Florida health care providers and insurers will use the state’s own dispute resolution process for out-of-network billing instead of the controversial methodology required by the federal No Surprises Act.
About 30 states, including Florida, already had their own balance billing laws when the new federal balance billing ban was enacted. The Centers for Medicare and Medicaid Services is currently determining whether these state laws can replace the No Surprises Act when it comes to matters such as resolving payment disputes.
agency this week revealed his conclusion that Florida’s methodology will determine the resolution of payments in most situations. That’s in addition to the dozen or so other states that have so-called “state-specific laws,” meaning their own laws will replace at least some aspects of the federal balance billing law.
This is good news for health care providers in Florida because the state’s dispute resolution process is much friendlier than the federal one, which depends on median rates for services in the health plan network if providers and insurers cannot reach an agreement. Hospital lobby groups and doctors are suing to block part of the law they say unfairly favors insurers.
In Florida, insurers must reimburse out-of-network emergency providers for the lesser of the provider’s fees, the normal and customary fee for a similar service in that area, or a mutually agreed fee. This typically results in higher reimbursement than under federal regulations, said Jack Hodley, research professor emeritus at Georgetown University’s Center for Health Insurance Reform.
“Regular and common are still based on provider fees,” he said. “It’s not based on the amount paid by the insurer, and so it’s likely to be more beneficial for providers than if they were operating under the federal system.”
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According to Becky Greenfield, a partner at Florida law firm Wolfe Pincavage, what really is “customary and customary” is often decided by a judge or jury when disputes reach court. She said she believes it is preferable to a federal dispute resolution process that relies on arbitrators and does not allow courts to review their decisions.
“This may take a little longer, but we believe this is the most honest way to get the right answer and fairly reimburse suppliers,” Greenfield said.
Florida offers a voluntary arbitration program for providers and insurers, but it appears to be rarely used. He appreciated 68 claims disputes in 2020. The claims pending ranged from US$1,256 to US$669,019.
Florida providers and payers will use the federal dispute resolution process when it comes to services provided to members of health care organizations for claims that are below certain thresholds, such as $10,000 for inpatient hospital claims with non-contracted providers . All states, including Florida, will use the federal process for air ambulance services, which states cannot regulate.
Not all “certain government laws” work in favor of providers. In California and Maryland, out-of-network payments are based on a percentage of Medicare that is often below the normal and generally accepted rate, Hodley said. In Texas, the methodology is similar to Florida in that the resolution of disputes depends on billing and regular and regular rates.
“In Texas, we are finding that the decisions being made are way above network rates,” Hodley said. “It’s a different mechanism than in Florida, but it has a similar end result.”
According to Hodley’s reading, seven more states have laws in place that are potentially “state-specific laws”, although the CMS has yet to release findings. These are the states of Colorado, Illinois, New Jersey, New York, Nevada, Ohio and Arizona.
It’s important to remember, Hodley said, that whether dispute resolution complies with state or federal laws, patients will receive the same protections under the No Surprises Act.
“Consumers will pay on-chain anyway,” he said, “but from a supplier and payer perspective, it matters.”