Florida healthcare providers can use the state-specific dispute resolution process for out-of-network bills instead of the federal methodology outlined in the No Surprises Act, CMS determined.
CMS on Jan. 19 unveiled its decision that Florida's Emergency Services statutes constitute specified state law under the No Surprises Act, meaning that Florida's methodology will determine payment resolution in most situations, according to an email from law firm Wolfe Pincavage sent to Becker's.
The decision is a win for Florida providers because the state dispute resolution process uses a more provider-friendly methodology to determine the reimbursement rate. In Florida, insurers reimburse out-of-network emergency providers the lesser of the provider's charges, the usual charge for a similar service in that region or a mutually-agreed-upon charge.
In contrast, the federal dispute resolution process uses a health plan's median in-network rate, known as a qualifying payment amount. Hospitals are suing HHS over the federal dispute resolution process, which they say unfairly favors payers.
Florida providers still must use the federal process in some instances, including for air ambulance services and when an uninsured individual is billed substantially in excess of the good faith estimate, CMS said.