Florida IDR Arbitration For Medical Revenue Recovery

The Florida Surprise Billing Law (SBL)

The Florida SBL, effective since 2016, includes the following key provisions:

1. Scope of Plans Covered:
   • The law applies to Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) plans.
2. Emergency and Inadvertent Services:
   • The law governs:
     • Emergency services.
     • Non-emergency services provided by out-of-network (OON) providers at in-network (INN) facilities.
3. Voluntary Arbitration:
   • Florida employs a "baseball-style" arbitration process for payment disputes.
   • This arbitration is voluntary for both carriers and medical providers.
     • If a medical provider initiates arbitration, the carrier can opt out, compelling the provider to pursue judicial remedies.
   • A pending bill in the Florida legislature proposes eliminating the voluntary nature of the arbitration process.
4. Reimbursement Rates:
   • Carriers are required to reimburse providers at Usual, Customary, and Reasonable (UCR) rates.
   • Payment is based on the lesser of:
     1. Billed charges.
     2. UCR rates.
     3. Agreed-upon reimbursement.
5. Timeline for Filing:
   • Providers have 12 months to file for arbitration and must object to a payment within this timeframe, per Florida regulations.
   • Although there is a 4-year statute of limitations for statutory causes of action, the 12-month window is critical, as objecting within this period is a prerequisite for initiating legal action.

These provisions are detailed in Florida Statute 627.64194.

Federal & State Coordination on Out-of-Network Rates

Regarding bifurcation and out-of-network reimbursement, CMS has clarified the following:

1. All-Payer Model Agreement:
   • Florida does not have an applicable agreement to determine out-of-network rates.
2. Specified State Laws:
   • The following state laws apply to determining out-of-network rates for items and services furnished to individuals in insured group health plans or individual insurance coverage:
     • Sections 408.7057, 627.42397, 627.64194(4), 627.64194(6), 641.513(5), and 641.514, Florida Statutes.
     • Rule 59A-12.030 of the Florida Administrative Code.
3. Claim Dispute Payment Thresholds:
   • These laws also cover disputes involving health maintenance organizations (HMOs) for claims above specific payment thresholds.

This information was documented in a letter from CMS to the Governor of Florida, dated January 28, 2022.