The Texas Department of Insurance (TDI) has fined Humana $700,000 and ordered the insurer to take corrective steps for not having enough in-network anesthesiologists in Harris, Bexar, and Travis counties this year.
According to TDI, four of Humana’s PPO and HMO network contracts for anesthesiologist services had been terminated between January and June, leaving consumers with no in-network facility-based anesthesiologists at more than 20 hospitals and surgical centers.
Texas Medical Association leaders praised the agency for its enforcement action.
Inadequate networks and narrow networks are a primary cause of surprise bills for patients. In recent years, TMA has pushed for greater efforts to make sure health plans have adequate networks.
“Protecting consumers from balance bills was a priority in this case, and we’ve done that,” TDI Commissioner Kent Sullivan said in a statement.
Testifying for TMA late last year, Houston emergency physician Arlo Weltge, MD, told the Texas House Insurance Committee that TDI’s network adequacy rules are generally strong, but the legislature could give TDI greater enforcement capacity to bolster its oversight of network adequacy.
Health insurers and HMOs in Texas are required to file annual network adequacy reports with TDI and to notify the agency and consumers of any network gaps. However, Humana submitted reports that included physicians no longer in its networks and did not adequately tell insurance regulators and consumers about the issue, TDI said.
Each contract has since been re-contracted, TDI said.
As part of the consent orders, Humana will reprocess affected patients’ claims as in-network claims.
“Not one Humana consumer will pay extra because of this network issue,” Commissioner Sullivan said.
TMA has created a draft TDI complaint letter (for members only) you can customize for your patients. We have it available in both English and Spanish. Complaints about a health plan’s network may include problems locating a specialist who is accepting new patients, finding a doctor within reasonable driving distance from the patient’s home, or inaccurate information in the health plan’s provider directory.
TMA also has developed a one-page patient handout describing the most common reasons for surprise medical bills.