Insurance & Billing
Frequently Asked Questions About ER of Texas Insurance and Billing: Answers to Common Concerns and Confusions
House Bill 1941
According to House Bill 1941, section 17.464, “Emergency care” means health care services provided in an emergency facility to evaluate and stabilize medical conditions of a recent onset and severity, including severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that the individual’s condition, sickness, or injury is of such a nature that failure to get immediate medical care could:
- Place the individual ’s health in serious jeopardy.
- Result in serious impairment to bodily functions.
- Result in serious dysfunction of a bodily organ or part.
- Result in serious disfigurement; or for a pregnant woman.
- Result in serious jeopardy to the health of the fetus.
For more information about House Bill 1941, click here.
Texas House Bill 3276
Texas Senate Bill 425
Senate Bill 425, passed by the Texas Legislature during the 84th Regular Session, requires all FECs to post notice of the following:
- This is a Freestanding Emergency Medical Care Facility.
- This facility charges rates comparable to a hospital Emergency Room and may charge a facility fee.
- This facility or physician providing medical care at this facility may not be a participating provider in your Health Benefit Plan provider network.
- A physician providing medical care at this facility may bill separately from the facility for the medical care provided to you.
Texas House Bill 2041
The following notice has been posted in accordance with Texas House Bill 2041 and is hereby effective September 1, 2019.
- This facility is a licensed Freestanding Emergency Medical Care Facility.
- This facility charges rates comparable to a hospital emergency room and may charge a facility fee.
- The facility or physician providing medical care at the facility may be an out-of-network provider for the patient’s health benefit plan provider network.
- The physician providing medical care at this facility may bill separately from the facility for the medical care provided to a patient.
- This facility is an out-of-network provider for all health benefit plans.
For more information about House Bill 2041, click here.
Further Resources
- Requirements Imposed by Families First Coronavirus Relief Act
- Requirements Imposed by the CARES Act
- Texas Department of Insurance
- ER Fees
Patient General - Frequently Asked Questions
EOB vs. Bill
The EOB you receive from your insurance company is not a bill. You will receive a document from your insurance carrier that very much resembles a bill, it is not a bill. It simply explains how your benefits were applied to a particular claim. It includes the date you received the service, the amount billed, the amount covered, the amount insurance company paid and any balance you may be responsible for paying. It also tells you how much has been credited toward any required deductible. It is recommended you keep a record of all EOBs for at least two years.
Each time you receive an EOB, review it closely and compare it to your ER of Texas bill.
Explanation of Benefits (EOB)
An Explanation of Benefits (EOB) is a statement of charges generated by an insurance company, ordinarily after receiving medical treatment.
- How the charges are processed by your insurance company
- Details concerning the services performed by the healthcare provider
- The healthcare provider’s charges
Learning how to read your EOB can help you track your expenses and avoid paying too much for services, it is not a bill.
Medical Bill
Your medical bill is a statement created by your ER of Texas of the amount that is owed by you. It can take over 30 days for you to receive the bill due to processing time and whether or not there is a need to send an appeal or documentation to the insurance carrier. Your medical bill will show:
- Payments made at the time of service
- How much your insurance company paid
- How much you owe
You should compare the EOB to the medical bill to determine if the procedures and charges are correct. Mistakes can happen. If you have questions or need help reading either document, do not be afraid to reach out to your provider or insurance carrier.
Patient Billing - Frequently Asked Questions
Q: How many bills will I get for my emergency room visit?
A: You will receive ONE bill for ONE visit. No Additional billing for lab testing, radiology, or physician fees.
Q: What is “balance billing” (sometimes called “surprise billing”)?
A: When you see a doctor or other health care provider, you may owe certain out-of-pocket costs like a copayment, coinsurance, or deductible. If an Out-of-network provider bills you for the difference between what your plan pays and the full amount charged for a service, this is called "balance billing."
Q: Does ER of Texas “Balance Bill”?
A: ER of Texas NEVER Balance Bills. It is prohibited by law for emergency room services.
Q: Are itemized statements automatically sent out for my emergency room visit?
A: No, you will receive a summary bill. To request an itemized statement please call the facility phone number listed on discharge paperwork to speak to a registration representative.
Q: What are my payment options?
A: You may pay with cash, check, or credit card. Review options for payments on your billing statement to pick which will work best for you. To make payment arrangements or request financial assistance, please call the patient advocate at the facility phone number listed on your discharge paperwork.
Q: What if there is an error on my bill?
A: If you have a question about your bill, or believe that it is incorrect, please call the patient advocate directly.
Q: Can I make an appointment to talk to someone in person about my bill?
A: Yes, you can schedule an appointment with the Patient Advocate.
Q: Why did my health plan only pay part of my bill?
A: Most health plans require you to pay a co-pay, deductible and/or coinsurance, and meet a specific amount for out-of-pocket expenses. You could be responsible for these changes along with non-covered charges. Please contact your health plan for a detailed explanation as to why only part of your bill was paid.
Q: What is a co-payment?
A: A co-payment, or co-pay, is a fixed amount that you pay for a covered health care services when you have received a service. The amount can vary by the type of service.
Q: What is a deductible?
A: A deductible is the amount you owe for covered health care services before your health plan begins to pay. For example, if your deductible is $1,000, your plan will not pay anything (except for preventive services and other excluded services started in your summary of benefits and coverage) until you have paid $1,000 for covered services. (Your health plan pays for covered services above the deductible, but you may be responsible for a co-pay or coinsurance.)
Q: What is coinsurance?
A: Coinsurance is your share of the cost of a covered health care services. You pay coinsurance after you have met your deductible. For example, if your health plan's allowed amount for an office visit is $100, and you have met your deductible, if you have 20% coinsurance your payment would be $20. Your health plan pays the rest. Coinsurance usually does not apply to HMOs.
Q: What does out-of-pocket maximum or limit mean?
A: Maximum out-of-pocket is the most you will have to pay for covered services in a benefit year. After you reach this amount, your health plan will pay for all covered essential health benefits from an in-network provider.
Q: What is the difference between an HMO plan and a PPO plan?
A: HMO stands for Health Maintenance Organization. With an HMO plan, coverage restricts to a particular group of physicians called a "network". Under HMO coverage, you must see your primary care physician (PCP) andif your PCP cannot treat you; they will refer you to an in-network specialist. *Exceptions: HMO patients do not need a referral during an emergency or for routine-care in-network visit to a gynecologist or obstetrician.
PPO stands for Preferred Provider Organization. With a PPO plan, coverage allows patients to choose any physician they wish, either inside or outside of their network. Under a PPO plan, you will still have a network of providers, but you are not restricted to seeing just those physicians. You have the freedom to visit any healthcare provider you wish.
HMOs and PPOs are both types of managed care, which is a way for insurers to help control costs. Staying in your network with an HMO, you can expect the maximum insurance coverage for the services you receive according to your plan. If you go outside of your network, your coverage disappears. With a PPO, you can visit doctors outside of your network and still get some coverage, but not as mush as you would if you remained in your network.
With a PPO, the trade-off for receiving a little bit of coverage outside of your network is usally incurring higher premium costs for the plan. An HMO offers no coverage outside of the network, but patients typically enjoy lower premium costs.
Q: If I have an HMO policy, can I be billed if they do not pay?
A: If you have an HMO policy, you should only be billed for the amount specified on your Explanation of Benefits (EOB). An EOB will be provided to you by your health plan. Your EOB is a statement of charges generated by your health plan, ordinarily after receiving medical treatment. Your EOB will include your co-pay, deductible, and coinsurance as part of an estimate amount for patient responsibility.
Q: Will my health plan pay for my treatment?
A: Contact your insurance company to verify that your health plan will be honored at the facility where you are being treated. Each health plan offered by an insurance company is different. Even within the same company, one health plan may cover a certain treatment while another does not.
Q: Why do I need to call my health plan if they do not pay the bill?
A: We will make every effort to resolve your account balance with your health plan. Occasionally, if we are unable to resolve the billing issue, we will need your assistance. You have the right to a toll-free number to call your insuarnce company free of charge with questions or complaints. You can find this number on a notice accompanying your policy. This requirement does not apply to small insurance companies.
Q: What do I do if I need assistance paying my bill?
A: ER of Texas offers payment options to resolve outstanding balances in a timely manner. If payment in full is not possible, we will work with you to set up a payment plan. Contact the patient Advocate to find the best solution for you.
Q: What if I do not agree with the amount my health insurance carrier pays?
A: If your health plan denied your claim or says it will not pay for a service, you can ask your health plan to reconsider. Every plan has an appeals process.
If you are not happy with the appeal turned out, you can ask for an external review. This lets an independent third party review your health plan's decision. You can ask for an external review if your health plan denied a service because it was experimental, investigational, or was not considered medically necessary. The health plan must honor the external review. External reviews are free to you.
Appealing a claim or service that was denied:
If your health plan denied your claim or says it will not pay for a service, you can ask your health plan to reconsider. Every plan has an appeals process.
If you are not happy with the appeal turned out, you can ask for an external review. This lets an independent third party review your health plan's decision. You can ask for an external review if your health plan denied a service because it was experimental, investigational, or was not considered medically necessary. The health plan must honor the external review.
External reviews are free to you.
Q: How do I get an external review?
A: You usually must go through your plan's appeals process before asking for an external review. You can skip the internal appeal if your condition is life-threatening or your plan stops covering a medication you are already taking.
The way to ask for an external review varies, based on the type of plan you have and who offers it. Here is how to ask for a review:
- If your plan is through your job with a large employer: Visit the U.S. Department of Labor's website to file an appeal.
- If you bought your plan through the marketplace, or it is a Children's Health Insurance Program plan, stand-alone dental or vision plan, or small-employer plan: Call 1-888-866-6205 or visit externalappeal.com. You have 60 days from the date your plan sent you its final decision to ask for an external review.
- If you have a marketplace plan bought before march 23, 2010: Fill out the form your plan sent you whenit denied the service. You can also get the form on your review request page. There is not a deadline, but it is back to ask for a review as soon as possible. For questions about the process, call our Managed Care Quality Assurance Office at 1-866-554-4926.
- If your plan is through your job with a school district, city or county government, union, or church: Follow the process in your benefits guide or ask the benefits coordinator at your job.
Resolving other health insurance complaints:
Most people who have health insurance in Texas have a self-funded plan. This means the employer pays health care claims itself, rather than an insurance company. An insurance company might administer the plan, but it does not pay the claims. The U.S. Department of Labor regulates self-funded plans. We have limited authority over them. File complaints against most self-funded plans with the U.S. Department of Labor. If you work for school district, city or county government, union, or church, complain to the plan.
If your complaint is about a plan bought on the federal marketplace, call the marketplace.
We can help you resolve complaints against fully insured plans. You can tell whether your plan is fully insured or self-funded by looking at your insurance card. Look for the initials "TDI" or "DOI." If you see them, your plan is fully insured, and you can file a complaint with us. Visit the Health Insurance Complaints page on our website to find out how. You can also call our Consumer Help Line. If you do not see "TDI" or "DOI" on your card, then your plan is self-funded.
Send complaints about providers to the right agency:
- For complaints against doctors, physician's assistants, or acupuncturists, call the Texas Medical Board at 1-800-2019353 or visit the Medical Board's website.
- For complaints about health care facilities, call the Texas Department of State Health Services (DSHS) at 1-888-973-0022 or visit the DSHS website.
- For complaints against pharmacists and pharmacies, call the Texas State Board of Pharmacy at 1-800-821-3205 or visit the Board of Pharmacy's website.
Q: Will I receive a surprise bill or a balance bill?
A: There is no surprise bill at ER of Texas, we do not balance bill.
Get help from TDI
For insurance questions or for help with an insurance-related complaint, call the Consumer Help Line at 1-800-252-3439 or visit the website.
Q: What is mediation?
A: Mediation can help you resolve disputes about bills from out-of-network providers. During mediation, the provider and your health plan discuss your bill. The goal is to agree on how much the provider will charge, how much your plan will pay, and how much you must pay. Once you start mediation, the provider cannot ask you for payment (other than for copayments, deductible, and coinsurance) until the mediation ends or you withdraw your mediation request.
You may ask for mediation if:
- You have a PPO plan or have coverage through the Employees Retirement System of Texas of the Teacher Retirement System. Mediation is not available for HMO plans, self-funded plans, Medicare, or Medicaid.
- The bill is from an out-of-network, hospital-based provider.
- The bill is for nonemergency care in an in-network facility or for emergency care from any emergency care provider.
- The amount you owe is more than $500, not including copayments, deductibles, and coinsurance.
To ask for mediation, fill out a form, get help with a surprise bill from a health care provider, visit: https://www.tdi.texas.gov/forms/consumer/cp029mediationform.pdf. You can also call our Consumer Help Line to get a copy of the form.
If you filed an appeal with your health plan, wait for the plan's decision before asking for mediation.
Free-Standing Emergency Department - Frequently Asked Questions
Q: What is a free-standing emergency department?
A: Free-Standing emergency department is open to the public 24 hours a day for the treatment of urgent and emergent medical conditions. CMS associated client emergency department is staffed with the same medical personnel and diagnostic equipment as a recognized facility. The primary difference is ER of Texas not being located on a hospital campus. No appointment is required to be seen at the facility. Should a patient need to be admitted to the hospital, an ambulance will be called to immediately transport the patient for direct admission.
Q: How is different from an urgent care center?
A: The emergency room is open 24-hours per day, 365 days per year, whereas most urgent care centers are only open 8 to 16 hours per day. ER of Texas is also capable of treating all urgent and emergent medical conditions, including heart attacks, strokes, respiratory distress, head injuries, abdominal pain, dehydration, orthopedic injuries (fracture), sports injuries and lacerations (cuts requiring sutures). These conditions are beyond the scope of treatment for most urgent care centers.
Q: How is different from a hospital-based emergency room?
A: ER of Texas provides the same emergency treatment patients receive in traditional hospital-based emergency room. While the national average wait time to be treated in most hospital-based emergency rooms is four hours, patients at ER of Texas will be immediately seen by a member of our clinical care team who will assess needs and begin care right away. As a free-standing emergency department, ER of Texas uniquely provides a convenient, comfortable, and welcoming atmosphere.
Q: What are free-standing emergency room state requirements?
A: The Texas Health and Safety Code now requires all free-standing emergency rooms to be licensed by the Department of State Health Services. Those licensed are the only free-standing facilities not owned or operated by a hospital that can advertise services using terms such as "Emergency" or "ER". Therefore, an urgent care center or 24-hour clinic can no longer use signage advertising emergency care unless that facility is licensed by the state as a free-standing ER.
As of September 1, 2012, the state also requires all free-standing emergency rooms to be open 24-hours a day, 7 days a week. A free-standing ER must be equipped and staffed to perform laboratory testing and radiology services and must keep age-appropriate medical equipment and supplies needed for emergency treatment on hand and ready for useat all times. Among the long list of required equipment and supplies are items such as:
- An emergency call system
- Oxygen
- Mechanical ventilator assistance equipment, including airways, manual breathing bag, and mask
- Cardiac defibrillator
- Cardiac monitoring equipment
- Laryngoscopes and endotracheal tubes
- Suction equipment
- Emergency drugs and supplies
- Stabilization devices for cervical injuries
- Blood pressure monitoring equipment
- Pulse oximeter or similar medical device to measure blood oxygenation
Because a free-standing ER is licensed by the state to perform emergency medical services and function the same as a hospital-based emergency room, by law insurance companies cannot refuse coverage and reimbursement for emergency medical treatment provided to an insured patient at a free-standing ER.
Q: Am I required to pay for services prior to being treated?
A: ER of Texas will treat all emergency room patients regardless of their ability to pay, including a medical screening examination and appropriate stabilizing treatment. Additionally, ER of Texas has various self-pay options to assist those in financial need.
Q: What insurance plans does ER of Texas accept?
ER of Texas accepts all private and commercial insurance carriers. Governmental plans and prohibited for billing.
Q: What if I have a governmental plan?
A: Independently owned, free-standing emergency rooms cannot accept Medicare/Medicaid payment. We often negotiate arrangements with health insurance plans for "in-network" status. Co-payments may be more, less, or equal to those of other emergency visits. State laws are requiring health plans to cover the costs of emergency department visits to independently owned free-standing emergency departments regardless of their contractual status. Most of these departments voluntarily agree to treat all patients, without regard for their ability to pay. Some states, most notably Texas, reuire this is as a condition of operation. In addition, governmental patients will have various cash pay options.
Q: What am I required to pay?
A: Patients whose insurance plans treat ER of Texas as in-network are required to pay the emergency room co-pay as designated by the insurance plan at the time of service. As with any visit to an emergency room, upon receipt of the explanation of benefits (EOB) from the insurance carrier, patients may also be required to pay a deductable or any coinsuarnce if it is determined to be patient responsibility by the insurance provider.
Q: What if I have to be admitted to a hospital?
A: ER of Texas will work in conjunction with your health insurance to cover the transportation charges from ER of Texas.
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Patients Share Their Experiences-
“I went to ER of Texas in the middle of the night on a weekend. I was greeted with a smile and was able to see a doctor right away. The staff were so professional & compassionate and took great care of me.”
- Connie -
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