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What Providers Need to Know Before They Balance Bill

A very important topic that can get providers into hot water if they do not take the time to understand the requirements of their managed care contracts and Florida law.

Florida Healthcare Law Firm Blog

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By: Karina Gonzalez

Balance billing occurs when a provider collects from a patient the difference between the amount billed for a covered service and the amount  paid for that service.  Balance billing does not apply when collecting deductibles, copayments or coinsurance.

Under Florida law, a provider may not balance bill a patient for any service, if an HMO is liable and responsible for payment.  Contrary to what many people believe, this is true whether you are in-network or out-of-network.  Even hospital based out-of-network physicians, such as anesthesiologists, pathologists, radiologists or emergency room physicians cannot balance bill HMO members where the hospital has a contract with the HMO or there was authorization given for an episode of care.

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  1. SM
    December 15, 2014 at 1:13 pm

    In Florida if a person has a commercial health insurance plan (ex: Humana PPO or Cigna HMO) as their primary insurance and that insurance does not pay in full, (leaving a dedcuctible, copay or coinsurance) and the member has a contracted Medicaid HMO plan as 2ndary, can the provider balance bill the member if the Medicaid plan does not pay because the contracted code billed to the primary insurance is not the same as the contracted code for the Medicaid? Ex: Humana PPO contracted billed code is 99213 and the contracted code for the Medicaid HMO plan is S9083. The Medicaid plan won’t pay because 99213 on the primary EOB and claim is not a payable code.

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