Balance Billing Proposal Gets Senate Sponsor

Jan 7, 2016

A consumer health measure aimed at protecting insured patients from surprise bills was filed Thursday by state Sen. Rene Garcia, R-Hialeah.  

Senate Bill 1442 would give patients in network-style plans called preferred provider organizations (PPOs) the same protections against out-of-network bills for treatment in emergencies. Patients with HMO plans already have this under Florida law. 

And in non-emergencies – say, for planned surgery at an in-network hospital – PPO patients would at least be entitled to a warning that some of those who will be sending bills are not in their insurance network.  The hospital would have to provide a list, and the out-of-network doctor would have to provide a written estimate of the extra charges in advance.

For the first time, millions of patients going under the knife would have as much warning on cost as drivers get at an auto-repair shop under Florida law.

Audrey Brown, president of the Florida Association of Health Plans, praised Garcia’s bill, which will be considered in the 2016 Legislature that starts Tuesday.

“Floridians with PPO health insurance policies deserve to go to health care providers and understand their financial responsibilities without being hit on the backend by a surprise bill from the provider, and this bill empowers them to do just that.”

Another who praised the Garcia bill is Florida Insurance Consumer Advocate Sha’Ron James. She held hearings on balance billing in October and released her findings in December.

Garcia’s bill incorporates many of her proposals.

“I look forward to working with him as this process moves forward,” James’s statement said.

In one respect, SB 1442 goes farther than James had suggested, in its requirement that non-network doctors give a written estimate of what their extra charges would be for non-emergency treatment.

However, Garcia omitted James’ proposal that the state require the insurer and out-of-network providers to submit to arbitration if they can’t compromise on a payment for service.  James said the insurer and provider should be forced to work out their own dispute, taking the patient out of the middle.

Instead, the Senate bill sticks to a longtime recipe for figuring out what the insurer should pay: the greatest of several rates, including Medicare payment for similar services and the “usual and customary” amount the plan pays in that region.

A bill pending in the House by Rep. Carlos Trujillo, R-Miami Dade, would protect PPO patients from balance-billing, but only in emergencies.  He has not publicly said whether he’s open to the non-emergency protections.

Surprise charges in non-emergency PPO cases are a growing phenomenon, and the largest single complaint to James’ office involved just such a case.  A Boca Raton woman who had surgery for a brain tumor at a hospital in her PPO network discovered afterward that the neurosurgeon did not have a contract with her PPO. She used up her retirement savings to pay his bill of more than $85,000.

While the Senate measure doesn’t prohibit such billing in non-emergencies, it would at least assure that the surgeon’s out-of-network status didn’t come as a surprise; the hospital would have had to reveal that beforehand. And the surgeon would have had to give the brain tumor patient an estimate of what he planned to bill her well in advance, giving her a chance to seek an alternative.

Among the providers that have defended balance billing are: ambulance services, emergency-room physicians, orthopedic surgeons and anesthesiologists. Neither the Florida Medical Association nor the Florida Hospital Association has publicly stated a position.

Carol Gentry is a special correspondent based at WUSF in Tampa. WUSF is part of Health News Florida, which receives support from the Corporation for Public Broadcasting.