TexPIRG Education Fund’s tips to protect yourself from surprise medical bills

Here's how to deal with surprise medical bills in Texas

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Bay Scoggin
State Director

Author: Bay Scoggin

State Director

(512) 610-0085

Started on staff: 2017
B.F.A., Emerson College

Bay runs the programs and campaigns for TexPIRG, focusing on democracy, transportation and consumer issues. Recently, he successfully defended utility consumers from a discriminatory rate increase in North Texas. Before serving in his current role, Bay held positions with Organizing for America and the California Democratic Party. In his free time, he enjoys following Dallas' professional sports teams.

Imagine you go to a hospital for a routine procedure. You’ve made sure your hospital and doctor are covered by your insurance. The procedure goes well and you head home to recover. Two weeks later, you get the bill, but instead of the copay you expected, you get a bill for nearly $4,000. Turns out, the anesthesiologist who assisted with your procedure was out-of-network and your insurance isn’t covering that bill as you expected. You’ve received a medical surprise bill and now owe the difference between what your insurance will pay that out-of-network anesthesiologist and what you were billed.  

What is a surprise medical bill?

You receive a surprise medical bill when, through no fault of your own, you are treated by providers outside of your insurance network. These “out-of- network” providers can charge exorbitant rates which are only revealed when the surprise bill arrives. The average emergency room surprise bill is around $600, but these bills can range into the tens or even hundreds of thousands of dollars. When out-of-network providers charge these high rates, it drives up costs for everyone. Consumers are burdened with higher bills that they had no way of avoiding. And  when insurers have to pay their share of this higher charge, they’re likely to pass on that cost to everyone by raising premiums. 

Know your rights

In Texas, some patients are protected from certain surprise medical bills. It is important to know your rights to protect yourself from these illegal out-of-network charges. If you have insurance through Medicare, Medicare, CHIP, or are on Veterans Affairs Health Care, you are fully protected from surprise bills. This tip sheet is for people covered under any other type of insurance.

Texas has a law to help protect some patients from certain surprise bills for care received on or after January 1, 2020. If you have state-regulated insurance or are in either the Employee Retirement System (ERS) or the Teachers Retirement System (TRS), you are protected from surprise bills in two situations:

  1. Emergency treatment by an out-of-network provider 

  2. Treatment by an out-of-network provider at an in-network facility when the patient has not voluntarily chosen out-of-network treatment.

In these situations, you cannot be charged for anything more than what you would normally owe for in-network treatment. The out-of-network provider should not send you a bill. If you do receive one, you should not pay it. Follow the steps below on “How to fight a surprise medical bill” and inform your insurer at once. 

Exceptions to surprise billing protections

Texas’ consumer protections against surprise medical bills do not apply to all patients and all situations.There are some exceptions. You could be required to pay an out-of-network bill in the following situations:

  1. If you signed a consent form and were given a written estimate of the amount the provider will bill you. You must also be given an option for an in-network provider. 

  2. If your insurance plan is not a state-regulated plan:

    1. If your plan is state-regulated, you will see “TDI” (Texas Department of Insurance) or “DOI” printed on your insurance card. If you are still unsure whether your plan is state-regulated, contact your insurer.

  3. If you are transported in a ground or air ambulance not covered by your insurer. Any out-of-network ambulance transport could result in a surprise bill. 

If your bill fits into one of these exceptions, you can still try to lower the amount you owe. See below “Tips for lowering your medical bill.”

How to prevent a surprise bill

Because Texas law does not protect everyone and every situation, there are a few steps you should take to prevent a surprise bill.

  1. Check with your insurer to make sure you are choosing a provider that is covered by your insurance. Make sure that the hospital or health care facility (lab, diagnostic center, surgery center) is in your insurance network before receiving treatment.

  2. When planning hospitalizations at an in-network facility, check with the facility to ensure that all providers (surgeons, anesthesiologists, and others), lab services (such as blood work) and imaging services (such as X-rays and MRIs) are covered by your insurance plan. Be specific in requesting that all services you may need are covered by your insurer.

  3. Know where your nearest in-network emergency room is for those times when it is possible to choose.  

Choosing an out-of-network provider

Most insured Texans are covered by an HMO plan which does not cover out-of-network services. If you do have a plan that has an out-of-network benefit, you can still choose an out-of-network provider at an in-network facility. However, actively choosing an out-of-network provider will result in a higher copay and additional costs your insurer will not cover. 

If you want to use an out-of-network provider, Texas law requires the following:

  1. You must give written consent to the out-of-network provider 10 business days before your treatment.

  2. You may cancel up to 5 days before your treatment.

  3. The consent form must give an estimated cost for the treatment.

Note: You should only sign a consent form if you are purposely choosing an out-of-network provider and are willing to pay the higher costs. If you are receiving emergency treatment or there was no in-network provider available, do not sign a consent form. 

How to fight a surprise medical bill

  1. Make sure you are looking at an actual bill or invoice. An “Explanation of Benefits” is not a bill.

  2. If the bill looks incorrect, do not pay it. Sometimes bills are sent before the insurance company has made its portion of the payment. Call your insurer and ask for more information.

  3. If you think you have received a surprise medical bill, you can use your rights to fight the charges. But first, be sure it is a bill covered by the consumer protections. Here are a few questions to ask. If you are able to answer yes to all these questions, then it is likely that you have received a surprise medical bill:

    1. Is your plan state-regulated? Look for “TDI” or “DOI” on your insurance card. This means that your plan is state-regulated. If you are still unsure, call the Department of Insurance at 1-800-252-3439.

    2. Is the bill for more than your typical copay for in-network services?

    3. Is the bill for treatment in an emergency room?

    4. If the care was not in an emergency situation, was the facility in-network?

  4. If you think the bill is illegal under state law, file a complaint with your insurer. Then, determine who you think made the mistake and file a complaint with the appropriate entity:

    1. To file a complaint against a provider, visit the Texas Medical Board complaint page or call at 1-800-201-9353.

    2. To file a complaint against a hospital or facility, contact the Department of Health and Human Services.

    3. To file a complaint against your health plan or insurer, contact the Texas Department of Insurance online or at 1-800-252-3439.

If your bill does not meet all the requirements above, you may still be able to lower the amount you owe. See the section below “Tips for lowering a medical bill.”

NOTE: If you purposely chose a provider who is not covered by your insurer, and you signed a consent form about out-of-network treatment, you may have waived your surprise billing rights. Check the consent form to make sure it meets the requirements in the section above “Choosing an out-of-network provider.”

Tips for lowering a medical bill

  1. Ask for an itemized bill and check that you are not being mistakenly billed for treatment you did not receive.

  2. Compare the itemized bill to your Explanation of Benefits to see whether your insurer is paying its share. Sometimes patients are billed for services because their provider sent the wrong billing code to the insurer.

  3. Contact your provider and ask about anything you don’t understand. 

  4. Contact your insurer to see if any mistakes were made on their end.

  5. If there are no mistakes, try negotiating with your provider. Many hospitals have patient advocate departments to help you negotiate the bill.

  6. Contact the Department of Insurance at 1-800-252-3439. They may be able to help you fight the bill.

  7. Keep careful notes of all conversations you have. Get the names of anyone you speak to. Keep your files in one place for easy access.

  8. Be patient and clear in your requests. 

Special information during the COVID-19 pandemic

Testing for COVID-19 is free of charge for both insured and uninsured consumers if it is medically necessary. This means that if you have symptoms or have been exposed to someone with COVID-19 you can get a free test. However, while the test itself is free, some Texans have faced high bills due to other fees. The best way to avoid these fees is to contact your provider to get a referral to their recommended testing site. When making your appointment, ask whether the site has other charges that are not covered by insurance. 

In Texas, you can also be tested at CVS, Walgreens, Walmart, eTrueNorth, and Health Mart, at no cost. You do not need a referral to be tested at these pharmacies, but you will have to complete a questionnaire to determine whether you are eligible. Eligibility for testing is based on CDC and state guidelines and testing capacity. To find out more about COVID testing in your state, use this resource

More consumer protections are coming in January 2022

In a victory for consumers, Congress passed the No Surprises Act to expand surprise billing protections to all insured Americans. This means that the millions of Texans on federally regulated plans who are currently without protections will be protected from surprise bills. The federal protections will closely mirror Texas’ laws, protecting patients from surprise out-of-network bills for emergency treatment and non-emergency treatment at in-network hospitals. Under the new law, insured Texans will also be protected from surprise bills for air ambulances.  

Bay Scoggin
State Director

Author: Bay Scoggin

State Director

(512) 610-0085

Started on staff: 2017
B.F.A., Emerson College

Bay runs the programs and campaigns for TexPIRG, focusing on democracy, transportation and consumer issues. Recently, he successfully defended utility consumers from a discriminatory rate increase in North Texas. Before serving in his current role, Bay held positions with Organizing for America and the California Democratic Party. In his free time, he enjoys following Dallas' professional sports teams.