This report is an update to KXAN’s “Medical Debt Lawsuits” investigation. Our team followed this legislation during Texas’ regular legislative session.
AUSTIN (KXAN) — Bernadette Moore remembers the frustrations.
Bernadette Moore filed a complaint with the Texas Attorney General’s Office after not being able to get an itemized bill last year. (Courtesy Bernadette Moore)
All she needed was an itemized bill after a vein surgery last August in the Dallas-Fort Worth area.
“They just gave me the runaround. I mean, nothing. I got bounced around to seven different people at one point. I was on the phone weekly,” she explained.
Moore said she is part of a health-sharing ministry where patients get reimbursed, but an itemized bill is required.
“I remember crying to them on the phone — ‘I cannot get ahold of this.’ I’ve never had this much problem receiving an itemized bill,” Moore said.
In November, she filed a complaint with the Texas Attorney General’s Office.
“I have requested an itemized bill … at least 20 times. As of Sept, that is a TX state law, that businesses must give an itemized bill,” she wrote in her complaint.
Through the Texas Public Information Act, KXAN obtained five itemized medical billing complaints sent to Attorney General Ken Paxton’s office since September 2023. That’s when the law went into effect requiring hospitals and other health providers to give patients an itemized invoice before sending bills to collections.
KXAN obtained seven complaints about itemized medical bills submitted to the Texas Health and Human Services Commission and the Office of Attorney General, from September 2023 to mid-January. Source: Texas HHSC and OAG (KXAN Interactive/David Barer)
State oversight
Senate Bill 490 also requires itemized bills be written in terms the patient understands and include medical codes and prices. The invoice can be issued electronically through a patient portal.
“It’s important for consumers to have more transparency in health care,” said State Rep. Caroline Harris Davila, R-Round Rock. “It has become so convoluted, so complicated, and it really shouldn’t be because when it’s complicated, people may put off care. They may make poor decisions about their health care.”
State Rep. Caroline Harris Davila, R-Round Rock pushed for medical bill transparency law. (KXAN Photo/Arezow Doost)
Harris Davila knows every detail of the itemized billing law — she wrote the companion House bill.
The legislation only applies to health care facilities and hospitals but does not apply to doctors or federally-qualified health centers.
The Texas Health and Human Services Commission is overseeing the rollout of the law and compliance. Since the law went into effect in September, the agency received two complaints that are pending investigation. These complaints are separate from what the Attorney General’s Office received.
Late last year, HHSC posted draft rules online and gathered informal comments from two providers including clarification needed on language of the law and concerns about the costs of providing itemized bills. Harris Davila said her office would reach out to the providers with concerns.
“We really think it might just be a misunderstanding of the way that they’re interpreting the bill. And so, we’re going to work with them and make sure that everybody’s on the same page,” she said.
Central Texans sued
Passage of the itemized billing law followed a KXAN investigation in September 2022 into a Central Texas hospital that sued hundreds of patients over unpaid medical bills. Many patients told us they couldn’t get details on what they owed.
Those cases are still being heard in Williamson County. Kasey Ybarra, from Liberty Hill, was in court in early February after being sued.
Kasey Ybarra and her sister in 2020 when they traveled to San Antonio for a liver transplant. (Courtesy Kasey Ybarra)
“They’re suing us for not paying, right. But they’re also suing my husband; my husband never got services there,” Ybarra explained.
The billing saga started in November 2020. Ybarra’s sister needed a liver transplant and Ybarra was a match. They traveled to San Antonio to have the surgery.
“It wasn’t even a thought … I don’t want to lose my sister,” she said.
After Ybarra returned home, she explained that she started having complications. She said she went to a Williamson County hospital for treatment. Then, last February, she was shocked to learn the hospital was suing her for almost $4,500. She had insurance and said she tried to make payment arrangements for anything not covered.
Ybarra said her attempt to make payment arrangements with the hospital didn’t work, and once the bill was part of a lawsuit, the hospital referred all questions to the attorney handling the case.
The medical billing transparency law doesn’t apply to cases before Sept. 1, Harris Davila said. KXAN investigators are not naming the hospital because Ybarra’s treatment happened before the law went into effect, and there is no evidence the hospital violated the law by suing her for medical debt.
Ybarra explained she also asked the hospital for an itemized bill but never received anything.
Backlog of cases
It’s a common defense Judge Angela Williams, Williamson County Justice of the Peace in Precinct 2, said she hears in her courtroom.
“I think it’s important that individuals have the ability to examine these itemized bills and know what they’re being charged prior to a court date,” Williams said.
In the year Williams has been in office, she said at least 60% of her small claims caseload has been for medical debt.
“Most of the cases are a year or two old, and I am still hearing those cases, and we continue to have new filings as well,” she added.
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Judge Angela Williams, Justice of the Peace in Precinct 2, hears medical debt cases regularly in Cedar Park. (KXAN Photo/Arezow Doost) -
Judge Angela Williams, Justice of the Peace in Precinct 2, hears medical debt cases regularly in Cedar Park. (KXAN Photo/Arezow Doost) -
Judge Angela Williams, Justice of the Peace in Precinct 2, hears medical debt cases regularly in Cedar Park. (KXAN Photo/Arezow Doost) -
Judge Angela Williams, Justice of the Peace in Precinct 2, hears medical debt cases regularly in Cedar Park. (KXAN Photo/Arezow Doost) -
Judge Angela Williams, Justice of the Peace in Precinct 2, hears medical debt cases regularly in Cedar Park. (KXAN Photo/Arezow Doost)
She now even has a copy of the itemized billing law right next to her during those cases. Some defendants have told her they haven’t been able to get an itemized bill until their day in court.
Kasey Ybarra at her home in Liberty Hill reviewing medical bills. (KXAN Photo/Arezow Doost)
“I let them know that there is a — there is a new bill. It’s Senate Bill 490. And while it may not help you today, it is beneficial that you know that this bill has been put into effect because of the concerns of the people,” Williams said.
KXAN Investigators were in the courtroom the day Ybarra’s case was heard and dismissed. Court documents show the hospital’s lawyer failed to appear in court.
Days after Ybarra was in court, she said she received some of the itemized invoices, but details of what services were provided were blacked out. She kept calling the hospital and said she finally got invoices without anything marked out.
“How do you trust a system that’s supposed to be there to help you, make you feel better, find things that are wrong with you? It’s like you get punished, you know, because you’re sick,” Ybarra said.
‘Do not give up’
The Texas Hospital Association, or THA, opposed the law due to costs it anticipated, according to legislative records.
“We issued comprehensive guidance to help Texas hospitals comply with the new law, and hospitals across the state have worked diligently to follow SB 490,” THA said in an emailed statement. “While this work comes with significant administrative cost, Texas hospitals are committed to making sure patients have transparency about their bills.”
THA has not specified why the law would lead to increased costs, and the law’s fiscal note said it did not anticipate any significant fiscal implications to the state.
Harris Davila said it’s too early to tell if any changes are needed in Texas but she’s already looking ahead.
“It’s just a lengthy process to get the itemized statement, even if you request it. And that’s actually something that we will try to work on next session,” she said. “I heard from people… ‘I noticed an error in my billing, but it took me so long to get through to the billing department to figure it out and get it resolved.’ And so, I think that’s a piece that we’re recognizing now that this law has been in effect.”
Bernadette Moore’s advice is to be your own advocate when trying to understand medical billing charges. (Courtesy Bernadette Moore)
KXAN investigators asked Paxton’s office about the status of the complaints filed and the process to investigate them, but as of this report no response has been provided.
“I simply received an acknowledgement that they received my complaint, but nothing since then,” said Moore regarding the complaint she sent the AG.
She added she finally got the itemized invoice two months after requesting it. She said there were charges for things that didn’t happen on the day of the surgery. She even mentioned the law when she requested the itemized bill.
“Do not give up,” Moore said about getting an itemized receipt. “If it’s happening to me, I wonder how many people this … is happening to also.”
Harris Davila urges patients who are not able to get an itemized bill to file a complaint through HHSC or contact her office. HHSC is responsible for taking disciplinary action against providers in violation.
She’s also now pushing for the law to be nationwide. She said she’s been working with the American Legislative Exchange Council or ALEC, a conservative organization of state legislators, on highlighting Texas’ law.
“I am actually working with that organization to be able to present at their next conference and talk with all these members from all across the states on how to get this bill implemented in other states because Texas is, you know, we do things differently here. We do things better here. We’re always looking forward. And so, I’m happy that we’re leading on this as well. And I’m so excited to help other states implement this.”
Investigative Photojournalist Richie Bowes, Graphic Artist Wendy Gonzalez, Director of Investigations & Innovation Josh Hinkle, Digital Special Projects Developer Robert Sims, Graphic Artist Christina Staggs and Digital Director Kate Winkle contributed to this report, which is part of the “Medical Debt Lawsuits” project.
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