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Sha'Ron James

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Ban 'balance billing' in emergencies, state advocate says

News Article

December 17, 2015

Palm Beach Post

A legislative proposal unveiled Thursday aims to help consumers like a Jupiter woman slammed with a bill of more than $23,000 for trauma-team charges her insurer has refused to cover.

“If there’s an emergency situation for a consumer, that consumer cannot be balance-billed,” Florida Insurance Consumer Advocate Sha’Ron James said about an overhaul of state law she proposed after months of hearings and research.

 “Balance billing” means surprise charges when insurers and medical providers, particularly those out of a health plan’s network, cannot agree on a charge — so they hand the consumer a bill for the difference.

The Jupiter woman is one of many who have contacted state officials to urge a solution, especially in emergencies where people have no realistic option to shop around or check who is in or out of a network.

By law, consumers would be “held harmless” in emergency situations, paying no more than the equivalent of in-network charges, James proposed. The plan would require insurers and non-network providers to work out their differences in binding arbitration if necessary, she said — but they can’t just bill the consumer and walk away.

Her efforts are designed to break a stalemate that saw legislation to address balance billing in Florida stall last spring, amid intense lobbying by opposing interest groups representing doctors, health plans and others. James said she is working to amend existing bills, among other options, in the legislative session that starts next month.

For example, HB 221 by state Rep. Carlos Trujillo, R-Miami, also seeks to avoid emergency balance billing but does not refer to arbitration. A call to Trujillo’s office was not returned.

James would include ambulance service under emergency balance-billing protection “to the extent permitted by applicable state and federal law.” As The Palm Beach Post reported, ambulance services such as Palm Beach County Fire Rescue often decline to join insurer networks, which can result in surprise bills for consumers. Palm Beach County Fire Rescue Capt. Albert Borroto referred questions about Thursday’s proposal to the county’s director of legislative affairs, Todd Bonlarron, who was not immediately reachable.

In non-emergency situations, hospitals and insurance plans would be required to make certain disclosures about possible costs to the consumer from non-network providers, James said, but the consumer would not be “held harmless,” as in emergencies.

James did not propose what some other states have done — resolve payment disputes by imposing a fixed scale based on, say, a percentage of what Medicare pays for certain services, such as 140 percent. James said her approach is to “move forward incrementally,” though she said she would eventually like to see greater protections even in non-emergency cases.

Take the Boca Raton woman who was diagnosed with a brain tumor. After reading coverage about surprise bills in The Post, she told James she went to a hospital in her health plan’s network.

To her horror, a surgeon she did not know was not in the network billed $85,000, leaving her to pay $81,890 on top of other charges and premiums. She said she had to cash in an IRA to pay off the bills.

Surprise medical bills affect about one in three consumers nationally, surveys show, leading to wiped-out savings, bankruptcy, ruined credit and other disasters for many.

Industry groups, meanwhile, have often blamed each another.

Insurers have shifted costs to patients through rising deductibles, co-pays and other methods, said Jeff Scott, general counsel for the Florida Medical Association. Scott was not available for comment Thursday, but he said in a October hearing: “These charges are surprises only to the uninformed patient.”

Health plans argue if out-of-network providers are allowed to charge whatever they like, it encourages them to stay out of networks and send premiums skyward for everyone.

“Some providers choose not to contract with health plans and, in fact, this is becoming a business model for some,” said Audrey Brown, president of the Florida Association of Health Plans, in October.

On Thursday, Brown said her group “supports efforts to end the practice of surprise balance billing and taking the consumer out of any payment disputes between insurers and providers.”

Health plans look forward to discussing the consumer advocate’s proposal to “ensure a fair arbitration process and that providers continue to have financial incentives to join health insurers’ networks,” Brown said.