KXAN (AUSTIN) — With four kids, Tracey Prieto has to be ready for the unexpected. A sick child, broken bones or stitches means an automatic trip to the urgent care near her house in Houston.

“I have private insurance and it’s easier for me to go to an urgent care and be seen within an hour and not have to worry about my other kids that are left at home,” said Prieto.

Prieto says past visits have resulted in letters from her insurance company asking for clarification about the visit, including the time her son was in a lot of pain and treated for an ingrown toe nail.

“Of course they wanted us to go to a podiatrist and get it taken care of, which we did,” said Prieto. “But we had to fix the immediate issue which was he couldn’t walk because his toe was the size of three fingers. I had to get it taken care of right then.”

She says the insurance company ended up paying the claim, but Dr. Daniel Roe with VIK Complete Care in Austin says that’s not always the case.

“There’s no question that the insurance industry is biased against freestanding ER’s,” said Roe.

He is the medical director of two local freestanding ER’s. He didn’t want to single out specific insurance companies, but said it is a “common practice” for the major companies to deny claims based on the final diagnosis because it doesn’t appear to them that it was an emergency visit.

“[A patient] thinks they break their ankle, they go to the ER,” said Roe. “The x-ray is negative — it’s a sprain and so because of that the insurer wouldn’t be willing to cover the cost of the visit because it wasn’t considered a true emergency.”

Prudent Layperson Standard

If you think you’re having a medical emergency and you go to an emergency room, Texas law states the visit should always be covered by your health insurance plan.

The state law is called the Prudent Layperson Standard, and has been on the books for years. Roe is supporting HB 2035, a piece of legislation filed by Rep. Julie Johnson, D-Carrollton, aiming to add the following language to existing law:

“Emergency care” means health care services provided in a hospital emergency facility, freestanding emergency medical care facility, or comparable emergency facility to evaluate and stabilize medical conditions of a recent onset and severity, including severe pain, regardless of the final diagnosis that is given…”

Dr. Roe says his practice always sides with the patient by collecting their co-pay and never circling back to ask for the portion insurance may not have covered.

He says it puts the financial burden on his business, but Jamie Dudensing, CEO of the Texas Association of Health Plans, says insurance companies are following the law.

“If any person shows up with severe pain, it’s an emergency,” said Dudensing. “Automatically — that cannot be changed and that cannot be denied.”

Dudensing believes freestanding ER’s are the ones tricking patients into coming in for non-emergency reasons, and then charging emergency care prices that are not covered. She said TAHP just turned in a complaint with the state accusing more than 30 freestanding ER chains of misleading the public by putting messages on their website making it look like they are “in-network” and accept insurance from some of the largest companies.

The COVID-19 pandemic exposed the issue to patients, according to Dudensing. She pointed to stories like Austin Emergency Center charging Pam LeBlanc’s insurance nearly $7,000 for one drive-thru COVID test.

“This pattern was already happening before Covid,” said Dudensing. “We were seeing $10,000 for a flu shot visit, we were seeing $50,000 bills for toe fungus.”

She says it’s up to each patient to know their in-network providers when it’s not an emergency.

When it is an emergency, Prieto hopes there will come a time when she does not have to face the extra line of questioning after the visit.

“Me as a person that pays for the insurance, I believe there should be a level of trust with us,” said Prieto. “That we are making the best decision for our life, for our child’s life.”