Balance Billing and Preferred Provider Organizations
July 5, 2016
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). 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 were free to balance bill the patient when the insurance company did not pay the physician’s full charge.