Know Your Rights When Your Healthcare Plan Fails to Pay for Medical Services Provided by Out-of-Network Physicians at In-Network Hospitals

by Latasha Gethers Hines | July 2019
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In Florida, typically a healthcare plan is responsible for paying for covered medical care and services provided to plan members when the patient receives services in a hospital even though the physician providing the services is not in the healthcare plan’s network. This article provides practical insight of Florida’s balanced billing law to help you challenge healthcare plans that fail to pay medical bills for services provided at their in-network hospital by an out-of-network physician.

Let’s explore a practical situation to help understand Florida’s law. A patient pre-registers at the hospital in her healthcare plan’s network to deliver her baby by cesarean birth. She pays the deductibles and co-payments for the delivery. On the day of the delivery, the patient experiences a complication. An out-of-network surgeon addresses the complication. The patient recovers well and leaves the hospital with a healthy baby.

Two months later, the patient receives an unexpected bill directly from the surgeon who addressed the complication after the baby’s delivery. The Explanation of Payment (also referred to as an Explanation of Benefits) the patient receives from her healthcare plan states that she is responsible for the full amount of the surgeon’s bill because the surgeon was not in the healthcare plan’s network. There is no dispute regarding the healthcare plan’s responsibility for the payment for the delivery of the baby.

Under Florida law, certain factors impact whether a healthcare provider that is not in a patient’s healthcare network can bill a patient for services provided at a hospital that is in the healthcare plan’s network. In many instances, Florida law protects patients from unexpected bills from out-of-network medical providers that provide services at in-network hospitals, commonly known as “balance billing,” by prohibiting the out-of-network physician from billing the patient. Where balanced billing is prohibited, the physician must dispute the lack of payment or the insufficient payment directly with the healthcare plan, not the patient.

Are the Services Covered by Your Healthcare Plan?

To identify who is responsible for the provider’s bill, the first step is to determine whether the medical care is a covered service under your healthcare plan. Your healthcare insurance documents describe the medical services the healthcare plan agrees to cover. Healthcare plan members may request their insurance documents from their healthcare plan. If you receive a medical service that is not covered by your healthcare plan, whether from an in-network provider or out-of-network provider, the healthcare provider may bill you for the full amount of the services, beyond deductibles and co-payments.

However, if the services provided by an out-of-network provider in an in-network hospital are covered by your healthcare plan, typically, the healthcare provider should not bill you, except for deductibles and co-payments.

Emergency Care Provided by an Out-of-Network Provider at an In-Network Hospital

If you are provided emergency medical services and care, your healthcare plan is liable for covered services whether the providers are in the healthcare plan’s network or not. In the scenario described above, if the complication during the delivery required emergency services and care, the healthcare plan must pay the out-of-network surgeon who provided the service. The surgeon must resolve the dispute regarding lack of payment or insufficient payment directly with the healthcare plan. This is often done through formal and informal appeals, pre-suit mediation, arbitration, or litigation. However, you should not ordinarily be held responsible for any payments other than co-payments and deductibles required by the terms of your healthcare policy.

Nonemergency Care Provided by an Out-of-Network Provider at an In-Network Hospital

If you are provided nonemergency services by an out-of-network physician while in an in-network hospital, there are instances where the out-of-network physician may be able to bill you directly for the full amount of the services provided. In the scenario above, if the complication addressed by the surgeon was non-emergent and the patient was given the opportunity to select an in-network surgeon to perform the procedure but opted to have surgeon on duty address the matter to avoid a future hospital stay, the surgeon may be able to seek full payment from the patient. The key is whether nonemergency services were provided and the patient had the option of selecting an in-network surgeon. If the patient was not given the option to select a participating surgeon, in a nonemergency situation, the healthcare plan is likely liable for the unexpected bill from the out-of-network surgeon.

What to Do if You Receive an Unexpected Bill from an Out-of-Network Provider.

Review your healthcare insurance documents.

Follow the healthcare plan’s appeals procedure and ask the plan to reconsider payment of the claim.

Contact the out-of-network physician and negotiate a lower price or a payment plan.