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Florida Providers’ Surprise to the No Surprises Act

Updated: Jul 1

On January 1, 2022, Provider Business Offices across the country scrambled to adapt to the enactment of the No Surprises Act. Primarily aimed to benefit patients, the No Surprises Act protects individuals from “surprise” bills for emergency services from out-of-network providers without prior authorization; out-of-network cost sharing on emergency (and some nonemergency) services; and out-of-network charges and balance bills for supplemental care, like laboratory services and anesthesiology, by out-of-network providers that work at an in-network facility. While the Act invariably eases the mind of healthcare consumers, out-of-network providers were left with one major question: “Who is going to pay for this?”


Pursuant to the No Surprises Act, Providers are forbidden from balance billing patients enrolled in group health plans or individual health insurance coverage. Instead, Providers disputing denials and/or underpayments for their out-of-network services are to initiate a federal independent dispute resolution (“IDR”) process with the patient’s health plan to pay for its claim.


The IDR proceedings are governed by a “baseball-style” arbitration process, in which the Provider and the plan present competing arguments as to the compensable value of the Provider’s services based upon the “qualifying payment amount” (“QPA”), and the arbitrator decides which party’s calculations apply.  While the QPA is determined by a variety of factors, many of which are currently being challenged in federal court, it is generally assumed that the QPA reimbursement rate is the median contracted rate for the same or similar item or service.


Unbeknownst to many Florida Providers, the federal No Surprises Act would have little effect on their existing billing procedures. Shortly before the federal bill was enacted, the Center for Medicare & Medicaid Services affirmed Florida’s pre-existing laws for nonparticipating provider reimbursement.


In 2016, the Florida Legislature enacted its own statutes prohibiting out-of-network Providers from balance billing patients enrolled in health maintenance organizations and set standards for determining the proper reimbursement on disputed claims arising from circumstances the No Surprises Act set forth. According to Florida Law, an insurer is solely liable to reimburse a nonparticipating Provider of covered nonemergency services provided to an insured.


Further, the Florida out-of-network reimbursement for these items and services are based upon the following factors weighed by the factfinder: the provider’s charges; the usual and customary provider charges for similar services in the community where the services were provided; or the Medicaid rate.


Finally, although the independent dispute resolution process is a large component of the No Surprises Act, existing case law in Florida allow for insurers, and the dispute resolution servicers themselves, to decline participation in the dispute resolution process altogether, thus leaving nonparticipating Providers no recourse but to file suit in their local jurisdiction.


While it is reassuring that Florida was on the cutting edge of healthcare reform, its Providers may still feel overwhelmed with the everchanging landscape of the industry and their ability to obtain the statutorily protected reimbursement rate for services that may no longer be balance billed to patients.


For more information on how Abril Law can assist your Facility or Practice obtain maximum reimbursement for your medically necessary services, contact us today.


This article is featured in the South Florida Hospital News July 2024 edition.

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