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Gottlieb
Solutions

Your Success Is Our Success

Gottlieb
Solutions

Your Success Is Our Success

Gottlieb Delivers Results: Texas Balance Billing Out of Network Arbitration Summary

Gottlieb Delivers Results

PROBLEM

Texas implemented a Balance Billing law as of 1/1/2020 at which time the largest commercial payor reduced their allowance for emergency medicine claims by approximately 85%. Texas has a defined arbitration process which applies to fully funded and non-ERISA self-funded health plans.

CHALLENGE

  • Material decrease in revenue.
  • ED groups do not always have access to the patients’ health insurance ID card, which tells you if the members benefit plan applies to the TDI arbitration process or is excluded from the law. This makes it difficult to know which claims are eligible submission.
  • Making the most advantageous arbitrator selection, to avoid arbitrators with high cost that will negate any additional revenue determined by what the arbitrator deems reasonable.   
  • Arbitration process, while yields favorable results, is very labor and time intensive.

RESULTS

95% of the cases have resulted in a favorable outcome for the ED group, with a net gain after arbitration costs. The results of our efforts has moved the decrease in reimbursement from approximately 85% to 50% on average.

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