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Insurance Consumer Advocate

Sha'Ron James


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Mailing: 200 East Gaines St.
Tallahassee, FL 32399-0308

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Insurance consumer advocate proposes arbitration for billing disputes

News Article

December 17, 2015

Politico Pro

TALLAHASSEE — Florida’s top insurance consumer advocate wants to quash the balance-billing dispute over emergency medical services through the use of binding arbitration.

Florida Insurance Consumer Advocate Sha’Ron James on Thursday unveiled a proposal that she says would keep insured patients who required emergency medical services out of the growing fights between doctors and insurance companies by putting into law a billing benchmark and establishing an arbitration process to collect anything beyond those limits.

“For us, what’s most important is that the consumer is being held harmless,” James told POLITICO Florida in a telephone interview Wednesday night.

She plans on offering the proposal as an amendment to HB 221 when the bill is considered at its next committee.

Balance billing occurs when an insured patient receives a bill from an out-of-network health care provider. The bill is for the difference between what the provider charges for the service and what the insurance company paid them. It is illegal in Florida to balance-bill an HMO patient, but it is allowable under an insurance product.

James' proposal would require insurance companies to pay out-of-network doctors and hospitals who provided emergency services and care care either the billed amount, an amount the insurer determines is reasonable for the emergency services, or a charge mutually agreed on by the insurer and the nonparticipating provider.

To get additional reimbursement, a provider would be required to initiate a binding arbitration process that would be administered by the Department of Financial Services. DFS would maintain a list of approved arbitrators who must be trained either by the American Arbitration Association or American Health Lawyers Association.

The party requesting arbitration would be required to notify the other party that they are seeking arbitration and make a final offer to resolve the dispute. In response, the non-requesting party must also make its best and final order to resolve the dispute. An arbitrator would look at both parties' best and final offer and choose one of the two amounts.

James held an all-day meeting on balanced billing in November, and developed the plan after hearing from interested parties and lobbyists at the meeting.

The proposal also would require hospitals and insurance companies to post disclosures. Hospitals would be required to list all the health insurance policies and HMOs accepted as well as a statement that physicians services are not included in hospital charges and that physicians may or may to participate in the same health policies as the hospital.

Insurance companies would be required to include in their contracts language that warns their policy holders that limited benefits will be paid when they voluntarily choose to see non participating health care providers.