Balance billing in Florida refers to the practice where a healthcare provider bills a patient for the difference between the provider’s charge and what the insurance covers.
Who Does Balance Billing Affect in Florida?
Balance billing mainly affects the following in Florida:
Out-of-network patients receiving emergency or non-emergency services. These patients are often unaware that a provider isn’t in-network, especially in hospital settings.
Individuals with PPO, EPO, or other commercial insurance plans. These patients are often unaware that a provider isn’t in-network, especially in hospital settings.
Uninsured patients receiving non-contracted care. These patients are often unaware that a provider isn’t in-network, especially in hospital settings.
Travelers receiving treatment outside their home insurer’s network. They may unknowingly visit non-network facilities or doctors, triggering higher out-of-pocket costs.
Florida has enacted specific consumer protection laws to limit this practice.
Is Balance Billing Legal in Florida?
Balance billing is illegal in Florida for many emergency and non-emergency situations involving out-of-network care at in-network facilities.
What Does Florida Law Prohibit?
Florida Statute $627.64194 prohibits balance billing in:
| Type of Care | Billing Status | Allowed Balance Billing? |
|---|---|---|
| Emergency Services | Out-of-Network | Not Allowed |
| Non-Emergency (HMO) | Out-of-Network | Not Allowed |
| Non-Emergency (PPO/EPO) | In-Network | May Be Allowed |
| Elective/Planned Out-of-Network | Yes | Allowed If Disclosed |
The law applies to both Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs).
What Is the Florida Balance Billing Protection Act?
The Florida Balance Billing Protection Act protects patients from unexpected medical costs tied to out-of-network care in emergency or certain non-emergency situations. It ensures that patients are not financially penalized due to limited control over provider networks during treatment.
The Act safeguards patients by:
Banning surprise medical bills for emergency services from out-of-network providers. Patients who receive emergency care at any hospital cannot be charged beyond their standard in-network cost-sharing.
Requiring insurers to cover emergency services as if they were in-network. Health plans must process out-of-network emergency claims under the same terms as in-network care, regardless of provider contracts.
Prohibiting out-of-network providers from billing the patient above in-network rates. Providers must accept the insurer’s in-network reimbursement and cannot seek the remaining balance from the patient directly.
This law applies specifically to state-regulated health insurance plans, including most HMOs and some PPOs.
When Did It Take Effect?
The law took effect July 1, 2016, and applies to both individual and group insurance policies regulated by the state.
How Does the Federal No Surprises Act Impact Florida?
The No Surprises Act (NSA), effective January 1, 2022, reinforces Florida’s rules at the federal level.
What Does the No Surprises Act Cover?
The federal protections extend beyond emergency care and include several common billing risk points:
Patients can no longer be balance billed for emergency care, even if the hospital or provider is not contracted with their insurance.
The law prohibits surprise bills from air ambulances, which often operate outside of insurer networks and have historically caused large medical debts.
Patients receiving care from out-of-network anesthesiologists, radiologists, pathologists, or assistant surgeons during an in-network hospital visit are protected from extra charges.
These protections apply whether the care is urgent, unplanned, or unknowingly provided by an out-of-network professional at an in-network location.
Who Enforces It?
Enforcement depends on the type of insurance plan:
| Plan Type | Enforcement Authority |
|---|---|
| Self-funded employer plans | U.S. Department of Health and Human Services (HHS) |
| Fully insured individual/group plans | Florida Office of Insurance Regulation (FLOIR) |
| Providers violating NSA rules | U.S. Department of Labor & HHS |
Patients can file complaints through the federal No Surprises Help Desk or Florida’s Division of Consumer Services, depending on their plan type.
How Does It Complement Florida Law?
The NSA fills critical regulatory gaps:
- Extends protections to employer self-funded plans, which are not subject to Florida’s 2016 law
- Covers air ambulance charges, which Florida’s law did not address
- Standardizes disclosure and consent requirements for elective out-of-network services
- Aligns provider payment dispute resolution under a federal arbitration process
Together, federal and state laws offer comprehensive safeguards for most patients against balance billing in Florida.
Can Florida Doctors Still Balance Bill Under Any Circumstances?
Yes, doctors in Florida can still balance bill in specific scenarios.
- One situation is when a patient knowingly chooses an out-of-network provider after being clearly informed of the costs.
- Another case involves services that are not covered by the patient’s insurance plan, such as certain elective or cosmetic procedures.
- Balance billing is also permitted for non-emergency services at out-of-network facilities when the patient gives documented consent in advance.
- Additionally, uninsured or self-pay patients may receive a balance bill if they’re given a Good Faith Estimate prior to care. In all instances, providers are required to obtain and retain written consent from the patient.
What Should You Do If You Receive a Balance Bill in Florida?
If you receive a balance bill in Florida, first review your Explanation of Benefits (EOB) to confirm what your insurer paid and whether the provider is out-of-network. Then, contact your insurance company to verify if the charge was processed correctly. If the bill appears to violate protections, dispute it in writing with the provider. For further support, file a complaint with Florida’s Department of Financial Services. If your bill exceeds $500 and qualifies under Florida’s mediation law, request formal mediation. It’s essential to keep all communication documented and request a full, itemized bill that shows the charges and service dates.
How Can Florida Patients Avoid Balance Billing?
To avoid balance billing in Florida, confirm whether all providers and facilities involved in your care are within your insurance network before treatment begins. If you’re uninsured or plan to self-pay, ask for a Good Faith Estimate. For planned procedures, inquire if any part of the treatment involves out-of-network providers, such as radiologists or anesthesiologists. When seeking care for non-emergencies, use in-network urgent care clinics instead of emergency rooms. Constantly review and understand consent forms, as they may disclose balance billing terms. These steps reduce the risk of unexpected medical charges and protect against financial exposure.
Which Entities in Florida Regulate Balance Billing?
Entities that regulate balance billing in Florida are listed in the table below:
| Entity | Role |
|---|---|
| Florida Office of Insurance Regulation | Oversees insurer compliance |
| Florida Department of Financial Services | Handles consumer complaints and mediation |
| Centers for Medicare & Medicaid Services | Enforces federal protections under NSA |
| Florida Board of Medicine | Enforces billing ethics for physicians |
Each body handles distinct aspects depending on the insurance plan type and provider.
Are There Exceptions for Air Ambulances and Specialty Services?
Yes, air ambulance services and some specialties still present balance billing risks. Most air ambulance companies operate independently of hospitals and are often not contracted with insurance providers. While the No Surprises Act prohibits balance billing for most air ambulance transports, ground ambulance services are typically not covered under either state or federal protections. Additionally, certain specialties, such as anesthesiology, pathology, and radiology, can result in surprise bills even when the primary provider is in-network. Patients should verify which emergency transport services are in-network and review any policy limitations before care is delivered.
What Is the Penalty for Violating Balance Billing Laws in Florida?
Violating balance billing laws in Florida can result in severe consequences for both providers and insurers. These may include monetary fines, forced refunds to affected patients, and disciplinary actions by licensing boards. In some cases, providers may lose their in-network contracts with insurers. Enforcement actions are carried out by state and federal agencies, depending on the type of violation. Providers who fail to comply with the balance billing protections under the No Surprises Act or state laws are subject to investigation, and repeat violations can result in increased penalties.
How Many People Are Affected by Balance Billing in Florida?
Data shows that balance billing has affected a large number of patients in Florida. In 2020, 22% of emergency room visits in the state involved out-of-network providers, according to the Kaiser Family Foundation. Among surprise medical bills, over 30% involved specialists, such as anesthesiologists, radiologists, and pathologists. After the implementation of Florida’s balance billing law, consumer complaints decreased by 43%, based on Florida Office of Insurance Regulation data. This suggests that legislative and enforcement efforts have significantly lowered the frequency of surprise billing incidents across the state.
What Rights Do You Have as a Patient in Florida?
Patients in Florida have the right to receive advance notice if a provider is out-of-network. For non-emergency services, they’re entitled to a Good Faith Estimate if they’re uninsured or paying out of pocket. Patients can dispute unfair bills through the Florida Department of Financial Services and request mediation for eligible disputes. Emergency care must be provided without discrimination based on network billing. Patients also have the right to file formal complaints to challenge billing practices and seek resolution through state regulatory bodies.
