FLORIDA - BILLING ISSUES

1. Does Florida regulate physician billing?

While Florida does not specifically regulate physician billing, it does require that under established standards of care, medical care must be provided pursuant to informed consent, must be adequately documented and must be lawfully billed to the patients and/or other payors. Physicians may not delegate to others nor reasonably rely upon others to ensure compliance with these patient responsibilities.

64 FL ADC 64B8-9.0075

Physicians and physician assistants with a practice setting in a hospital or other facility or who practice in a federally qualified health clinic or other state or federally regulated program that provides an equivalent risk management and oversight of physicians and physician assistants, may reasonably rely upon the licensed facility to ensure that medical care is lawfully billed to the patients and/or other payors.

64 FL ADC 64B8-9.0075

3. What must be included in a billing statement that is requested by a patient?

An itemized statement when requested by the patient must state, in language reasonably comprehensible to an ordinary person, the specific services rendered, including a specific description and charge for each service, procedure, or test.

( a ) If insurance codes are used to identify services, procedures or tests then the statement must include an explanation of each code and such explanation must be reasonably comprehensible to an ordinary person.

( b ) If abbreviations are used to identify services, procedures or tests then they must be of such common usage as to be reasonably comprehensible to an ordinary person.

( c ) The use of general categories such as "neonatology" or "cardiology" or use of terms such as "other" or "miscellaneous" without a reasonable explanation of the service, procedure or test in language reasonably comprehensible to an ordinary person is not in compliance with this rule and is therefore not sufficient.

( d ) A licensed physician shall provide an itemized statement in a manner consistent with the provisions of this rule if the physician has rendered any professional service and the patient requests an itemized statement of such service without regard to whether the patient was charged any fee by the physician.

( e ) A licensed physician shall provide an itemized statement in a manner consistent with common practice and state or federal guidelines if the physician has rendered any professional service and the patient, or the patient's insurer, or the administrative agency for any federal or state health program under which the patient is entitled to benefits requests an itemized statement of such service be provided to the insurer or administrative agency.

64 FL ADC 64B8-9.011

4. Are Florida physicians permitted to balance bill under Medicaid provider agreements?

No. Physicians must accept Medicaid payment as payment in full, and are prohibited from billing or collecting from the recipient or the recipient's responsible party any additional amount except, and only to the extent the agency permits or requires, copayments, coinsurance, or deductibles to be paid by the recipient for the services or goods provided. The Medicaid payment-in-full policy does not apply to services or goods provided to a recipient if the services or goods are not covered by the Medicaid program.

F.S.A. § 409.907

Copyright Kern Augustine Conroy and Schoppmann, P.C. Used with permission.