Florida suppliers, insurers won’t use federal accident bill resolution process

Florida health care providers and insurers will use the state’s own out-of-network billing dispute resolution process, rather than the controversial method in the federal No Accidents Act.

When the new federal balance billing ban passed, about 30 states, including Florida, had enacted their own laws to govern balance billing. The Centers for Medicare and Medicaid Services is now determining whether these state laws can supersede the No Surprise Act when it comes to issues such as payment dispute resolution.

This week, the agency disclose its findings The Florida approach will determine payment solutions in most cases. This comes after about a dozen other states were found to have so-called “state-specific laws,” meaning their own laws would supersede at least some aspects of federal balance billing laws.

This is good news for health care providers in Florida, because the state’s dispute resolution process is much friendlier to them than the federal one, which will follow the health plan’s if providers and insurers can’t reach an agreement. Median rate for web services.Hospital and doctor lobby groups are Sue to block that part of the law, which they say unfairly benefits insurers.

In Florida, insurance companies must reimburse out-of-network emergency service providers to the lesser of the provider’s fee, the usual and customary charges for similar services in the area, or a mutually agreed upon fee. That often results in higher reimbursement than federal regulations, said Jack Hodley, a research professor emeritus at Georgetown University’s Center for Health Insurance Reform.

“Usually and customary is still based on what the provider charges,” he said. “It’s not based on the amount paid by the insurer, which is why it’s probably more beneficial to the provider than if they were operating under the federal system.”

What’s really “usual and customary” is usually decided in court by a judge or jury, said Becky Greenfield, a partner at the Florida-based law firm Wolfe Pincavage. She said she believes it is preferable to the federal dispute resolution process, which relies on arbitrators and does not allow courts to review their decisions.

“It may take longer, but we believe this is the fairest way to get the right answer and reimburse providers fairly,” Greenfield said.

Florida offers a voluntary arbitration program for suppliers and insurance companies, but it appears to be rarely used.it evaluates 68 claims disputes in 2020. The related claims ranged from $1,256 to $669,019.

Providers and payers in Florida will use federal dispute resolution procedures to process claims for services to health maintenance organization members below a certain threshold, such as a $10,000 inpatient claim from a non-contracted provider. All states, including Florida, will use federal procedures for air ambulance services that cannot be regulated by those states.

Not all “specific state laws” are in the provider’s favor. In California and Maryland, out-of-network payments are based on a percentage of Medicare, which is generally lower than usual and customary rates, Hodley said. In Texas, the approach is similar to that in Florida in that dispute resolution relies on billing fees and usual and customary rates.

“What we found in Texas is that these decisions are much higher than network rates,” Hodley said. “It’s a different mechanism than Florida, but the end result is similar.”

According to Hodley’s interpretation, the laws of another seven states could constitute “specific state laws,” although CMS has yet to release its findings. These states are Colorado, Illinois, New Jersey, New York, Nevada, Ohio and Arizona.

It’s important to remember that patients will have the same protections under the No Accidents Act regardless of whether dispute resolution follows state or federal law, Hodley said.

“Consumers pay for in-network cost-sharing anyway,” he said, “but from a provider and payer perspective, it does matter.”

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