Texas Health Plans Mislead Elected Officials with False Claims

In recent testimony, the Texas Association of Health Plans (TAHP) referenced a large medical bill, $53,000 for an ingrown toenail, as an example of price gouging by independent freestanding ERs. However, analyses by multiple third-party billing companies show that the patient was treated at a hospital outpatient department (HOPD), and that the reason for the large bill was due to a billing error by the facility’s billing company.

A close look at the bill issued to the ingrown toenail patient makes it clear the facility that issued this bill is not a freestanding ER at all, but is an ER affiliated with a larger hospital. The bill includes the CPTO 11755 and 20972 medical codes, however independent freestanding ERs do not bill for these services. Also, the use of an S medical code indicates that the facility can accept Medicare, which independent freestanding ERs are not currently able to accept.

Furthermore, the bill issued to the patient contains evident errors, as the use of the 11755 and 20972 medical codes have nothing to do with the patient’s complaint or observation stay. In fact, the 20972 code is for a surgery on the metatarsal performed by an orthopedic surgeon, which is never performed in any emergency room setting.

If the goal was truthfulness and accuracy, these obvious errors would have been easy for the staff at Blue Cross Blue Shield of Texas to identify and correct, however they chose instead to erroneously attack the freestanding ER industry and mislead legislators. Instead of addressing the HOPD’s billing error, the insurance company paraded the example around the Texas Capitol and falsely attributed the bill to the independent freestanding ER model.

It is a long running narrative of the health plans that independent freestanding ERs intentionally remain out-of-network so they can bill excessively for medical services, and misattributing this bill to independent freestanding ERs helps spread this story further. However, we know from a recent survey that insurance companies are to blame for freestanding ERs not being able to obtain in-network contracts. This fabricated example is just another deceptive attack on the freestanding ER industry and another attempt to mislead legislators.

BCBS intentionally circulated inaccurate information to legislators, which was the basis for Sen. Hancock’s SB 2064 relating to “unconscionable” billing by independent freestanding ERs. Sen. Hancock filed the bill to protect consumers from large out-of-pocket medical costs. However, this example, which has become the poster child for SB 2064, would not have been impacted by his legislation at all because the bill only targets independent freestanding ERs, not hospital-based ERs like the one in this claim.

To better understand some of the devious and questionable public relations tactics of the health plans, let’s recount what’s taken place just this session. Recently, Blue Cross Blue Shield of Texas, along with other vocal opponents of the freestanding ER industry, produced a study comparing utilization of urgent cares, freestanding ERs, and hospital-based ERs. Not only was the data called into question, the study’s own co-author stated in an op-ed that the study compares apples to oranges. He also warns that the findings have been extrapolated incorrectly, enough to threaten emergency care. The study has since been removed from the Annals of Emergency Medicine and is pending evaluation of the integrity of the data.

More recently, TAHP was confronted in the House Judiciary & Civil Jurisprudence Committee by Rep. Matt Rinaldi for using fake patient reviews on Yelp to attack the freestanding ER industry. The negative reviews referenced were from hospital-based ERs, and yet again were passed off as complaints against freestanding ER facilities.

Now the ingrown toenail case study is the latest attempt by insurers to mislead legislators and boost their own profits by blocking access to emergency services. The credibility and ethics of TAHP and its membership must be called into question as they continue to spout misinformation as the basis for unnecessary legislation. Real data and verified facts are the basis for sound public policymaking. Misleading legislators both hurts the public and threatens the very fabric of our democratic state.

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