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V.T.C.A. Health and Safety Code § 324.101

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Facility Policies

Each facility must establish and maintain policies for billing of facility health care services.  The policies must address:

  • Discounts of facility charges to uninsured individuals;
  • Discounting of charges to indigent consumers who qualify for indigent services on sliding scale or other written charity care policy;
  • Providing an itemized statement;
  • Whether interest will apply to services not covered by a third party payer, and the interest rate;
  • Complaint procedure;
  • Providing a conspicuous written disclosure to a patient upon admission (or upon discharge from a hospital emergency room or emergent admission) that:
    • Confirms whether the facility is a participating provider with the consumer’s health plan coverage;
    • Informs the consumer that a facility-based physician may not be a participating provider with the consumer’s health plan;
    • Informs the consumer that he/she may receive a bill from the facility-based physician for the amount not covered by the consumer’s health plan;
    • Informs the consumer that he or she may request a list of facility-based physicians who have medical privileges at the facility;
    • Informs consumers that they may request confirmation from a facility-based physician of participation in the consumer’s health plan, and under what circumstances the consumer may be responsible for the health care charges not paid by the health plan.
  • The requirement that a facility provides a list, upon a patient’s request, of the name and contact information of each facility-based physician with medical staff privileges;
  • If the facility’s website includes a list of physicians with staff privileges, the website must also include each physician’s name and contact information.

All such policies must be posted conspicuously in the waiting area, business office, or admission areas. 

The facility must provide its estimate for any elective inpatient procedure or nonemergency outpatient surgical procedure upon request or before scheduling the admission for the procedure.  The estimate must be provided within 10 business days of the request.  The facility must also advise the patient that:

  • The request for an estimate may result in a delay in scheduling the procedure;
  • The actual charges for the procedure may vary based on the person’s medical condition and other factors;
  • The actual charges for the procedure may be different than what is actually paid by the consumer or his or her third party payer;
  • The consumer may be personally  liable for payment for the procedure depending on his or her health plan coverage;
  • The consumer should contact his or her health plan for accurate information on health benefits, deductibles, copayments, coinsurance, and other provisions that may affect the individual’s liability for payment for procedures.

The facility must provide an itemized statement of billed services upon a consumer’s request within 10 business days.  However, this applies if the consumer makes the request within 1 year of being discharged from the facility.  A facility must provide an itemized statement of billed services to a third-party payer who is responsible for paying the amount.  The third-party payer must request the statement from the facility and must have received a claim for payment.  The facility must provide the statement within 30 days of the request.  If a third-party payer receives a claim for payment of part but not all of the billed services, the third-party payer can request an itemized statement of only the billed services for which payment is claimed or to which any deduction or copayment applies.

A facility that violates this law may be subject to enforcement action by the appropriate licensing agency. 

If a consumer or third-party payer requests more than 2 copies of a billing statement, the facility may charge for the third and subsequent copies.  The fee may not exceed the sum of:

  • A basic processing fee, which must include the fee for providing the first 10 pages of the copies and which may not exceed $30;
  • A charge for each page of:
  • $1 for the 11th through the 60th page of the provided copies;
  • 50 cents for the 61st through the 400th page of the provided copies; and
  • 25 cents for any remaining pages of the provided copies; and
  • The actual cost of mailing, shipping, or otherwise delivering the provided copies.

If a consumer overpays a facility, the facility must return the overpayment within 30 days of determining that an overpayment has been made.

Current as of June 2015