Seven years ago, when Austinites Andrew and Stephanie Szatan had their son Jude at St. David's South Austin Medical Center, they received a $1,000 bill from a pediatrician who was out of network with their insurance and who only briefly looked at their new baby.
Andrew Szatan jokes that he didn't know it was the dad's duty to check IDs at the door to make sure everyone who touched his baby was in-network with their insurance.
"I was so mad about it," he said of the bill. "I'm just not going to pay it."
Once in a while, a new bill collections agency calls to try to recoup that money. He still won't pay it.
What can you do when you get a medical bill that just doesn't make sense or you are denied care? The American-Statesman is offering this guide to help you understand your rights and where to go when you have insurance questions. Austin's three big hospital systems and major Texas insurance companies would not respond to our request for interviews on this subject. Consumer advocate groups and the Texas Department of Insurance did help sort through the confusing world of health insurance.
For the Szatans, their medical bill woes have continued as they battle insurance companies, hospitals and doctors' offices. Jude was diagnosed at age 4 with a complicated form of epilepsy. In November, an insurance company actually retracted a payment to a doctor's office a year after that company had paid it, making the family responsible for the bill.
Andrew Szatan, who works as a marketing manager, found himself canceling work meetings to call that health insurance company and the doctor's billing department and being told, "Sorry, it's your insurance."
Eventually, the doctor's office agreed to eat the $1,800 bill, but Andrew Szatan spent hours on the phone trying to navigate between the insurance company he no longer had and the doctor's office that has made a difference in his child's life.
"Even when things are stable and good (with Jude's medical condition), there's always something with insurance companies," Stephanie Szatan said.
When your insurance provider doesn't believe you
Rylie Skahill wakes up every day in her parent's Pflugerville home in debilitating pain radiating from her back. Three years ago, she was diagnosed with complex regional pain syndrome. She sees a physical therapy doctor, a pain doctor and a spine surgeon for her condition.
"It takes a lot away from me," she said. "I can't walk very long distances. ... I can't work full time. I can't wash the dishes without pain. I can't even shower without excruciating pain."
Skahill, 26, was scheduled to undergo the first step in having a spinal cord stimulator placed in her back on Nov. 1 to help send different signals to the nerves in her back to override the bad pain signals her brain is sending.
The day before her surgery was scheduled, her insurance company refused to cover it. In its denial letters, it told her, "You do not have complex regional pain syndrome."
Skahill says her pain and her condition were well-documented in her medical records. "I've tried pretty much all other options," including medications and nerve block injections, she said, yet the insurance company would not approve a trial to see if the stimulator would work.
Skahill spent hours on the phone trying to appeal. "It was truly the most frustrating and defeating thing," she said.
The only thing Skahill could do was wait out the rest of 2024 and switch insurance carriers in January. She started the approval process again, and on Feb. 4, she was fitted with a trial stimulator that made a "noticeable difference in my burning pain. I was even able to go for a 30-minute walk, something I haven't done in years."
With proof that a stimulator would make a difference, her doctors were able to schedule the surgery for the permanent stimulator for the end of March.
Skahill and the Szatans tell their stories knowing that they are lucky. Not everyone has the ability to switch insurance companies. Not everyone can spend hours on the phone to navigate the complexities of their insurance plans and their medical records.
Fighting for better patient rights
They are both part of the new group Texas Coalition for Patients, which has members who are patients and doctors as well as partnerships with the Livestrong Foundation, the National Alliance on Mental Illness Texas, the Texas Association of Neurological Surgeons, the Texas College of Emergency Physicians, the Texas Hospital Association, the Texas Medical Association, the Texas Orthopaedic Association and the Texas Organization of Rural & Community Hospitals.
This legislative session, the coalition is advocating for bills that would no longer require Texans to use the same pharmacy benefit manager where the health insurance plan has a financial interest in that pharmacy (House Bill 2750), and bills to prevent insurance companies from using artificial intelligence to deny, delay or modify health care services (House Bill 2922 and Senate Bill 815).
They also are against House Bill 138 and Senate Bill 818 that would create a program to analyze the cost of health insurance legislation but would not include participation by providers and patients. And they are fighting hard against House Bill 139, which would let employers offer health benefit plans that do not provide all state-mandated health coverage. Those mandated services include preventative cancer screenings, newborn care, mental health services, reconstructive surgery after a mastectomy, and autism services.
If these bills pass, they would join the hundreds of prior state laws that regulate insurance, but not all state laws apply to everyone with health insurance in Texas. And that's just one of the things that make knowing your health insurance rights feel impossible.
Ready to pick health insurance during open enrollment? Here are questions you should ask.
Know your health insurance policy
Your insurance company should have a chart with major topics and what it pays and what you owe, but read the fine print because there are exceptions.
Here are just some of the questions you should ask as you sign up for insurance and if you have a preplanned medical event:
- What exactly does your policy cover in each situation? Emergency room versus hospital stay? Urgent care versus doctor's office? Primary care physician versus specialist? How does it treat mental health visits? In-patient rehab versus out-patient rehab?
- What are your deductibles and maximum out-of-pocket costs and what do those include? All doctor's visits? Prescriptions? Equipment?
- What are your co-pays and when do they kick in, or do you owe a percentage of the cost?
- Are your doctors in network or out of network? Look those up under the insurance website and then confirm with the provider.
- Same thing for the hospital or surgical center, lab or infusion center, etc. In network or out of network?
- Also, read the details about specific procedures. Are they covered? Do you need prior authorization?
Your provider should provide an estimate before a scheduled procedure. Call your insurance company and verify that the estimate is accurate to your policy. Get your insurance company's estimate in writing as well.
You can go to a hospital's website to get an estimate of what your procedure costs. Those numbers are not individualized but will give you a ballpark figure.
Hate the health portals? Austin company's app vows to solve your medical records problems
Take good notes
Write down somewhere everything that happened at every doctor's visit, hospital trip, treatment or screening session. Your patient portal should have those notes, too, but sometimes there are discrepancies. Have a friend or family member who is with you do the note-taking if you are not able.
A lot of providers use a billing service, and those services can easily mess up the medical billing numbers, known as CMS codes, regulated by the Centers for Medicare and Medicaid Services because they weren't at the appointment or in the hospital with you.
An EOB is not a bill
Your provider is required to give you an explanation of benefits, or EOB, after you receive services. This is not what you pay, though. It's kind of like the heads-up, "we're going to charge your insurance for these services."
That EOB does include important things. Instead of throwing it in the trash, take a look at the services listed. Are those accurate? Or are you and your insurance company about to be billed for something that never happened or you never received?
This is a great way to spot medical fraud or an honest human error like a miscoding of services. Also look for upcoding, the practice in which the provider codes differently to say that you are sicker than you are or received a higher level of treatment than you received.
Your insurance should also provide you with a statement of what it will pay and how much you owe. Compare that statement, the EOB and the actual bill once you receive it to make sure they are the same.
If you don't have all three, push back until you get what you need to compare them.
You also should not pay a provider until all the providers you used for that situation have been billed and insurance has paid them all. And make sure your deductible and maximum out-of-pocket expenses have been credited.
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Prescription drug benefits are their own special bill
See if your plan has a preferred pharmacy or a preferred way for you to receive your medication. Some will require that maintenance medications be ordered through a mail order pharmacy instead of at your corner pharmacy.
Check your insurance plan's preferred drug list and what its rules are for generics versus name brand. If you can't have the generic or need a medication that is not on its list and a substitute won't work, get your doctor's office to advocate with the insurance and the pharmacy to get you the medication you need.
Check for a better deal: GoodRx or Amazon's pharmacy might actually be less expensive than using insurance. Still submit those receipts to your insurance to see if those purchases will count toward your deductible and maximum out-of-pocket expenses.
Research if your really expensive mediations, especially injectables or infusions, have a co-pay assistance program through the manufacturer.
When you do receive your medication, count it. Seriously. Did you get 90 pills or 87?
When you need to fight a medical bill
First read your bill to make sure it is accurate about the services provided, the dates and the patient who received them. And make sure that under your insurance policy's fine print those services are covered.
Call your insurance company to make sure you were accurately billed under your policy and that the insurance portion has been fully paid.
It is illegal for providers to perform "balance billing." That is the practice of the insurance company saying you only owe for the co-pay (let's say $35), for example, but the provider charging you the difference between the negotiated rate with the insurance company (perhaps $150), which the insurance company pays, and what they think they should be paid (let's say $250). You do not owe the $100 the provider cannot collect from the insurance company.
You also cannot be charged out-of-network costs for certain services such as emergency room treatment, ground ambulances and emergency medical services, or when you don't have a choice of doctors.
If the insurance payout is the problem, call the provider to help make the argument with the insurance company that these services are covered.
Often, a three-way call between you, the provider's office and the insurance company can make sure everyone is talking about the same thing and there were no errors.
When calling either a provider or an insurance company, keep escalating to someone who can help.
Sometimes breaking out of the billing company phone run-around is necessary. Find out who is the local person at your provider's office or hospital who can help you.
Also, if you have insurance through your employer, get your benefits coordinator involved. They need to know if the system isn't working.
As enrollment deadline looms, what's the difference between Medicare, Medicare Advantage?
How long am I responsible for a medical bill and what happens if I don't pay?
In Texas, under the Civil Practice and Remedies Code, Civil Practice and Remedies Code, a health care services provider must bill the responsible party no later than what is required in that insurance plan or if there is no listed time under that plan, no later than the first day of the 11th month after the services were provided.
If the provider does not issue that bill in time, it cannot collect any money other than what the patient was obligated to pay (the co-pay).
If it is a hospital, a 2023 Texas law says it has 30 days to provide you an itemized bill after the services were given and after receiving the final payment from a third party (insurance company. The hospital cannot send you to medical collections until they have provided you with that itemized bill.
If you get a bill that is several years old, question it. Sometimes a billing company sends out a "ghost bill" accidentally that either got caught in their system or wasn't marked as paid.
Be sure you actually owe any bill before you pay it, because it is incredibly difficult to get money back once you've paid.
Medical debt does not affect credit scores. The creditor cannot garnish wages or take your home.
Often, providers or debt collections company will offer payment plans and even work out a deal to lower the debt amount. Do not get a medical credit card because those have very high interest rates. If you do go into collections, the debt collector does have to show you an itemized bill and prove what you owe.
If you feel like a debt collection company is not acting appropriately, bring in the Texas attorney general's office to pursue legal action.
What happens if I am denied coverage?
Doctors now hire people to spend eight hours a day talking to insurance companies to get prior authorizations approved and other insurance matters.
Insurance companies are now using artificial intelligence to process batches of claims instead of giving claims individual attention. Sometimes AI gets it wrong.
Only 1% of patients file an appeal when something is denied, but of those who do, 50% of appeals are successful, according to health research group KFF.
When you get those denial letters, read them carefully for why you were rejected and who did the rejecting.
Read your policy or ask your insurance company if there were requirements you needed to meet before approval. Get that list of requirements and go down item by item with your doctor's office about how you fulfilled those requirements. Sometimes it comes down to one doctor's note in your file that the insurance company has used as the basis for denial.
Have your doctor's office appeal and you appeal as well. Document how you fit the requirements, including the other treatments you have tried, and why a lower level of care is not adequate.
Ask for a peer-to-peer review with your doctor and their expert and demand that the expert be an expert in that field. A cardiac procedure should not be reviewed by a dermatologist, but that does happen. Be the squeaky wheel and continue to appeal.
Document everything including whom you spoke to, on what day and time, and the nature of that conversation. Insurance companies record their calls. You can ask them to review the prior calls by giving them the dates and times and the employee's name.
Often there are four or five levels of appeals you can go through. There also are companies that will audit all your health insurance claims and medical bills to look for bad bills, upcoding or miscoding, and other problems including denials. Those like HealthLock charge a monthly fee and a percentage of what they save the patient in medical costs.
Who is in charge of my health insurance?
When you've reached a roadblock with your insurance company, you need to know where to go and which organization has oversight of your insurance company. Look on your insurance card. If it says TDI or DOI, then the Texas Department of Insurance can help you and all the laws of the state apply to your health insurance.
Despite its name, the Texas Department of Insurance only regulates about 20% of the commercial health plans in Texas, but it can offer guidance on where to go for the other 80%. Before calling the department at 800-252-3439, search this list to get to the right place:
If you get your insurance through a private employer (not a government entity): the U.S. Department of Labor regulates your plan, but reach out to your human resources or benefits coordinator first. They should advocate on your behalf as the payer of your plan.
If you have Medicaid or Children's Health Insurance Program in Texas, contact the Texas Health and Human Services Commission.
Medicare: U.S. Department of Health and Human Services
City and county employees: File a complaint to the address in your patient benefits booklet.
Federal employees including postal workers: U.S. Office of Management
State employees: Employee Retirement System
Teacher Retirement System-Care: Teacher Retirement System of Texas
Health care sharing ministries: Office of the attorney general of Texas
University of Texas employees: University of Texas System
Military service members: Tricare Standard
Sources: Texas Department of Insurance; Katherine McLane, spokesperson of Texas Coalition for Patients; Patricia Kelmer, senior director of health plans at U.S. PIRG Education Fund; Scott Speranza, CEO of HealthLock; Dr. Chris Kean, chief operating officer at TSAOG Orthopaedic & Spine; Dr. Amin Mery, Hill Country Allergy and Asthma; and Louise Norris, health insurance analyst at HealthInsurance.org.
