Our healthcare advocacy team currently represents numerous Freestanding Emergency Rooms (FSERs) across the State of Texas, and these facilities and physician groups provide an invaluable service to their customers, often providing medical care in life-or-death situations. These facilities provide unparalleled convenience for timely and efficient emergency care to patients. However, insurance companies are jeopardizing this relationship by arbitrarily refusing to pay valid claims or by refusing to pay the full amount of the claim as required by the law.
FSERs are under pressure. Under the Texas Emergency Care Statutes (Texas Insurance Code Section 1271.155 and related provisions), health plans are generally required to pay out-of-network providers for emergency care at the usual and customary rate, yet insurers routinely reimburse far less. As a result, patients who visit freestanding emergency rooms are often surprised with large balance bills. This dilemma is created by the health insurance companies’ refusal to cover and reimburse appropriate expenses related to the visit. Patients are understandably outraged at the unexpected bills but wrongfully believe the emergent care center is to blame.
FSERs are put in a precarious situation. When patients ask about the cost of treatment, an FSER often cannot give an accurate answer, because it cannot predict what a health insurance company will ultimately reimburse. Texas law is specific about what reimbursement is owed for out-of-network emergency care, yet insurers frequently pay far less than that amount. Unfortunately, the health insurance companies’ behavior can create the perception that emergency care facilities are not being transparent and honest in their billing practices, which can hurt the facility’s reputation and overall business.
CB Trial also handles hospital and hospital group representation, and currently represents these physician groups and facilities against some of the largest insurance companies in the world. If you are involved in a physician group, hospital or treating facility and are experiencing slow pay, underpayment, and denial of claims, call our firm today.
What Texas Law Actually Requires
Texas law requires health plans to reimburse out-of-network emergency providers at the usual and customary rate for the care they deliver. In practice, insurers often pay a fraction of that amount, leaving the facility underpaid and the patient exposed to a balance bill. The dispute is rarely about whether care was necessary; emergency providers are legally obligated to treat and stabilize any patient who arrives, regardless of coverage. The fight is over how much the insurer owes for that care.
How These Payment Disputes Get Resolved
The path to recovery depends on when the claim arose and how the patient’s coverage is structured. For emergency-care payment disputes accruing on or after January 1, 2020, Texas provides a mandatory arbitration process under Chapter 1467 of the Insurance Code for resolving out-of-network reimbursement fights between providers and health plans. Other claims may proceed on contract or assignment theories depending on the facts. Federal ERISA rules can also govern when the patient’s plan is an employer-sponsored health plan, which changes the analysis significantly.
Because the right mechanism varies from claim to claim, and because insurers have sophisticated teams working to minimize payouts, freestanding emergency rooms and physician groups benefit from counsel who handle these reimbursement disputes specifically. The goal is straightforward: recover the amount the facility is actually owed for the emergency care it was legally required to provide.
How We Help Freestanding ERs and Physician Groups
Our team represents FSERs, physician groups, and hospital facilities in disputes over slow payment, underpayment, and denial of out-of-network emergency claims. We assess each claim to determine the correct reimbursement owed, identify the right forum or process for pursuing it, and press insurers to pay what the law and the parties’ agreements require. If your facility is being underpaid for emergency care, we can help you evaluate your options.
