§ 146.003.Certain Claims Barred

The sanction, and it is measured by what the delay cost the patient.

Subsection (a): a provider who violates the billing deadline may not recover from the patient any amount that the patient would have been entitled to receive as payment or reimbursement under a health benefit plan, or that the patient would not otherwise have been obligated to pay had the provider complied.

The bar is not the whole bill. It is confined to the amount the patient lost by the delay — so a patient with no coverage at all loses nothing from late billing and the provider recovers in full.

The mechanism it addresses is the plan’s own filing deadline. Health plans require claims within a set period, and a provider who bills after it has passed cannot be paid by the plan. Without this section the provider would turn to the patient, who would owe personally what insurance would have covered.

The second limb reaches beyond coverage — any amount the patient would not otherwise have been obligated to pay, which captures negotiated network discounts and similar reductions lost through late filing.

Subsection (b) closes the obvious route around it. Where recovery from the patient is barred, the provider may not recover from any other individual who, because of a family or other personal relationship with the patient, would otherwise be responsible for the debt.

That reaches a spouse liable under community property principles and a parent liable for a child’s necessaries — people who would otherwise absorb exactly the loss the section is preventing.

The bar operates automatically. It is a limit on what may be recovered, available as a defence rather than requiring the patient to sue.