas Health Presbyterian in Kaufman, due to contract negotiations between the private insurance company and physician group Texas Medicine Resources hitting a wall. The affected emergency rooms include not only Texas Health Presbyterian in Kaufman but also the Texas Health facilities in Allen, Dallas, Denton, Plano, Rockwall, Arlington, Azle, Cleburne, Fort Worth and Stephenville.

Notably, the contract dispute is not related to these hospitals themselves, or even their emergency departments, but all of the emergency rooms at these locations are staffed by physicians from Texas Medicine Resources, a physician group based out of Allen who are arguing that Blue Cross Blue Shield is paying them a fraction of what they get from other insurance companies.

“We have been in network with Blue Cross Blue Shield for around 25 years,” president of Texas Medicine Resources Ralph Maine said. “In that 25 years we have received one increase in 2008 and since then we haven’t been able to agree on any increases. They’ve made small offers but they were not appropriate. Consequently we’re still operating on rates from the ‘90s and we are getting paid about half of what they’re paying other physicians in this market. We’ve asked for them to make it fair. They’ve declined. That puts us in this position.”

While Maine is hopeful that his organization and Blue Cross Blue Shield will eventually be able to come to a compromise, he also stands firm arguing that he’s only doing what any employee would do in a similar situation.

“My hope is that it gets worked out, but the reality is they’re so far apart from the other payers in the market,” Maine said. “It’s going to be difficult. My life is a lot easier if we’re in the network; I don’t have to answer questions from patients. But it has to be an appropriate rate. It is incredibly frustrating. Imagine you worked somewhere for 25 years. You got one increase in that 25 years and then you find out that all the new people getting hired are getting paid twice as much. I’m just doing what every other employee would do if they were in the same situation.”

Maine notes that since the contract dispute does not affect the hospitals or emergency departments outright, the majority of services patients may receive at Texas Health Presbyterian and other area Texas Health hospitals will not be affected. 

“It has nothing to do with the emergency department at all,” Maine said. “The hospital and the emergency department are still all under network of Blue Cross Blue Shield. It only involves a tiny little piece, which is the physician charge. If you come in and you get cat scans and blood tests and all that kind of stuff, that’s still done by the hospital. But if I see you as a physician and I send you a bill, that would be out of network But you shouldn’t notice a difference because we won’t balance bill the difference. And our bills are small compared to the rest of the hospital charges. It’s really not that big of a deal.” 

Although Maine is assuring Blue Cross Blue Shield customers that Texas Medicine Resources won’t balance bill them, the reality is there is nothing stopping them from doing so and it could leave North Texas residents with significantly higher bills after seeing a physician under contract with Texas Medicine Resources than they would have seen if the physicians were still in the Blue Cross Blue Shield network. As of press time, there is a senate bill authored by Senator Kelly Hancock that would eliminate balance billing from doctors out of insurance networks, but until it is passed it offers no protection to consumers affected by this or any other contract dispute.

“The most important thing is what does this mean for patients,” Maine said. “The answer is very little. Could it mean a lot? Yes. But that’s just not how we do business. We are required by law to bill the patient their copayment or deductible that they may or may not have met. But we won’t put patients in the middle; our fight will be with Blue Cross. We’ve seen thousands of patients every year that are out of network with Blue Cross Blue Shield and gotten zero complaints.”

Although Maine’s comments promising not to put patients in the middle of the contract dispute are reassuring, statements released from both Blue Cross Blue Shield and Texas Medicine Resources appear to contradict this. Texas Medicine Resources posted a statement at ERTruths.com that reads “unfortunately, BCBSTX is jeopardizing your access to in-network emergency care,” while a statement posted by Blue Cross Blue Shield of Texas at StandingwithTexas.com calls Texas Medicine Resources’ demands “unreasonable” and warns customers that they are at risk for “surprise bills.” Notably, a quick Google search of Texas Medicine Resources yields an average review score of one star out of five based on seven reviews all of which were posted in the last 10 months with customers complaining of questionable billing practices and negative impacts on their credit scores. Several Kaufman Herald readers also expressed their concern based on their own histories with emergency care. 

“If you work in a hospital, especially ER, I think you should have to be in network,” Amanda Velasquez said. “It’s deceiving to the patient who gets that bill in the thousands when you have insurance. I was in a wreck in 2015 and was careflighted to Parkland. They did the same thing. I owe over $150,000 and I had insurance. That’s after my insurance paid around that same amount and the doctors, who I had no choice of, billed separately and wouldn’t work with my insurance. It’s not right.”

“My husband had knee surgery in [at Texas Health Presbyterian in Kaufman] in January and we were never told that the anesthesia doctors are also not in network,” Lynn Jones said. “We found out when we got the bill. We have Blue Cross Blue Shield, so if we have an emergency we will bypass Kaufman even though I believe it is a good hospital.” 

Maine says that ideally, Texas Medicine Resources would be in network with all insurance companies and cited new contracts with a number of other companies around the state. But he also says it was precisely these other contracts that brought to his attention how much lower the payout was from Blue Cross Blue Shield by comparison.

“In the last few years, we’ve been able to add on a United contract, a Texas Health Aetna contract and a Signa contract, so we’re in network for those right now,” Maine said. “But when we do that, it makes the Blue Cross Blue Shield contract stand out so much because it’s less than half of what we get from other insurers. And we’re just trying to make it right. As long as I’m in network with them, my options are limited. But if I’m not, then all of the options that are available to me to try to get an appropriate rate are there. We are actually asking for less than the 50th percentile in Texas. So we think we’re being incredibly fair." 

This dispute highlights what has become a hot-button issue not only in North Texas, but also around the country as candidates gear up for the 2020 election. The U.S. is currently the only “highly developed” nation that does not offer universal healthcare to all citizens. However, recent polling suggests that the majority of Americans now think the country should move to a universal healthcare system such as the Medicare for All Bill that Vermont Senator and high-profile presidential candidate Bernie Sanders introduced last month which would eliminate the need for private health insurance as a whole while retaining it as an option for those interested in supplemental insurance in addition to eliminating deductibles, premiums and copayments in exchange for higher taxes. Other presidential candidates such as Texas’ Julian Castro and Beto O’Rourke have indicated that private insurance should still retain its prominent role in the market, but that state governments should provide a public option to buy into Medicaid regardless of income. Despite President Trump’s claim in March that the GOP will be the “party of healthcare,” he has revealed no plan to adjust the current system whatsoever and is backing a lawsuit to repeal the Affordable Care Act which would cause 30 million Americans to lose health insurance and would allow insurers to once again discriminate against customers based on pre-existing conditions. 

Regardless of national debates and local contract disputes, however, Kaufman Herald readers unanimously agree that something must be done to fix this failing system.

“The hospitals need to provide in network providers or drop the insurance,” Diana Lewis said. “It should not be the insured’s responsibility to check on every detail. I think it is irresponsible of the local hospital and providers to refuse negotiation but continue to be the only doctor available.” 

“It’s ridiculous,” Misti Julian said. “In a time of needing true emergency care, no one is going to stop and ask if the doctors or facility covers them. Our entire health care system is a joke and a scam. It’s disgusting.”

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