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House Panel Sides With Doctors On Insurance Claims

Leon County Judge John Cooper on June 30, 2022, in a screen grab from The Florida Channel.
The Florida Channel
Leon County Judge John Cooper on June 30, 2022, in a screen grab from The Florida Channel.

A bill that would restrict the ability of health insurers and HMOs to retroactively deny claims passed the House Appropriations Committee on Wednesday, scoring a victory for physicians.

But many of the “yes” votes for the bill (HB 217) will turn to “no” if the bill isn’t changed, committee members warned.

The federal Affordable Care Act, better known as Obamacare, gives insurance customers a three-month grace period before policies are canceled, so long as the customers previously paid at least one month’s premium. During the first month of the grace period, the insurer must pay all appropriate claims for services. For the second and third months, insurers can notify health-care providers that payment of claims may be denied. While many aspects of the federal law affect all health-insurance policies, the grace-period provision applies only to policies sold on exchanges created under the law.

The state House bill, though, would apply to claims off the exchange and would prevent HMOs and insurance companies from retroactively denying claims after patient eligibility has been confirmed and authorization numbers have been provided. The limitation on retroactive denials would apply to any group or individual HMO policy issued on or after Jan. 1, 2019, but it does not apply to Medicaid managed-care plans.

Debate about the bill has pitted doctors, who are concerned about not getting paid for care they provide, against the health-insurance industry.

“We all know what we are trying to accomplish and it’s a fundamental question of fairness,” House Appropriations Chairman Rep. Carlos Trujillo, R-Miami, said Wednesday. “I think the fairest fix … is that providers are made aware that the person is in a cancellation period and they can make an informed choice whether they proceed with that procedure, obviously non- emergency or not. I think that’s ultimately where the bill will end up.”

House Health Care Appropriations Chairman Jason Brodeur, R-Sanford, supported the bill but says he limited his review to the bill’s fiscal impact on the state group health-insurance program. That is because the bill was in a budget committee Wednesday.

Brodeur warned, though, that he would review the policy aspects of the bill before it goes to the Health & Human Services Committee. He listed policy issues that he said he reserves his “right to light myself on fire about in HHS.”

Similar bills have been filed for several years and generally have been favored by the Florida Senate. This year’s Senate version (SB 182) is awaiting final passage in that chamber. But this is the first time that the bill also has momentum in the House.

Bill sponsor Bill Hager, R-Delray Beach, had prepared an amendment for Wednesday’s meeting that would have precluded HMOs and insurers from denying claims during grace periods unless they told providers that the patients were in a grace period and that payment was uncertain. However, if the health insurers did not inform the provider that premiums were outstanding and the patients were in a grace period, the determination would have been binding and the insurers would have been precluded from seeking to recoup payment from the providers.

Hager says he withdrew the amendment because he “knows how to count,” inferring the bill would have been killed had he included the changes.

But a Florida Medical Association lobbyist said the amendment would have fine-tuned the bill.

“If the insurance company tells the physician that the patient is in grace period, then they can retroactively deny claims later on,” FMA General Counsel Jeff Scott says, explaining his group’s support of the withdrawn amendment. ‘If they don’t tell the physician, then they would have been stuck having to pay the claim.’

Meanwhile, a spate of insurance and business lobbyists testified against the bill, including representatives from America’s Health Insurance Plans, Associated Industries of Florida and Florida Blue.

Florida Association of Health Plans Vice President and General Counsel Wences Troncoso told members of the House committee that the bill was nothing more than a codification of the idea of the Affordable Health Care Act.

“And that’s the idea of free health insurance,” Troncoso said.