Florida Governor Signs Out-of-Network Payments Legislation

On April 14, Florida Gov. Rick Scott (R) signed into law legislation (Chapter No. 2016-222) 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 (FSA) and a number of stakeholders including the Florida Radiological Society, and only received final Senate passage in the waning hours of the last day of the session. The legislation is effective July 1, 2016.

Most importantly, the measure details 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 new law 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 new law 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 law, providers are at the whim of insurers’ determination on usual and customary charges as no independent benchmarking system is provided within the language.

FSA, ASA, and other stakeholders strongly encouraged 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. The American Medical Association (AMA) recently held a CEO in-person meeting on this subject.  An in-person meeting, hosted by ASA and the American College of Emergency Physicians, of the physician leaders and applicable staff of the medical specialties will take place 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 [email protected].