A proposal led by Miami-Dade lawmakers to protect patients from receiving unexpected medical bills for out-of-network care — a goal that doctors, hospitals and health insurers all say they support — is in trouble in the Florida Legislature this week after a last-minute change that consumer advocates worry is undermining support for the legislation.
The coalition of political support behind the bill is a “delicate agreement,” said Laura Brennaman, director of Florida Community Health Action Information Network, or CHAIN. An amendment to the bill tacked on in the Senate, a week before the end of the legislative session, could be “an effort to scuttle the bill altogether without any real validity,” she said.
Supporters of the proposal passed by the Florida House say the legislation would protect consumers from receiving surprise medical bills from doctors and hospitals that do not have a contract with the patient’s insurance plan, an increasingly common — and lucrative — practice known as “balance billing.”
Opponents say the legislation would undermine the power of physicians, particularly hospital-based doctors, to negotiate fair payment for their services. The amendment added March 3 would prohibit insurers from denying claims for some members.
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Nearly one third of privately insured Americans received a surprise medical bill where their health plan paid less than expected in the past two years, according to a survey by the Consumer Reports National Research Center.
Florida Sen. Rene Garcia, a Hialeah Republican and sponsor of the Senate’s version of the bill, called the amendment “a political move” and blamed two groups of physicians — anesthesiologists and radiologists — for fighting “tooth and nail” to stop the legislation.
“They’ve tried everything they can,” he said. “By them doing that, it’s just a clear indication that they want to see this bill killed because they want to continue to balance bill, and they’re the ones who have been the number one abusers.”
Jay Epstein, a Clearwater anesthesiologist and past president of the Florida Society of Anesthesiologists, accused Garcia and Florida Rep. Carlos Trujillo, a Miami Republican who sponsored the bill in the House, of “coming down really hard on the side of the insurers.”
“To have the insurance company be given unilateral power to just decide what I’m going to get paid for my services just makes no sense,” Epstein said.
The issue in dispute — with doctors and hospitals on one side, and insurance companies on the other — is what constitutes fair payment for medical care when there is no contracted rate. Most often, the patient is billed for the difference between what the insurer chooses to pay and what the doctor or hospital charges for the service.
They want to see this bill killed.
Florida Sen. Rene Garcia, a Hialeah Republican
Balance billing has become more frequent in large part due to the rise of “narrow network” coverage plans, which offer members access to fewer doctors and hospitals in exchange for a lower monthly premium.
That’s the predominant type of coverage offered in Florida on the Affordable Care Act exchange, also known as Obamacare. More than 1.7 million Floridians have enrolled in an ACA plan in 2016, including nearly 644,000 in Miami and Fort Lauderdale, according to the Department of Health and Human Services.
The state’s insurance consumer advocate, Sha’Ron James, noted at an October hearing on balance billing that her office has received complaints for years, mostly related to emergency room visits and pre-planned surgeries where someone on the medical team, such as an anesthesiologist, is out of the insurance network.
Balance billing is causing headaches for Americans with private health insurance, according to a national survey sponsored by the nonprofit Kaiser Family Foundation and released in January.
Kaiser’s survey found that one in five working-age, insured people reported trouble paying medical bills. A key theme: Insured patients owed much more than they expected because of medical care they inadvertently received from an out-of-network doctor or hospital.
25 percent of people in a Kaiser Family Foundation survey said they or someone in their household had problems paying medical bills in the past year
Scott Feldman of North Miami Beach is still trying to resolve a bill that he received from a physicians group after his visit to a local hospital emergency room in February 2014.
A small business owner, Feldman, 58, buys his own health insurance for about $900 a month. When he went to the emergency room at Jackson North Medical Center because of intense pain in his left shoulder, he said the admitting nurse told him that his Florida Blue plan was in network.
Feldman said he spent about nine hours at the hospital, where doctors performed a heart exam and took X-rays and other diagnostic images. A month later, he started to receive bills — first from the radiologist, then from the emergency physician, then from the hospital for his 10 percent co-payment.
He paid the co-payment of about $492, but refused to pay the radiologist’s bill for $192.87 or the emergency physician’s charge for $1,621.66.
Feldman said it’s not that he can’t pay the bills. It’s a matter of principle.
“The primary thing that bothered me,” he said, “was that I went in there with so much pain, and when they said I was in network, I didn’t have to worry about that anymore. All I had to deal with was my shoulder. When I got done, I found out they really didn’t have my back.
“They should have said to me, ‘The doctors we have on staff now for whatever reason will not be in network’, and then it would have been my choice to stay there or go elsewhere.”
To have the insurance company be given unilateral power … just makes no sense.
Dr. Jay Epstein, past president of Florida Society of Anesthesiologists
Under the legislation proposed by Garcia and Trujillo, hospitals and other medical facilities would be required to inform patients if they use out-of-network doctors and that those doctors may bill the patient separately.
The bill would prohibit out-of-network doctors and hospitals from billing patients — beyond what their insurance pays — for emergency room care, and for covered surgeries and other procedures at in-network facilities. And it provides additional methods for doctors, hospitals and insurers to negotiate payments without involving the patient.
Florida law prohibits balance billing — but only for members of a health maintenance organization, or HMO, and only for emergencies and covered services provided in an in-network facility. Trujillo said the bill he proposed would extend those protections to a new group of consumers — those who belong to preferred provider organizations or exclusive provider organizations.
“We need to protect the consumer,” he said.
Narrow network plans are the predominant types of coverage sold on the Affordable Care Act exchange for 2016 in Miami-Dade and Broward counties, including the lowest-cost standard plans.
Standing in the way of those protections, however, is a lot of money. According to a 2014 survey by the Florida Office of Insurance Regulation, insurance companies reported $97.9 million in potential balance billings associated with out-of-network emergency claims. An additional $1.3 billion in potential balance billings reportedly were associated with non-emergency claims.
Calling the consumer protections in Garcia and Trujillo’s proposal “the first of its kind in the country,” Brennaman of Florida CHAIN said the contentious issue for doctors, hospitals and insurers is resolving their payment disputes while leaving the patient out of it.
“That’s where the bill gets dicey,” she said. “But from a consumer advocate perspective, the consumer should be held harmless.”