Author
By: Brian Piper, PhD
In 2019 the Texas Legislative session passed several new laws related to freestanding emergency centers. These laws attempt to restrain what freestanding emergency centers charge and established a new arbitration process for resolving fee disputes over out-of-network emergency services. RPC can provide data and expert testimony in arbitrations involving freestanding emergency centers. We can also help facilities avoid charging “unconscionable” fees.
Avoiding Unconscionable Charges
The 2019 Texas Legislature passed House Bill 1941, “An Act relating to unconscionable prices charged by certain health care facilities for medical care.” This new law took effect September 1, 2019. It determines when the Attorney General may act against a freestanding emergency center for “unconscionable charges.” The law defines charges as “unconscionable” if they equal or exceed 200% of the average charge for the same or substantially similar service provided in nearby hospital emergency departments.
RPC can help freestanding emergency centers avoid problems with the Attorney General by adjusting their charges to be below the threshold. RPC has the most recent hospital charge data from the Department of State Health Services and perform the necessary analysis. RPC can:
- Take the chargemaster for the FSED
- Identify the relevant hospitals
- Calculate the average charge for each hospital for each CPT and HCPCS code in the FSED’s chargemaster using the most recent 12 months of data from the state
- Adjust the hospital charges for inflation using Bureau of Labor Statistics data
- Identify the FSED charges by CPT code at or above 200% of the average hospital ER charge (the “unconscionable prices”)
- Provide the FSED the data in an EXCEL workbook with a report explaining our sources and methods
- RPC can also determine the revenue impact of eliminating “unconscionable prices” by analyzing the FSED’s most recent twelve months of claims data against a revised chargemaster.
Payment Disputes Involving Freestanding Emergency Centers
RPC can assist clients in both in-network and out-of-network payment disputes involving freestanding emergency centers. For out-of-network disputes, RPC can determine the usual, customary, and reasonable charge for services, or determine the payment due under federal or state law. Freestanding emergency centers and their physicians are covered by Senate Bill 1264. Beginning in 2020, their out-of-network payment disputes are subject the mediation and arbitration processes established by the Act. RPC can help providers and health plans to determine reasonable payment for service under the criteria in the Act.
RPC can also help providers and health plans resolve in-network payment disputes involving freestanding emergency centers when the parties disagree about the interpretation or calculations in the agreement. For in-network claims, Texas’ Prompt Pay Act allows providers to be paid full charges, penalties, and interest when health plans do not pay the negotiated rate or dot not pay promptly or correctly. RPC can make the calculations to determine amounts owed under the Prompt Pay Act.