Navigating Texas Insurance Laws

Navigating Texas Insurance Laws A Must-Read Billing Survival Guide for Healthcare Providers

Are you a healthcare provider in Texas struggling to keep up with changing billing regulations?
You’re not alone, and you’re in the right place. Understanding insurance laws in Texas is crucial for keeping your practice compliant and your revenue cycle healthy.
In this guide, we’ll break down everything you need to know to navigate the complex world of Texas medical billing. We will cover deadlines, dispute resolutions, surprise billing protections, and electronic filing rules.

Why Understanding Texas Insurance Laws Matters

Texas has some of the most well-defined insurance regulations in the country, particularly aimed at protecting patients from unfair billing practices and ensuring providers are paid on time. However, healthcare professionals and billing companies must stay compliant with these laws or risk claim denials, penalties, and legal trouble.

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Why Understanding Texas Insurance Laws Matters

Key Aspects of Texas Medical Billing Laws Every Provider Must Know

1- Timely Billing: Don’t Miss the Clock

Under Texas law, providers must bill patients no later than the first day of the 11th month after the date of service. Delays beyond this timeline can result in denied claims and missed reimbursements.

2- Claims Submission Deadline: 95 Days Is the Magic Number

Texas requires providers to submit claims within 95 days of the service date. Exceptions exist only under extreme circumstances, like catastrophic events. If you miss this deadline, you may lose your right to payment altogether.

3- Electronic Billing: It’s the Law

Texas mandates electronic submission and processing of medical bills for providers and insurance carriers, with few exceptions. Electronic submissions reduce errors and accelerate processing, but only if your systems are compliant.

Violations can lead to severe penalties and disputes, so tread carefully when billing patients for any out-of-network services.

4- Prompt Payment Requirements

Health plans in Texas are legally required to pay clean claims promptly, usually within 30 days for electronic submissions and 45 days for paper claims. Late payments can trigger interest penalties payable to the provider.

5- Independent Dispute Resolution (IDR)

In Texas, when payment disputes occur, particularly in out-of-network scenarios, providers have the option to utilize the IDR portal for arbitration or mediation. This process helps achieve a fair resolution while keeping patients uninvolved in the conflict.

6- Billing Procedures and Coding Standards

Billing must:
  • Be submitted in the name of the licensed provider
  • Reflect the usual and customary charges
  • Include accurate billing codes per official coding standards

Failure to adhere to proper coding guidelines can result in claim denials or audits.

7- Complaint Process for Unfair Billing Practices

If you suspect fraud or unreasonable charges, or if your practice faces unfounded allegations, you can file a formal complaint with the Texas Department of Insurance (TDI).

8- Financial Assistance Options

Organizations like Texas Health Resources offer financial assistance programs for patients struggling to pay their medical bills. Informing your patients about these programs can prevent billing escalations and encourage faster settlements.

9- No Surprises Act: A Federal Layer of Protection

Texas has implemented and aligned its laws with the No Surprises Act, further shielding patients from unexpected charges and outlining arbitration pathways for provider-payer disagreements.

Final Thoughts: Partner with Experts Who Know Texas Billing Inside-Out

Navigating Texas insurance laws doesn’t have to feel like walking a legal tightrope. With the right guidance and billing partner, your practice can stay compliant, avoid claim denials, and focus more on patient care than paperwork.

MaxRemind specializes in helping healthcare providers across Texas streamline their billing processes. We assist them in meeting deadlines and maximizing reimbursements. Our services ensure that they remain fully compliant with state and federal regulations.

Start your FREE TRIAL with MaxRemind today for a compliant healthcare practice in Texas.

Partner with Experts Who Know Texas Billing Inside-Out
FAQs
What happens if I miss the 95-day claims submission deadline in Texas?

The claim may be denied, and unless you qualify for an exception (like a natural disaster), you might not get paid.

Is electronic billing mandatory for all providers in Texas?

Yes, except for a few specific cases. It’s important to check if you qualify for an exemption.

How can I initiate the IDR process?

You can begin arbitration or mediation via the Texas IDR portal on the Texas Department of Insurance website.