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Round one of emergency care and billing tussle goes to insurers over docs

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It was the insurance industry versus the provider community when a House subcommittee took up a bill that prohibits balance billing for emergency services on Wednesday, with the insurance and HMO industry emerging the victor.

Over the objections of the Florida Medical Association, the Florida Hospital Association, the Florida Radiological Association and the Florida Chapter American College of Surgeons, the subcommittee passed a bill that would ban physicians from balance billing insured patients for emergency services and care.

Healthcare providers already are prohibited from balance billing for HMO patients.

As amended, HB 681 also changes current laws that outline HMOs must reimburse out-of-network physicians for rendering the emergency services to the greater of:

  • The Medicare allowable rate;
  • The usual and customary reimbursement received by a provider for the same service in the community where the service was provided; or
  • The amount negotiated with a provider who does not have a contract with the HMO for the service.

Currently HMOs are required to reimburse out-of-network providers who provide emergency care:

  • Provider charges
  • The usual and customary provider charges for similar services provided in the community;
  • The charge mutually agreed to by the health provider and HMO within 60 days of submittal of the claim.

The same reimbursement requirements are added to insurance statutes as well as Medicaid statutes to apply to Medicaid HMOs.

Insurance Consumer Advocate Steve Burgess testified that his office supports the balance billing ban for insured patients. Burgess works for Chief Financial Officer Jeff Atwater, who also supports the balance billing ban.

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