Like most patients, Robert Delfino did what his doctor told him: Go to the hospital for an outpatient cardiac procedure to determine the cause of his heart condition.
Delfino, 54, was following the advice of his cardiologist, listed in his insurance company’s provider network catalog.
Fortunately for Delfino, of Delray Beach, his coronary blockage was not serious enough to require a stent. The real problem came two months later, when Delfino received a bill for $15,000 from the hospital, which was not an in-network provider.
Delfino was incredulous. A self-employed real estate appraiser, he had bought his health plan on the Affordable Care Act exchange at healthcare.gov.
“I thought my in-network doctor would take me to a network facility,” he said. “I thought the insurance company would call me if it was out of network.”
Delfino’s experience is an increasingly common one known as “balance billing,” or the unexpected charges patients receive for medical services from a doctor or hospital that does not have a contract with the patient’s insurance plan. In such cases, the consumer ends up owing the difference between what the insurer chooses to pay and what the doctor or hospital charges — although one Miami legislator is aiming to change that.
Patients can be on the hook for thousands of dollars, according to testimony from consumers and patient advocates who spoke at an October hearing on balance billing held by Florida’s Insurance Consumer Advocate, Sha’Ron James.
James noted that her office has received “numerous complaints” about balance billing for several years, and that the practice happens most often in emergency room settings or during pre-planned surgeries where someone on the medical team is out-of-network, such as an anesthesiologist.
Balance billing is prohibited by Florida law — but only if you’re in a health maintenance organization, or HMO, and only for emergencies and covered services provided in an in-network facility.
Consumers who belong to preferred provider organizations (PPOs) or exclusive provider organizations (EPOs) are not covered by the statute.
But a bill introduced this fall in the Florida House seeks to prohibit balance billing in emergency situations for members of PPOs and EPOs. Sponsored by Rep. Carlos Trujillo, a Republican from Miami, the bill has drawn spirited opposition from physician associations, hospital groups and political conservatives who have compared the legislation to “Obamacare.”
Trujillo defends his bill as a consumer protection issue, and he argues that it should be a bipartisan concern because patients from either political party can be hit with unexpected medical bills for an emergency when they did not have the time or ability to look for an in-network provider.
“At that point, all choice is out of your hands,” he said, “and you shouldn’t be … punished after the fact.”
Trujillo introduced a similar bill last year, only to see the Senate sponsor withdraw it from consideration. Trujillo said he is working this year with Sen. Rene Garcia, a Hialeah Republican, to introduce a companion bill in the Senate.
But some healthcare providers say the bill would undermine their ability to negotiate a fair price from insurance companies for their services.
Jonathan H. Slonin, an anesthesiologist and president of the Florida Society of Anesthesiologists, said insurers and their desire to create “narrow networks” with fewer healthcare providers are causing patients to suffer through balance billing.
Slonin is the Florida medical director of anesthesia for a Tennessee-based hospital staffing firm called Team Health, and he said the group tries to contract with as many insurance plans as possible. But he refuses to accept what he considers below-market rates for his services.
“Unfortunately, there are insurance companies that choose to have narrow networks so they can force people to certain physicians,” said Slonin, who practices in Port St. Lucie, “and they don’t pay appropriately and so the only choice is to not accept that.
“I have to pay the bills, too,” he said.
But Audrey Brown, president of the Florida Association of Health Plans, said some healthcare providers oppose the legislation because they can extract higher payments from consumers than they can from the insurance companies.
“They are basically using it as a business model to upcharge the consumer because there is no protection in place,” said Brown, who supports the bill.
Trujillo’s bill would require out-of-network doctors and hospitals to be paid the greater of three payment methods for emergency services provided to consumers with PPO and EPO plans: the Medicare rate; the usual and customary reimbursement paid by insurers in a geographical area; or an amount agreed upon through mediation.
Balance billing could affect low- and middle-income consumers who buy plans on the ACA exchange.
EPOs are the predominant types of health plans sold on the exchange for 2016 in Miami-Dade and Broward counties, including the lowest-cost standard plans that are most popular among the 1.3 million Florida residents covered through the exchange in 2015.
Many consumers buying plans on the ACA exchange tend to use the emergency room more often than other insured consumers, according to a February study by the nonprofit Commonwealth Fund, which found that emergency room visits by those newly insured through the exchange are likely to increase.
Delfino of Delray Beach just wishes someone would have informed him of the extra costs he would face for what he considered an urgent procedure to find out what was wrong with his heart. He was in and out of the hospital in three hours for the cardiac catheterization but has yet to pay the bill he received in October 2014.
“I’ve been fighting it,” he said.
“I know your health and your life is the most important, but when you don’t have that kind of money, you should have been told that,” Delfino said. “I just feel disgusted with the system. … Nobody before the operation called me … to say, ‘It’s going to be more money.’ ”
A previous version of this article stated that PPO health plans will be sold on the Affordable Care Act exchange in Florida for 2016. No PPO plans are offered on the exchange in Florida for 2016.