The Problem of Balance Billing: “I’m dying! But don’t touch me if you’re not in my insurance network.”

Effective today, July 1, 2016, a brand new law goes into effect which will finally protect Florida’s citizens from getting surprised by unfair medical bills.  This law helps eliminate the problem of “balance billing,” which sticks an unsuspecting individual with the total cost of medical services even though the individual thought he was covered under his health insurance.  This means that bill, which can be in the thousands of dollars, is now the responsibility of the individual because the insurance company refuses to pay.

How does this happen?  In most cases, these unfair medical bills have occurred when the person goes to a hospital’s Emergency Room and the person receives services from a medical professional that is not within the insurance company’s approved provider network.  This occurs because the ambulance has a protocol to take a person to a specific hospital and this specific hospital is out-of-network.  Or, it occurs because a person simply needs to get to the closest possible Emergency Room on his own and the person receives treatment from an ER doctor not within the network.  In either example, the person receives medical services from someone who is NOT within the insurance company’s approved network of medical providers.  And, if there’s no coverage, then the huge bill must now be paid from the person’s own pocket.

Unfortunately the law is a little too late for me and I’m a victim of what this law will prevent going forward.  Here’s how it happened to me.  On an early Saturday morning, having just woken up, my kitten snuggles her head under my chin.  Without any warning, my kitten smacks me in the face, her razor-sharp claws tearing into my right eye.  When I tried to open my eye, all I could see was a cloud of colors.  My husband rushes me to the nearest hospital Emergency Room.  Our family insurance coverage was the best that could be bought at the time and I knew the hospital was in our insurance provider network.  Unfortunately, I would never have thought, nor was I thinking about anything other than losing my sight, to check to make sure the ER doctor was within my insurance company’s approved provider network.  I found out the hard way that the ER doctor was not within my network (even though the hospital was).  And, rather than having a co-pay of $25, I got stuck with a $1900 bill.  I argued with the insurance company that it was unreasonable to believe I had any choice in the matter.  My insurance company disagreed.

The solution to this problem of “balance billing” is found in a brand new law at Florida Statute 627.64194.  This law requires the insurance company, not you, to pay the out-of-network medical professional in the same manner as a medical professional within your network would be paid under your plan.  Consequently, if you receive medical services from an out-of-network provider (a hospital or the ER doctor) and it is through no choice of your own, you should receive the same coverage as if the provider was covered under your health insurance plan.  Under this new law, no longer will you have to check the treating doctor’s name against your provider network as you wait in the emergency room.

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