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services that are covered by the HMO, and the physician is neither authorized by the HMO nor referred by the HMO, the physician may bill the patient directly for all charges. 2. If an HMO patient, in a non-emergency situation, knowingly goes out of network to a non-contracted physician for services that are not covered by the HMO, and the physician is neither authorized by the HMO nor referred by the HMO, the physician may bill the patient directly for all charges.3. If an HMO, in a non-emergency situation, denies authorization for a service on the grounds that it is not medically necessary, then the treatment is not considered a “covered service,” and a contracted or non-contracted physician may bill the patient directly for all charges. 4. If an HMO, in a non-emergency situation, denies authorization for a service on the grounds that it is not a covered service, a contracted or non-contracted physician may bill the patient directly for all charges. 5. If a non-contracted physician does not seek authorization from the HMO for a service, and is not authorized or referred by the HMO, the physician may bill the patient for all charges. 6. If a non-contracted physician contacts the HMO and receives authorization for a covered service for an eligible subscriber the physician may not bill the patient and must accept whatever the HMO pays the physician as payment in full (minus any applicable co-payment).The law further states, in subsection (4), that a provider or any representative of a provider, regardless of whether the provider is under contract with the HMO, may not collect or attempt to collect money from, maintain any action at law against, or report to a credit agency a subscriber of an organization for payment of services for which the organization is liable, if the provider in good faith knows or should know that the organization is liable. This prohibition also applies during the pendency of any claim for payment made by the provider to the organization for payment of the services and any legal proceedings or dispute resolution process to determine whether the organization is liable for the services if the provider is informed that such proceedings are taking place. THE BALANCE BILLING AND PREFERRED PROVIDER ORGANIZATIONS Prior to 2016, the laws that regulated balance billing with regard to enrollees of health maintenance organizations (HMOs) did not apply to preferred provider organizations (PPOs) or exclusive provider organizations (EPOs). The basic rule in section 641.3154, Florida Statutes - If an HMO is liable for services rendered to a subscriber by a provider, regardless of whether a contract exists between the organization and the provider, the organization is liable for payment of fees to the provider and the subscriber is not liable for payment of fees to the provider – applied only in the HMO context. Physicians who did not participate in their patient’s PPO or EPO were free to balance bill the patient when the insurance company did not pay the physician’s full charge. After a multi-year effort by consumer groups, insurance companies, the state consumer advocate’s office, and a number of legislative leaders, the Florida legislature passed HB 221, which the Governor signed into law on April 14, 2016. This legislation, which goes into effect on July 1, 2016, provides that the PPO/EPO patient’s insurance company is solely liable for paying a nonparticipating physician’s fees (the patient can only be billed for applicable copayments, coinsurance, and deductibles) under the following circumstances: a. For the provision of covered emergency services provided to an insured in accordance with the coverage terms of the health insurance policy; and b. For the provision of covered nonemergency services provided in a facility that has a contract with the PPO/EPO and provided when the insured does not have the ability and opportunity to choose a participating provider at the facility who is available to treat the insured. In these two instances, the patient is only responsible for paying any applicable copayment, coinsurance, or deductible. The insurance company is responsible for paying the full amount otherwise due the physician, and must pay for services as specified in section 641.513(5). This statute provides that reimbursement for services shall be the lesser of: (a) The provider's charges; (b) The usual and customary provider charges for similar services in the community where the services were provided; or (c) The charge mutually agreed to by the health maintenance organization and the provider within 60 days of the submittal of the claim. As with most new pieces of legislation, there are a number of questions that will wind up being resolved by the regulatory agencies or by the courts. An unanswered question is who determines what the “usual and customary provider charge” is and what method is to be used to make such determination. During negotiations on HB 221, the FMA sought first to require insurance companies to pay the full provider charge. After this approach was rejected by the legislature, the FMA next attempted to define “usual and customary” in a clearly objective way, not subject to interpretation by insurance companies. The preferred approach was to tie the amount of required reimbursement to a set percentile of the FairHealth Database. The legislature rejected this approach as well, and finally accepted compromise language that set reimbursement according to the ambiguous provisions of the HMO balance billing law. The key here is that, due to constant pressure from the FMA and its allies, the legislature also rejected language that would have set the reimbursement amount at the physician’s usual and customary payment, or the amount deemed reasonable by the insurance company. While the exact method of defining the “usual and customary charge” was not specified, it is clear that it is to be based on the physician’s charges – not amounts paid by Medicaid, Medicare, other governmental payors, or pursuant to commercial participating provider agreements. In practice, the physician will submit his/her bill for out-of-network services to the patients PPO/EPO plan. The insurance company will either: (1) determine that the billed amount reasonably represents the “usual and customary charge” for the particular service provided, and will pay the charge; or (2) will determine that the usual and customary charge is an amount lower than the billed charge, and will pay the lower amount. In the instance where the physician believes that the insurance company has unfairly paid an amount less that the true usual and customary charge, the physician can attempt to negotiate a higher amount with the insurance company, can file a lawsuit in county or circuit court (depending on the amount at issue – circuit court jurisdiction is generally reserved for disputes in excess of $15,000), or can submit the matter to the “statewide provider and health plan claim dispute resolution program.” While anecdotal evidence suggests that physicians have eschewed the dispute resolution organization process in the past, changes were made to the statute in HB 221 that will hopefully make the process more physician friendly: a. The resolution organization must review and consider all documentation submitted by both the health plan and the provider; b. The resolution organization must make findings of fact in its recommendation; c. The resolution organization must conduct an evidentiary hearing upon request of either party (costs to be equally shared); d. The resolution organization may not communicate ex parte with either party; e. The resolution organization’s written recommendation must include how the organization calculated the amount due (which must be calculated under the provisions of s. 641.513(5)) and include any evidence relied upon; and f. AHCA’s final order is subject to judicial review pursuant to s. 120.68. The FMA will work to ensure that AHCA requires the dispute resolution organization to calculate the amount due based on the plain wording of the applicable statute – that is, based on the usual and customary charge, not the usual and customary