Florida’s Surprise Bill Law Could Be Template For Federal Legislation

Florida is one of nine states that have taken on unexpected health care bills by passing comprehensive regulations. 

Still, a recent study by the Kaiser Family Foundation found that patients in the state are among the most likely to get surprise bills.

That's because some health insurance plans fall under federal regulation. These plans are typically provided by large companies or unions, which hire major insurers to administer them. The plans are self-funded, meaning they pay claims out of their own funds.

Congress is working on legislation that would apply to all plans. Lawmakers are addressing a form of surprise bills called balance billing, which happens when a patient goes to a hospital that is in their network but are seen by a doctor who is not.

Some say Florida's 2016 law provides Congress with a good template for federal legislation.

“We would just like to see legislation that's more balanced and doesn't give too much power to the insurance companies,” said Dr. Michael Lozano, a physician at Envision Healthcare and the medical director for Hillsborough County Fire Rescue.

Florida's law provides a process for doctors and insurance companies to work out billing disputes without costing patients more.

When a patient is seen by an out-of-network doctor at an in-network hospital, Florida’s law says patients are only responsible for paying the doctor an in-network fee.

It's up to doctors and insurance companies to work out the remainder of the bill. The law provides a process for those negotiations.

Lozano says any federal legislation should also include the process - called dispute resolution.

“You need a fair process where if they have a dispute they have a way that they can come to an agreeable resolution of how to pay for a bill and not make the patient part of that,” he said.

In the past, doctors who challenged insurance companies on billing disputes were often overpowered by attorneys at large insurance companies, Lozano said.

“An individual doctor or maybe a group of 10 doctors who are in a practice, that’s nothing when they have to go up against these huge insurance companies,” he said. “Nobody wants to see the patients being stuck in the middle or being stiffed with the bill or having to be shuffled back and forth.”

The Kaiser study found among people with large employer coverage, an average of 22% of emergency room visits in Florida result in at least one out-of-network charge.

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