DOH Investigation Regarding Alleged Improper Balance Billing Closed With a Finding of No Probable Cause

Posted on Firm News, Health Care Law News by Erin Ferber

With the implementation of the No Surprise Act on January 1, 2022, patients, insurers, and regulatory authorities have begun taking a closer look at the billing practices of healthcare providers, especially for out-of-network providers.

Due to decreasing reimbursement rates, increased oversight, and challenging hurtles to get credentialed, more providers are choosing to operate as out-of-network providers.  In other words, rather than credentialing with commercial plans such as UnitedHealthCare, Blue Cross Blue Shield, Aetna, or Cigna, healthcare providers elect to operate as cash-pay providers in order to avoid the bureaucracy that can come along with being an in-network provider.

As an out-of-network provider, you are not forced to accept an contracted rate of reimbursement and are able to balance bill a patient for any amounts not paid by insurance.  That being said, the No Surprise Act and Florida’s parallel statute limit a healthcare providers ability to balance bill a patient for emergency, and certain nonemergency services.

As an out-of-network provider who was on-call, a South Florida urologist was accused of improperly balance billing his patient for services provided in the hospital setting but after the patient was admitted from the emergency department.  Relevant here, an out-of-network provider may balance bill a patient for covered nonemergency services unless the patient did not have the ability and opportunity to choose a participating provider at the facility who is available to treat the patient.  In most nonemergency situations, a patient will have the ability to select an in-network provider.  Failing to do so allows an out-of-network provider to then balance bill the patient for any portion of the reimbursement for services not covered by insurance.

In this situation, the Department of Health agreed and closed the investigation with no finding of probable cause.

Nicholson & Eastin, LLP, regularly assists providers with licensure investigations, as well as navigating the evolving rules regarding reimbursement, including the No Surprise Act and Florida’s parallel statute.  Please do not hesitate to contact us for assistance with either type of matter.