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Insurance Consumer Advocate

Sha'Ron James


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Tallahassee, FL 32399-0308

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Bid to end 'surprise billing' by health care providers hits home stretch

News Article

February 24, 2016

Sun-Sentinel

A proposed law aimed at preventing health insurance consumers from being hit by surprise bills from out-of-network providers is getting closer to the finish line in the state legislature.

A House version of the bill has been approved in three committee stops and will next be considered on the full House floor. The Senate version is scheduled for debate Thursday morning by that chamber's Appropriations committee.The bill aims to remove consumers from disputes between insurers and physicians over costs of services by out-of-network providers. Often, patients are stuck with surprise bills for the difference between what providers charge and insurers are willing to pay.

Complaints have been mounting over the past few years from patients who go to emergency rooms, urgent care clinics or specialists that they think are part of their paid provider organizations — or PPOs — only to receive surprise bills later from providers such as anesthesiologists who weren't in their networks for the balance of services not reimbursed by the insurance company.

If the reforms become law, patients could not be billed for emergency services or covered non-emergency services provided in a hospital or other facility in the patient's insurance network for any amount that exceeds the co-insurance, co-payment, or deductible contracted between the patient and the insurer.

In an example cited last fall by Sha'Ron James, the state's insurance consumer advocate, a Boca Raton woman who had surgery for a brain tumor in a hospital in her PPO network discovered afterward that the neurosurgeon was not contracted with her PPO. The $85,000 surprise bill wiped out her retirement savings.

Patients in HMO plans are currently protected from billing by out-of-network providers after emergencies. The bills expands those protections to patients in PPO-style plans.

For non-emergency care, hospitals would have to post names and links of all contracted insurers, as well as names and contact information of all practitioners and practice groups under contract with the hospital. Patients would be given statements that services may be provided by out-of-network providers, and that they should contact practitioners to determine to which networks they are contracted.

The bills have the support of two warring groups — the Florida Association of Health Plans and the Florida Medical Association.

The medical association came on board after a dispute resolution process was added, as well as language mirroring HMO laws that prohibit balance billing. Those laws require insurers to pay either billed charges, a "usual and customary" charge for that service in the community where it's provided or a negotiated rate.

The Florida College of Emergency Physicians would like to see further revisions that would provide a fair definition of what's considered "usual and customary" in a community, said Dr. Steven Kailes, president of the Florida College of Emergency Physicians.

Many of the billing disputes arise because insurers reimburse based on cost schedules that are outdated or Medicare-based, Kailes said. His organization would like any new law to require rates to be tied to real-world pricing.

Still, Kailes said the current version of the bill is superior to the original version introduced at the beginning of the session. "We're comfortable with what's in there now, just skeptical we won't be fighting with the insurance companies over that 'usual and customary' definition."

Without a fair way to agree upon rates, "specialty coverage for emergency rooms is going to diminish, and that threatens the health care safety net for patients," Kailes said.

Audrey Brown, president and CEO of the Florida Association of Health Plans Inc., said her organization of health insurers is happy with the bills, which "prohibit health care providers from billing a consumer the balance of the retail charges above the individual's copayment or co-insurance amount and the amount the insurer reimburses for the services."

However, Brown said, "we are concerned about continued efforts by certain specialties such as radiologists and anesthesiologists to carve themselves out of the legislation."

A proposed revision excluding those professions from the law is scheduled to be considered Thursday.

In an email on Wednesday, Insurance Consumer Advocate James called the current versions of the bills "a step in the right direction toward protecting consumers" but added, "more work may need to be done to address all forms of surprise medical bills that a consumer may face in emergency and non-emergency scenarios alike." Additionally, she said. "there may be work to be done to address adequate provider networks."