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Sha'Ron James

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Surprise medical bills: Fla. seen as U.S. model as consumers speak out

News Article

March 18, 2016

Palm Beach Post

Personal stories from across Palm Beach County and the state clearly resonated, consumer advocates said — and set the stage for Florida lawmakers’ last-minute passage of what one group calls a national model for protection against surprise medical charges.

“I do think it’s a great model for other states,” said Chuck Bell, programs director for Consumers Union, the Yonkers, N.Y.-based advocacy arm of Consumer Reports. “We need a healthcare system where consumers are not being used as pawns.”

For consumers that have been caught in the surprise medical bills trap, it’s simply a matter of fairness.

“It’s wonderful news,” Joyce Trapp of Loxahatchee said after the bill passed.HB 221, if signed by the governor, won’t change the past, she said, but it could protect others like her in the future: “If it helps one person, it would be worth everything.”

She and her husband Jeff, a decorated law enforcement officer injured in a motorcyle accident, told The Palm Beach Post about more than $10,000 in out of pocket costs and collection notices for more than $6,000.

A version shared on Facebook produced “a firestorm of comments” from others sharing similar stories, she said. Co-workers sought her out.

“People said, ‘Oh, we saw your picture in the paper,” she said. “They were saying, ‘The same thing happened to me.’ “

Or take the Boca Raton woman with the $81,000 bill.She said she went to a hospital in her insurer’s network for a brain tumor, only to get a stunning bill from a surgeon not in network. She had to liquidate a retirement account to pay it, state insurance consumer advocate Sha’Ron James said in a public hearing in October. The woman contacted the advocate’s office after reading Post coverage, officials said.

A fundamental question kept emerging: Is it fair for consumers who are trying to play by the rules — who have insurance and try to choose facilities in their health plan’s network — to be blindsided by charges from providers they may not know are out of network?

There is generally no problem, most parties agree, when consumers make an informed decision to use an out-of-network doctor. But the bill is designed to address cases where consumers have no reasonable choice. That can mean not only emergencies but also, for instance, an out-of-network anesthesiologist for a scheduled procedure at an in-network hospital.

Florida lawmakers listened this year after similar efforts stalled a year ago. It came down to almost the final minute, but HB 221 passed on the session’s last day, March 11.

A handful of other states have comprehensive provisions designed to guard against what is sometimes called “balance billing,” but Florida’s may be the most direct and clear in many respects, said Bell of Consumers Union.

Florida broke through a political and lobbying deadlock that has bogged down similar attempts in other big states like California and New Jersey, he said.

The Florida bill “follows the logic of what the consumer can reasonably do,” Bell said. “I think it’s a big win not just for patients but for making billing more efficient.”

The Florida Medical Association was among several groups that indicated support for the bill, but some organizations representing medical specialty fields have expressed deep concern. They say their members have families too and they want a fair solution, but this hands too much power to insurers.

“What we ended up with was the insurers, experiencing record profits already, getting handed the ability to unilaterally set physician payment rates,” said Jay Epstein, chairman of legislative affairs for the Florida Society of Anesthesiologists. “What undoubtedly will result is the need for physicians to litigate what is bound to be dramatic underpayments.”

Epstein continued, “Patients will benefit, for sure, but they no longer have a skin in the game when it comes to being responsible for their insurance plans and health care choices, and that will distort the market. Conclusion: carriers win, doctors and the system lose.”

Others in the medical community have argued insurers are responsible for many things consumers may regard as unpleasant surprises — like rising co-pays and deductibles and narrow networks.

But health plans contended the bill was critically needed because some medical providers had incentives to stay out of networks as a “business model.” That meant they could not only accept what the insurer paid, but also bill consumers for whatever balance they saw fit.

That puts the burden on consumers, who typically have little leverage to fight back. In the worst cases, big surprise bills can wipe out savings, increase the risk of bankruptcy, or damage credit records.

“I believe Florida is now at the forefront of ending the practice of balance billing and could be a model for this kind of legislation going forward,” said Audrey Brown, president of the Florida Association of Health Plans. “It has an immediate impact on consumer wallets.”

It did not come without plenty of legislative drama right to the end.

Senate sponsor Sen. Rene Garcia, R-Hialeah, said on the floor amendments including one supported by incoming Senate president Joe Negron, R-Stuart, would “gut” the bill. One change the Senate adopted, only to withdraw hours later, carved out anesthesiologists and radiologists from the bill.

Shortly before 6 p.m on the final day, both chambers accepted an amendment requiring insurers to cover certain costs for patients with Down Syndrome, a priority of outgoing Senate president Andy Gardiner, R-Orlando.

The final legislation is designed to hold consumers harmless in billing fights, charging them no more than the equivalent of in-network costs. The bills blocks balance billing when “the insured does not have the ability and opportunity to choose a participating provider at the facility who is available to treat the insured.”

Insurers and medical providers out of the network have to work out payment disputes on their own. The consumer is no longer in the middle of that fight, bill supporters say.

In addition, consumers will receive more notice and transparency from both insurance companies and providers, officials said.

James, the state’s insurance consumer advocate, brought together sparring interest groups in a hearing on balance billing last fall. She traveled around the state including Palm Beach County to talk with consumers in person on a variety of insurance topics. After the bill passed, she said the impact on Florida families will be “tremendous.”

Even with protections it does establish, the bill does not cover everything. Ambulances services, which typically decline to join insurer networks, were dropped from the legislation after heavy lobbying.

Bill supporters do not expect Gov. Rick Scott to veto it, though a number of medical groups are clearly not happy with it. Scott’s office is reviewing it, a spokeswoman said.

If it does become law, it reflects the power of individual stories from people who told legislators they did not want to see the issue buried again.

In this case, enough people in positions of power listened.

“This legislation is a win for every Florida family,” said Florida Chief Financial Jeff Atwater of North Palm Beach — “both those that have experienced balance billing in the past and those that thankfully will not have to.”