Florida is poised to become the second big state after New York to shield patients from surprise out-of-network medical bills, and California may not be far behind if lawmakers there can cinch a similar deal with physicians.
The issue has caught fire around the country, with even health professionals facing the personal experience of unexpected bills for hundreds or thousands of dollars. Consumers Union reported last year that among people who had emergency department visits, hospitalizations or operations in the previous two years, 37% received a bill for which their health plan paid less than expected. Among those who received a surprise bill, nearly 1 out of 4 got a bill from a doctor they did not expect to get a bill from.
Legislators and insurance officials in Georgia, Hawaii, Missouri, New Jersey and Pennsylvania are studying the issue or considering legislation. “It's not a red or blue issue, it's really bipartisan,” said Betsy Imholz, special projects director at Consumers Union. “Every legislator and staffer understands it and often has been a victim of it.”
Nearly everyone agrees that patients who unwittingly receive services from out-of-network providers at in-network facilities should be protected from these bills. The political holdup is determining how much to pay the out-of-network providers. Florida left it up to a to-be-developed dispute resolution process, while California is still trying to solve that issue.
Florida's Republican-dominated Legislature passed a bipartisan bill last month that would protect patients from paying balance bills from out-of-network providers in both emergency and non-emergency situations. This would apply when the patients go to a healthcare facility in their health plan network and inadvertently receive services from a non-network provider. Patients would only be responsible for paying their usual in-network cost-sharing.
Plans and nonparticipating providers would have to work out payment for those services through a state-arranged, voluntary dispute-resolution process, with a penalty assessed to the party refusing to accept an offer that was close to the final arbitration order. The negotiation would be based on the usual and customary rate for the particular area. Disputes could be taken to court. The bill would only apply to PPO-type plans, since Florida already bars balance billing HMO patients.
Republican Gov. Rick Scott has until April 14 to decide whether to sign the bill, which has strong support from the state's chief financial officer. The Florida Medical Association and other major stakeholder groups back the bill, though anesthesiology and radiology groups oppose it. The Florida Hospital Association said it agrees “with the general direction of the legislation.” Scott's office did not return a call for comment.