A patient’s betrayal by Texas’ health care system
She fought back from near-fatal sepsis, then got caught in the crossfire over a $36,000 ER bill
WEATHERFORD — Brittany Parsons had no idea how close to death she was when she stumbled into an emergency room that night in February 2018. Her fever was nearing 104 degrees and her body shook uncontrollably as her organs began to shut down.
Since then Parsons has battled back from near-fatal septic shock, but alongside that fight came another, this one with a Texas health care system that hit her with a $36,000 bill and then misled or abandoned her at every turn. Both the free-standing emergency room where she sought initial care and the insurer she assumed covered her treatment appear to have skirted or outright ignored state law and Texas insurance regulations.
So, too, did the Texas Department of Insurance, the state agency that enforces insurance rules, erroneously telling her it could do nothing to help. “We feel betrayed by everyone,” said Parsons, a 34-year-old stay-at-home mom of two.
Hers is more than just another story of a patient caught in the crossfire between insurers and providers. It is how the health care system in this state can become so broken that one of the most basic tenets of health insurance is undermined: In emergencies, especially life threatening ones, insured patients must be covered.
Parsons’ doctors warned her it might take a full year to
recover and what she needed most was rest and calm. What she got instead were 16 months and untold hours on the phone and writing emails, pleading for help from billing clerks at Excel ER, the freestanding emergency room that first treated her, and with customer service representatives for her insurer, Blue Cross and Blue Shield of Texas. Neither would budge and seemed more intent on blaming the other side. She filed two appeals; both were denied. Her father, a hospital administrator, intervened figuring he knew the ways of health care. He, too, got nowhere.
It was only this month, after the Houston Chronicle began asking questions, did the Texas Department of Insurance open an investigation and Blue Cross and Blue Shield of Texas agreed to reverse its previous decision and pay nearly all of Parsons’ bill.
“When the insurance company tells you they’re done and aren’t going to pay any more and the provider says we still want money, what are we supposed to do?” she asked, her voice catching, “We were in big trouble and every door had been closed in our face.”
Pile of bills
Earlier this month, the kitchen table in Parsons’ rural Weatherford home was strewn with piles of overdue medical bills and health plan benefit explanations. The numbers blur together but one sticks out: $36,069.49. That’s the amount Excel ER said she owed and was headed for collections because Blue Cross and Blue Shield of Texas balked. The insurer wanted Parsons to tell the facility to lower its price; the facility wanted her to tell the insurer to pay up.
It all started on the morning of Feb. 24 when Parsons awoke with a rash and odd pain in her leg. As the day wore on, it got worse. By the time she put her kids to bed, she could barely walk. Then the fever hit. When she called her doctor, he said to get to an emergency room immediately.
Excel ER, a 24-hour freestanding emergency room, was about 10 miles away. She worried about insurance coverage so, before leaving, she checked the facility’s website, which said it accepted “all insurance plans.” What she did not realize — despite a state law to force insurance network transparency — is that “accepting” her insurance did not mean the facility was in-network. The facility was, in fact, out-of-network which left her vulnerable to higher charges.
When she arrived at the ER, the staff began running tests and worked to stabilize her. They quickly concluded she needed to be transferred to a hospital because her condition was so dire.
Parsons spent seven days at Texas Health Harris Methodist Hospital in Fort Worth, three in the Intensive Care Unit. She was diagnosed with sepsis, a potentially fatal complication from an unknown infection. The billed charge from that hospital was about $56,000, most of which her husband’s Blue Cross and Blue Shield health maintenance organization (HMO) plan paid, leaving them with a few thousand dollars of out-ofpocket costs.
But then, months later, she got a seven-page bill from Excel ER that said she owed more than $36,000 for the roughly six hours she was there. Stunned, she called for an explanation and instead got an earful from a billing clerk who complained that Blue Cross and Blue Shield had been “unfair” to them.
“I’ll tell you what’s unfair,” Parsons snapped. “That I got a bill for $36,000.”
Phone calls and emails to Excel ER for comment were not returned.
Parsons also called her insurer who said it would not fully pay an inflated bill. Among the charges were $90 for a Tylenol with codeine and $305 for IV tubing, which the insurer allowed $2.48 and $8.44 respectively. In all Blue Cross and Blue Shield initially paid just $950 for the facility and doctor — less than 3 percent of the claim. That meant the bulk of the fivefigure bill landed in her lap.
The worst of it is it never should have happened.
No help from state
Under Texas law, insurers are required to pay the “usual and customary” amount to providers in emergency care regardless of whether the facilities are part of their network. Such vague language, though, leaves the door open to gaping billing disputes that can be shifted onto patients.
But a lesser-known mandate called the “hold harmless” rule is designed to shield HMO patients such as Parsons, from those fights. Under the Texas Administrative Code, HMO patients are only responsible for out-of-pocket costs such as co-pays and deductibles. Insurers are required to pay enough to satisfy a provider and, if an agreement cannot be reached, the patient is not to be stuck in the middle by either side.
Parsons had no idea such protections existed and did not learn of it even when her husband, Matt, called the Texas Department of Insurance last fall to contest Blue Cross and Blue Shield’s denial of their appeal. Instead, he was told they were not eligible for the state’s mediation process to settle disputes because they were enrolled in an HMO plan. The agency said it could do nothing to help.
That is, at best, incomplete information. HMO members are indeed ineligible for the state’s mediation system, but that is because they are supposed to be protected by the “hold harmless” rule. Further, the state agency is required to investigate complaints and potentially refer violations to its enforcement division. That did not happen until the Chronicle began making inquiries.
“What happened isn’t the type of customer service we expect of our agency and our staff,” Stephanie Goodman, the department’s spokeswoman, said in a statement. “Even if a caller doesn’t qualify for mediation, our staff are trained to discuss other options.”
On May 8, the agency contacted Parsons and opened an investigation. Six days later, Blue Cross and Blue Shield paid all but about $1,300 of the original billed charges.
The insurance company said it could not comment on the case because of privacy laws. But in a statement, Blue Cross and Blue Shield said, “It is always our goal to keep our members out of billing issues with a provider, so we’re continually working to improve our processes to ensure claims are handled appropriately. When we identify gaps in our processes, we promptly address them as we are committed to providing our members with the highest possible level of service.”
Rising complaints
The number of “hold harmless” complaints lodged with the department against insurers has climbed rapidly, from two in 2016 to 156 last year, according to the agency. So far this year, 95 were filed.
Of the 270 total complaints in the past three years, 222 resulted in insurers making higher payments to providers, Goodman said. The rest are pending or did not warrant revised payments.
Still, that is 222 patients who never should have been in that position, said Stacey Pogue, senior health policy analyst at the Center for Public Policy Priorities, an Austin advocacy group. Complaints, she added, are “always a tiny fraction of the real number.”
Jamie Dudensing, CEO of the Texas Association of Health Plans, the state insurance trade group, said any uptick in hold harmless complaints is not due to delays or denials of payments, but rather it is the fault of providers for sending inflated bills. Last summer, the insurance trade group sued the Texas Department of Insurance in part to get rid of the hold harmless rule, contending the agency had set an unfair payment mandate for insurers.
The agency declined to comment. The lawsuit is pending.
Eroded trust
Parsons’ joy in learning that her claim is being paid is tinged with bitterness.
“If we hadn’t had a reporter asking questions,” she said, “we would still owe $36,000.”
She wonders how many others in Texas have paid bills they do not owe because they were told they had to.
Not long after she was released from the hospital, she suffered a severe asthma attack that she feared might be a heart attack. Last month she awoke with a fiery neck pain, which turned out to be a bulging disc. Both times she told herself to wait it out until she could get to the doctor’s office. She is now afraid to go to the emergency room.
“It’s hard to trust a system that has let you down,” she said.