March 14, 2016
Florida Legislature Sends Governor Out-of-Network Payments Legislation
On March 11, the Florida Legislature approved legislation (S1442 / H221) requiring new payment processes for out-of-network providers of emergency and nonemergency services. The legislation was strongly opposed by the Florida Society of Anesthesiologists and a number of stakeholders including the Florida Radiological Society. Once Florida Governor Rick Scott (R) receives the bill, he has 15 days to sign or veto the measure.
Most importantly, the measure would detail new processes for payment to providers of emergency and nonemergency services when the provider is not a preferred provider at a facility that is in network. Specifically, the bill requires that an insurer pay a nonparticipating provider (such as a physician anesthesiologist) of such services, as follows, reduced only by insured cost-share responsibilities as specified in the health insurance policy and within the applicable provided timeframe:
Reimbursement for services shall be the lesser of:
- The provider's charges;
- The usual and customary provider charges for similar services in the community where the services were provided (which is not defined in law and will be determined only if contested which involves a financial burden on the provider); or
- The charge mutually agreed to by the insurer and the provider within 60 days of the submittal of the claim.
This legislation is very concerning as it removes any patient responsibility whatsoever, even in nonemergent settings, and places insurers in the position of independently dictating payment for emergency and nonemergency health services. Under this legislation, providers are at the whim of insurers’ determination on usual and customary charges as no independent benchmarking system is provided within the language.
FSA and other stakeholders are strongly encouraging Governor Scott to veto this ill-considered measure.
Recognizing the evolving impact out-of-network payment has on the advocacy and public relations efforts of state component societies, the Executive Committee (EC) approved an Ad Hoc Committee on Out-of-Network Payment (AHCONP), chaired by Sherif Zaafran, M.D. Internally, AHCONP is initially focusing efforts on developing public relations, legislative strategy, and payment benchmarking resources. Externally, AHCONP is leading efforts to ensure medical specialty organizations are working together on these issues. AMA recently held a CEO in-person meeting on this subject and discussions are underway for an in-person meeting of the physician leaders and applicable staff of the medical specialties in May.
Should you have any questions or are in need of assistance with current or pending out-of-network payment legislation in your state, please contact Director of State Affairs Jason Hansen at firstname.lastname@example.org.