My HMO sent me to a network hospital, but the anesthesiologist was non-network and billed me. Do I owe it?

Texas wrote this rule for HMO coverage, and the term to know is facility-based provider. It means a physician or provider who provides health care services to patients of a health care facility [1]. Was the facility a network provider? Then your HMO must pay the covered service. It pays at the usual and customary rate, or at an agreed rate [2]. It must pay that physician or provider directly [2]. The deadline is the 30th day after a clean electronic claim. For a claim on paper it is the 45th day [2].

Now your side. A non-network facility-based provider may not bill you more than your copayment, coinsurance and deductible [3]. The law adds that you do not have financial responsibility above that amount [3]. The same bar covers anyone claiming as an agent or assignee of the provider [3]. So a billing company sits in the same place. Your share is based on the amount the HMO first determined payable [3]. If its internal appeal changed that amount, the changed one is used [3]. And it may not be based on any additional amount determined to be owed to the provider under Chapter 1467 [3].

There is one carve-out, and it has parts. The section does not apply to a nonemergency service that you elect in writing, in advance, for each non-network provider [4]. And before the service, that provider must give you a complete written disclosure [4]. The disclosure must explain that the provider has no contract with your plan [4]. It must disclose projected amounts you may be responsible for [4]. And it must disclose the circumstances under which you would owe those amounts [4]. Did nobody hand you that? Then write that down in your letter.

Your own paperwork should carry the proof. For a service by a non-network provider, your HMO must put a notice in the explanation of benefits [5]. That notice must state the billing prohibition that applies [5]. It must also give the total the provider may bill you, with your copayments, coinsurance, deductibles and other amounts itemized [5]. So put the explanation of benefits next to the bill. Is the bill higher than that total? That gap is what you dispute. These sections are the HMO ones. A preferred provider policy, or a plan your employer pays itself, runs on other rules.

Check that the hospital was a network provider in your plan on that date [2]. Then find the billing prohibition statement and the total you may be billed on your explanation of benefits [5]. Then look through your papers from before the service. Look for a written election naming that provider, and for a disclosure with projected amounts [4]. Whether a form you signed at the front desk meets that test: "Don't know yet" here, so ask for a copy of what you signed.