New Florida Health Laws Prohibit Unexpected Balance Billing and Demand Greater Pricing Transparency

Posted on Health Care Law News by Robert Nicholson

Florida recently became the latest state to enact legislation protecting consumers from unexpected medical bills through balance billing.  Unexpected “balance billing” happens when a patient is unaware that they are receiving treatment from a medical provider that is not covered under his or her health insurance plan (i.e., a provider who is “out-of-network”). This may happen during a medical emergency, but it can also happen when patients go to in-network hospitals and assuming that all the medical providers there are also in-network or covered under their health plan, or when they are referred to an out-of-network provider for ancillary services.

Many providers who treat patients at in-network hospitals, for instance —such as anesthesiologists and emergency room physicians—may not be part of the health plan’s network, even though the hospital is in-network.  The new legislation protects consumers from unexpected medical bills from these providers, using a combination of policy approaches – such as advance notice, greater transparency, and an independent process to resolve disputes between payers and providers.  More specifically, Florida’s new law prohibits surprise billing in emergency situations for all types of products, including preferred provider organizations (PPOs) and exclusive provider organization (EPOs).

In addition, the new law protects consumers when they are at in-network hospitals for non-emergency services, but are unknowingly treated by out-of-network physicians for covered services. The law requires that insurers “are solely liable for the payment of fees” minus any applicable cost-sharing amounts and prohibits out-of-network practitioners from balance billing. It also requires increased transparency and notice to consumers about the possibility of being treated by an out-of-network practitioner. For example, hospitals must post on their websites the health plans with whom they are in-network, and put consumers on notice that patients may be seen by out-of-network practitioners.

Florida also recently enacted a new transparency law that requires hospitals and other health care facilities to post in a public database the average amount they are paid for a specific procedure, which puts Florida at the forefront of the push to increase health care price transparency. Importantly, the average amount paid for a specific procedure is far different from the standard “charge” information required by many states.  In addition, the new law pairs pricing information with quality measures, which are important for consumers and require practitioners who provide services in hospitals, such as anesthesiologists and radiologists, to also produce cost estimates.  Only Florida, New Hampshire, Colorado and Maine have such “average price” laws in place.  Although 26 other states have statutes requiring hospitals to state publicly some sort of price, in almost every case the sticker price is published—not the lower rates the hospitals actually are paid.  Under the Florida law, the state is required to develop a user-friendly online platform where hospitals, urgent care centers, offsite diagnostic facilities and ambulatory surgical centers must post their procedure costs.

These are important new pieces of legislation that could fundamentally change the delivery of healthcare in Florida, especially in terms of bringing prices into the sunshine.

The Florida health law firm of Nicholson & Eastin, LLP assists health care providers of all types with compliance issues such as the new pricing laws discussed above, as well as preparation of compliance plans, compliance reviews, self-disclosures, HIPAA compliance, and a myriad of other healthcare regulatory issues. Please feel free to contact the Firm regarding any compliance questions.