Once a hospital is paid by Medicare, it is barred from balance-billing the patient except for a small co-payment. Because Medicare pays less than “reasonable value” for services charged by Florida hospitals, where a hospital believes that the patient is likely to receive a monetary recovery in a personal injury case, it may refuse to bill Medicare. Hospitals do this hoping to receive more from personal injury cases than from Medicare.
Unfortunately, this conduct is legal. There appear to be no rules, statutes or case law barring this conduct.
The law is less clear with regard to Medicaid. Some believe that Medicaid must be billed, while others do not. As with Medicare, hospitals are not allowed to balance-bill after being paid by Medicaid.
Where Medicare or Medicaid pay and a personal injury recovery follows, both will be reimbursed from the recovery. Accordingly, neither (namely, taxpayers) loses out.
Hence, where hospitals refuse to bill Medicare, the consumer/patient ends up paying more.
This is not to say that patients will always pay the full hospital charges from their personal injury cases. The patient only pays for the “reasonable value” of the services rendered.
The reasonable value of hospital care in Florida has been determined to have the following non-exclusive elements:
1) an analysis of the relevant market for hospital services including rates charged by similar hospitals for similar services, 2) the amount a hospital accepts as payment in full from other payers for identical services rendered, and 3) the cost to the hospital of rendering the hospital care in question. One of the nation’s leading experts on hospital policy and hospital billing and collection practices believes the reasonable value of hospital care to be the Medicare Rate plus 25% (See Witness Testimony of Dr. Gerard Anderson), of the Johns Hopkins School of Medicine.
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Jeffrey P. Gale, P.A. is a South Florida based law firm committed to the judicial system and to representing and obtaining justice for individuals – the poor, the injured, the forgotten, the voiceless, the defenseless and the damned, and to protecting the rights of such people from corporate and government oppression. We do not represent government, corporations or large business interests.