Wednesday, July 1, 2009

Out-of-Network Healthcare Provider Payment News

Florida Senate Bill 1122 takes effect today. The law amends Florida Statutes section 627.638 to require health insurers to make payment directly to hospitals, physicians, and other providers of treatment when the provider is not a member of the insurer's network. Previously, despite the patient's assignment of healthcare benefits to the provider upon admission, some insurance companies relied on language in the member's handbook requiring payment to be made to the patient rather than the provider. Under the new law, the provider should expect to be reimbursed by the plan directly, irrespective of the terms of the patient's member handbook. The Florida Medical Association has more information on this legislation and its benefit at

Also of note to healthcare providers, last week the Senate Commerce Committee issued a report for Chairman Rockefeller entitled Underpayments to Consumers by the Health Insurance Industry, detailing the pattern of inadequate payments by Managed Care Organizations for out-of-network treatment resulting from their improper method for calculating the usual and customary rate. We've blogged before about the insurers' use of Ingenix to unilaterally determine out of network provider reimbursement rates, and our law firm has been seeking reconsideration of underpayments on behalf of hospitals and physicians in State and Federal court for many years.

This report explains how underpayment for out-of-network care affects consumers. There is a definite benefit to patients in the ability to seek medical treatment from the provider of their choice, and according to the report insurance companies charge significant premiums for the patients' enjoyment of this benefit - roughly $1,700 per year for a Federal employee, for instance. But this benefit can only be enjoyed in full when the insurer reimburses the provider in accordance with the parties' intentions and with applicable law. According to statistics released by New York Attorney General Andrew Cuomo and cited by the Senate Committee report, health insurers' calculation of usual and customary rates results in payments equaling only 70% of the actual market rate, leaving the patient to pay the remainder, and thereby frustrating enjoyment of the benefit of choice paid for by the consumer. More on this issue as it relates to consumers can be read in this article at Health News Florida.

Attorney General Cuomo, the Senate Commerce Committee and the Florida Legislature are to be applauded by providers and patients alike for seeking to prevent future nonpayment or underpayment, but for the most part their legislative efforts do not address the issue of prior wrongs. Providers should be encouraged to seek independent analysis of the reimbursement rates received for out-of-network services and to seek appropriate and adequate compensation on all claims through available legal remedies.

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