April 21, 2016
Because of a new law, Florida patients won’t have to pay for medical care by doctors outside their insurance network if the service was performed at an in-network hospital. The law effectively bans a practice called “balance billing.” But some emergency room doctors say the new law misses the mark.
Balance billing, often referred to as “surprise billing,” is a practice doctors use to recoup costs insurers won’t pay.
Sometimes patients go to hospitals within their insurance networks, but the doctor treating them is not in-network — hence the “surprise.” When the law takes effect in July, though, doctors instead will have to settle reimbursement through arbitration with insurance companies.
Steven Kailes is president of the Florida College of Emergency Room Physicians. He wants to know who decides what’s reasonable when it comes to the amount of that reimbursement.
“The thing that will make our concerns about insurance company manipulation hopefully go away is if insurers and providers could not agree on what a reasonable out-of-network charge should be,” he said. “Then they could use the FAIR Health database to look for what the usual in the community would be.”
Kailes said using that database, which combines insurance reimbursement rates, average out-of-pocket patient costs, and procedure prices, would help keep the new Florida process fair. He hopes to pitch FAIR Health to regulators when they implement the new law. But until then, Kailes said he’s in wait-and-see mode.
“In an effort of good faith, we don’t really know which direction this bill is going to change things. Maybe the insurers will play nice, so to speak. Maybe they’ll play fairly,” he said.
Another new Florida law creates a similar database, but one Kailes says doesn’t go far enough.
An almost-companion measure to the balance billing law, the bill sponsored by Sen. Rob Bradley, R-Orange Park, and Rep. Chris Sprowls, R-Palm Harbor, gives patients the right to ask about the cost of a procedure up front. It also gives the state the ability to hire a contractor to create a health care price database.
Both the balance billing and health care transparency bills were part of a greater effort by legislators to control the cost of health care.
Gov. Scott also signed into law a measure giving advanced nurse practitioners and physician’s assistants to prescribe controlled substances. That measure had failed to win final approval for the last few years.