New Florida Law Protects Residents from Surprise Medical Bills

By Sandy Ahn, Jack Hoadley and Sabrina Corlette

Florida has become the latest state to enact legislation protecting consumers from unexpected medical bills, often referred to as surprise balance bills. As we found in a report and blog funded by the Robert Wood Johnson Foundation, approximately one-fourth of all states have enacted laws that attempt to protect consumers from surprise bills. However, these states have varying approaches to protecting consumers, with varying degrees of effectiveness. For some states, the protection is limited to reasonable advance notice for the consumer that they might receive services from an out-of-network physician while they are at an in-network facility. In other states, such as Colorado, the protection is stronger and requires health plans to hold the consumer harmless, meaning that the health plan is responsible for paying the surprise bill, no matter how high the charge. In other states, protections from surprise balance bills are only available to people enrolled in certain types of plans. For example, until recently, Florida’s law only protected consumers enrolled in health maintenance organizations (HMOs).

What is surprise balance billing?

Surprise bills can occur when a patient is unaware that they are receiving treatment from a medical provider that is not covered under his or her health insurance plan (i.e., out-of-network). This may happen during a medical emergency, but it can also happen when patients go to in-network hospitals thinking that all the medical providers there are also in-network or covered under their health plan. However, many practitioners who provide services to patients at in-network hospitals—such as anesthesiologists, pathologists or emergency room physicians—may not be part of the health plan’s network, even though the hospital is in-network.

What does Florida’s new law do?

Florida’s bipartisan legislation protects consumers from unexpected medical bills (HB 221). The legislation only happened because stakeholders and regulators agreed to work together and compromise. In October 2015, the Florida Office of the Insurance Consumer Advocate held a public forum to receive public and stakeholder input about how best to address the issue of unexpected medical bills. Georgetown’s own Jack Hoadley presented the findings of our report. With this recent legislation, Florida joins New York and Texas as states that use a combination of policy approaches – such as advance notice, greater transparency, and an independent process to resolve disputes between payers and providers.

Florida’s new law prohibits surprise billing in emergency situations for all types of products, including preferred provider organizations (PPOs) and exclusive provider organization (EPOs). In addition, the new law protects consumers when they are at in-network hospitals for non-emergency services, but are unknowingly treated by out-of-network physicians for covered services. The law requires that insurers “are solely liable for the payment of fees” minus any applicable cost-sharing amounts and prohibits out-of-network practitioners from balance billing. It also requires increased transparency and notice to consumers about the possibility of being treated by an out-of-network practitioner. Hospitals must post on their websites the health plans with whom they are in-network, and put consumers on notice that patients may be seen by out-of-network practitioners.

Florida’s new law further strengthens the dispute resolution process for health plans and medical providers to resolve payment issues. It encourages non-participating providers to charge, and health plans to offer, reasonable amounts prior to invoking the dispute resolution process. If the dispute resolution process is initiated, the law requires the dispute resolution organization to be transparent and publish the evidence or data the organization used to make its findings.

Publicity over unexpected medical bills and consumer complaints can land the issue of surprise bills squarely on the political agenda, as it recently did in Florida. While it is often very challenging for policymakers to balance the competing interests of payers, providers, and consumers, in this case, key stakeholders came together with a legislative solution. Time will tell whether the new requirements will meaningfully protect consumers from surprise balance bills.


17 thoughts on “New Florida Law Protects Residents from Surprise Medical Bills

  1. Pingback: NAIC Roundup: Catching Up on the Spring Meeting and Looking Ahead - Center on Health Insurance Reforms

  2. Where do I go to get help with an ER balance bill? My insurance says I am covered in or out of network for only a $100.00 co-pay.
    While out of town my husband went to ER for kidney stones – we got a bill for $4,988.33. Insurance says tell them they are not allowed to balance bill, hospital says insurance can not tell them what to bill so now we owe it. HELP!!

  3. We retired in March 2017 my husband had a heart attack in July went to emergency room and died. his insurance will not pay as when he left work he took out a policy which was only in effect for 4 months. the ER hospital bill just came in the mail in his name for 28,000.00 plus I did not sign anything at the hospital as they took him in a ambulance when I got to the hospital he had died. We live in the state of Florida am I responsible for this charge?

    • First let me say I am sorry for your loss. You can not be held responsible for your husband’s medical bills. Although my personal feelings are and I state only my personal feelings. You did call the ambulance to bring your husband to the Hospital for help. I feel that the people that did help him should be entitled to some form of payment of course what the bill is and what they should get are 2 different things. $28000 you can divide that by a bit shouldn’t be paying more than $3500.00 however this is how Hospital and doctors stay in business. If everyone thought they shouldn’t be responsible then there wouldn’t be any help to give. I personally would try and do what I can to pay but definitely not the whole $28000.00 that is just monkey wash.

  4. I am having the same issue. My husband saw a Dr in the Emergency Rm and the ER was covered because it was in network but the Dr was out of network. Now they are sending me a bill for $1,793.00. I have went rounds with the telling me that they can not balance bill me due to HB 221 and they are telling me that there is no such thing and that I have to dispute it with my insurance company. My insurance company is the one who told me about the HB 221 bill. They refuse to write off what they should everything except $178.31. This is ridiculous!!! Any Help would be appreciated.

  5. I am on Medicare and qualify for Florida’s ‘Medically Needy’ Medicaid program which has a high “Share of Costs”, meaning my 20% that Medicare doesn’t pay has to be over a certain amount every month before the excess – if any – is covered…..much like catastrophic protection under a secondary insurance plan – however it is now the middle of December 2017 and Medicaid is just now getting around to paying for services from April and May 2017. It is clear the program does not operate as it should other than to sound good in theory and the program has been structured to create a nightmare for patients… I’m getting turned into collections from hospitals and doctors for the same amount that Medicaid is responsible to pay them – in essence trying to collect TWICE from both me AND Medicaid. The Florida healthcare system is seriously broken, hopefully the legislature will fix this, but I’m afraid Florida is a VERY consumer UNfriendly state to live in, especially for senior citizens like myself.

    Whats worse, once you are involved in an automobile accident, many doctors and hospitals immediately abandon your care even on non-accident issues !

    I’ve also run into a doctor who refused to see me to monitor medication for an infection I was being treated for unless I prepaid my Medicare 20% prior to even MAKING the appointment for the follow through…he was about 15 miles away and they expected me to drive there not feeling well just to SET the appointment..obviously I changed doctors even though the Dr who prescribed the antibiotics was legally responsible to supervise my treatment he prescribed.

    It was similar to the heart surgeons who canceled my heart surgery just days prior to the surgery because I didn’t have the $1,750 in cash that the Medicaid Share of Costs program was to cover they demanded I advance them promising they would pay it back to me once they received it.

    Do legislators and regulators know this is going on ? Do they care ?

    Money first, patient well being second. Disheartening.

    • In a case where the doctor is requiring you to pay the 20% up front you first call Medicare and let them know this. Then you pick up the phone or go into your local Medicaid office and let them know that they are asking you for money. You may not ask for money when you are Medicare/Medicaid until Medicaid responds to them stating they will not pay.
      It is disturbing that patient’s on the share of cost program must stub a toe (I know many) and go to the ER in order for their share of cost to be met every month.

  6. I had back surgery Dec 5, 2017. The neurosurgeon used a “neuromonitoring physician” as a guide when he is getting too close to the spinal cord. I was not aware that this physician was out of network. I have a very good “no deductible” plan through the hospital that I work for but as you can guess, I was balance billed $407.94 which was applied to my out of net deductible. When I rcv’d the first bill from the provider’s billing office I called to find out why I was getting a bill. I was told that they would appeal and that it may take a few months but usually the insurance will reconsider or negotiate an amount with my insurance to pay them or adjust it off. I was assured that I would not owe this amount.

    I called my insurance today and was told that there are no records showing that the provider’s billing office even attempted to contact or appeal. At this point I am past timely for appealing this myself but the provider’s billing office can still appeal.

    What other recourse do I have if they persist in wanting me to pay this bill? Our billing office never does this to our patients. We would adjust it off.

    Thank you for your time.

  7. I was in a car accident in 2018 to where the other driver was at fault I did not have medical insurance so the the hospital reduced my fees but at the time of me settling with the other party’s insurance company which they sent my check to the hospital now the hospital is stating that the original amount has to be paid that they build not the reduced amount can they change the amount that they provided to me when I originally didn’t have insurance

  8. I recieved a bill from a physician’s office one year and four months since I was seen. Am I still responsible for the bill. There was never a bill sent to me. I was told by the office that they only billed the Insurance company, but never contacted me.

  9. I received services from Elite Imaging – Miami Beach in June, 2018 and during the first week of January, 2020 (18+ months later) I received an invoice from this company stating that I owe them $300. and are requesting immediate payment. There is no description or reason for this invoice and I would appreciate being informed if I have any obligation to pay this invoice since there is no explanation for this balance . Thank you

  10. My son who has Crohn’s Disease went to the ER and told them he has Cigna. After several tests he had to go for an emergency surgery which was Thanksgiving morning. Nurse called a doctor and finally had six inches of his intestines removed. Months later received a surprised bill of $75,000 which Cigna declined to pay. This year he has Blue Cross/Blue Shied as his employer switched to another insurance company. Does this fall under the Florida law.

    • Sorry to hear about your son! I hope he is feeling better. Whether or not he is entitled to balance billing protections under Florida law could depend on the type of insurance he has through his employer. Some employer-based coverage is not regulated by the state, it is regulated by the federal government through the U.S. Department of Labor. Either way, your son should contact his employer’s HR department and ask if they can help resolve this billing issue. If the plan is a state-regulated one, he could also try contacting the Florida Insurance Consumer Advocate, available at 1-877-MY-FL-CFO. Website is: Best of luck!

  11. I had the memorial healthcare plan and they deny paying any of my medical bills even though I had plans for the past 4 years and now I’m stuck with collections medical bills which destroyed my credit file what can I do say surprise me cuz when I got the plan they told me that I was covered to go to the hospital for emergency visit and if any doctor needed to do further they would cover that as well so they surprised me and I found out that they do not cover everything matter fact they haven’t covered any of my bills Memorial healthcare plan I now and I’m trying to get them to pay my medical bills free from 3 months prior to me beingdisable

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