Insurance Careers

TEXAS HEALTH CARE STATUTES

The Texas Department of Insurance Code, Section 1301.155 on Emergency Care requires that insurance companies pay emergency facilities “at the insured’s in-network benefit level” for all services. Additionally, the Patient Protection and Affordable Care Act added numerous patient protections that require health plans covering emergency services to provide such coverage without need for prior authorization, regardless of the participating status of the provider, at the in-network level.

The “prudent layperson” standard is a generally accepted principle in the healthcare industry that applies to emergency medical care. This standard was created to protect consumers from high medical costs that arise from emergency situations, allowing them to be charged at in-network rates. However, insurance companies have been reluctant to ?apply this standard for care issued at freestanding emergency centers (FECs). By not providing usual and customary reimbursement rates, insurance providers violate the intent of the medical community and legislators who turned the prudent layperson standard into law.

Furthermore, health plans are required to pay for emergency visits for medical situations in which a person believes his or her health is threatened. The final diagnosis should not influence whether the insurer pays for the emergency room visit, and insurers cannot legally apply the claim towards the out-of-network benefits.

ATTENTION: ALL CLIENTS

The following notice has been posted in accordance with Texas Senate Bill 425 and Texas House Bill 3726 is hereby effective September 1, 2017

  • This facility is a freestanding emergency medical care facility.
  • This facility charges rates comparable to a hospital emergency room and may charge a facility fee.
  • This facility or a physician providing medical care at this facility may not be a participating provider in patient’s health benefit network.
  • The physician providing medical care at this facility may bill separately from the facility for the medical care provided to a patient.
  • This facility is not a participating provider in any health benefit plan provider network.
  • However, by state law, your health insurance company is required to process your emergency room visit at in-network benefit levels if you think you are having an emergency.
  • Physicians Premier will help you enforce your rights to this legitimate benefit. You cannot be expected to look for an in-network site when you are having an emergency when every second counts.
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