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What are we working on at #AbrilLaw? We are currently representing a clinical pathology group contracted to provide ancillary services at an in-network acute care hospital. The provider’s claims are being denied or underpaid after being adjudicated as out-of-network.

Pursuant to Florida Statutes, as well as binding precedent from this jurisdiction, our position is that the defendant health plan is in fact liable for payment of medically necessary services rendered to its members.

In accordance with Florida Statutes § 627.64194(3), an insurer is solely liable for payment of fees to a non-participating provider of covered nonemergency services provided to an insured in accordance with the coverage terms of the health insurance policy, and such insured is not liable for payment of  fees to a nonparticipating provider, other than applicable copayments, coinsurance and deductibles, for covered nonemergency services that are (a) provided in a facility that has a contract for the nonemergency services with the insurer which the facility would be otherwise obligated to provide under contract with the insurer; and (b) 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.

Additionally, under Florida Statutes § 641.3154(1), if a health maintenance organization 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.

Similarly, subsection 69O-191.049(2) of the Florida Administrative Code states that in the event the HMO has not contracted directly with a hospital based physician provider delivering services in the hospital, including, but not limited to, pathologists, radiologists, anesthesiologists, and emergency room physicians, the HMO shall pay for medically necessary and approved physician care rendered to a non-Medicare subscriber at a contracted hospital which services are covered by the HMO subscriber contract.

Furthermore, the Third District Court of Appeal has consistently held that an HMO is liable for compensating an out-of-network provider for medically necessary services rendered in an in-network facility.

Abril Law strives to ensure that all healthcare providers, hospitals, and physicians alike, are adequately compensated for their services, giving the providers the freedom to focus exclusively on their core competencies, to treat patients and save lives.