Texas Laws On Health Insurance And Billing By Health Care Provider

Did you know that there is a law in Texas which requires a health care service provider to bill the patient or other responsible person for services, not later than the first day of the 11th month after the date the services are provided. This law is found in the Texas Civil Practices & Remedies Code, Section 146.002.

Whether a patient receives care at a hospital or clinic in Dallas, Texas, or in Arlington, Grand Prairie, Weatherford, or anywhere else in Texas, the health care service provider is required to bill the patient or the issuer of health benefits plan for services within the time frame set out above. An exception would be the unlikely event that the contract between the health care provider service provider and the health care insurer provide a longer time to submit the bill for services. It is an unlikely for this exception to exist because from a practicle standpoint, no health care service provider is going to sign a contract requiring them to wait longer than 11 months before getting paid.

If the health care service provider is required to directly bill the third party payor who is operating under State or Federal law, including Medicare and Medicaid, the requirement is the same as stated above.

The context under which a health care service provider does not immediately bill for their services is usually going to arise in two situations. The first is, they forget about it. In other words the patient is seen and treated and the paperwork gets lost or set aside and the office simply makes a mistake in not sending in the bill for services. The second way it arises is where the provider learns of or believes the treatment arises from an accident wherein a 3rd party insurance company is going to have to pay the medical expenses of the injured patient. The normal situation for this is in the car wreck cases.

In a car wreck situation the medical provider treats the injured party then sends them the bill rather than billing the injured persons insurance provider. The health insurance company, whether it be a company like Blue Cross / Blue Shield or Humana, or Medicare or Medicade is going to pay substantially less on the bill because of the discounts they get. The 3rd party insurance is not entitled to the discounts and thus may be liable for much greater amounts including the total bill. Discounts can be as high as 90%. At first this may seem ok but, what if, in the end, say a year later, there is not a recovery in the car wreck from the 3rd party insurance company.

When Section 146.002 is violated, then Section 146.003 becomes applicable. Texas Civil Practice & Remedies Code, Section 146.003 says when 146.002 is violated, the health care service provider may not recover from the patient any amount that the patient would have been entitled to receive as payment. This means that the debt goes away.

This is another example where an experienced Insurance Law Attorney can make sure that a person is not taken advantage of, by an insurance company or a health care service provider.