Re:        S236 / HB837 – Proposed Repeal of §627.428, Fla. Stat. 

             Applicability to Health Insurance Policies

Dear Esteemed Representative/Senator:

I recently became aware of proposed bill HB837/S236. There are several changes proposed in the bill, however, I write specifically to address the proposed repeal of Section 627.428 of the Florida Statutes as applied to health insurance policies. It would be detrimental to patients in Florida if this section of the Florida Statutes were repealed as applied to health insurance.

If passed, this bill will take away Patients’ Rights to fight if legal action is needed to overturn a denial for medical treatment and prescriptions, disempowers physicians and physician directed healthcare & gives more power to health insurance companies to act as doctors instead of the patients’ treating physicians. 

HB837/S236 fails to consider the intricacies of healthcare. It does not appear that the legislature or proponents of the bill have any understanding of the healthcare system and the detrimental consequences a repeal of this section would have on patients that are insured under health insurance policies issued in Florida when coverage is denied. Health insurance denials have increased significantly since 2021.

 

 

Multiple organizations, including the American Medical Association and the American Hospital Association have called on Congress to address the increased health insurance denials and prior authorization burdens because they negatively impact patient care and the doctor/patient relationship. 

As health insurers continue this upward trend of denial of health insurance claims, it is imperative that the fee statute remain in effect for health insurance policies to allow patients to adequately defend themselves when they are faced with claim denials that directly impact their health. When a patient needs healthcare, the last thing they should have to worry about is how they will pay for that care and whether the insurance company will cover the care. They need access to a legal advocate when their life is at stake. In the most extreme circumstances, a patient could die without the ability to obtain the necessary medical treatment and a legal advocate is crucial. You can read more about statistics on health insurance denials here:

1.      Modern Healthcare, Health systems see increasing claim denials as payer ‘delay tactic’,  https://www.modernhealthcare.com/insurance/insurance-claim-denial-rates-rising-health-systems-struggle 

2.      American Medical Association, Prior Authorization Reform Initiatives, https://www.ama-assn.org/practice-management/prior-authorization/prior-authorization-reform-initiatives 

3.      Physician Grassroots Network, https://physiciansgrassrootsnetwork.org/prior-authorization 

4.       American Hospital Association,  Addressing Commercial Health Plan Challenges to Ensure Fair Coverage for Patients and Providers, https://www.aha.org/guidesreports/2022-11-01-addressing-commercial-health-plan-challenges-ensure-fair-coverage-patients-and-providers 

5.       AHA presses Department of Justice to investigate routine denials from health insurers

https://www.healthcarefinancenews.com/news/aha-presses-department-justice-investigate-routine-denials-health-insurers

Overview of Health Insurance Denials

Most health insurance denials are based on the following:

• Not medically necessary
• Policy exclusion
• Lack of pre-authorization
• Services alleged to be experimental and investigational.

A list of common denials is as follows:

• Denial of emergency medical services
• Denial of specialized chemotherapy deemed investigational
• Denial of chemotherapy for terminally ill cancer patients
• Denial of specialty medications
• Denial of medical services for quadriplegic patient
• Denial of substance abuse services
• Denial of mental health services 
• Denial of specialty medications
• Denial of hospital services
• Denial of brand name drugs needed over generic brands 

Without access to legal services, when there is a denial, patients would suffer health issues and complications because of delays in care, suffer financial burdens or can simply die. It would also not allow doctors to dictate the patient’s care, and instead, would give insurance companies a blanket authorization to do as they please without any accountability. Legal action is often the last resort because doctors and patients submit appeals to insurance companies in an attempt to resolve any denials of treatment and medication. 

Section 627.428, Fla. Stat. serves its purpose well for health insurance policies because the issues that arise as to claim denials do not amount to big payouts or damages. Instead, the issues that arise in health insurance denials directly impact patient health and well-being and save lives. There is no balance in the healthcare industry. Patients and physicians struggle against a giant industry. 

The statute does what the scales of justice require and the legislature originally intended– to balance the playing field against billion-dollar health insurance companies because regular individuals do not have resources to protect themselves against these companies. There is no balance in the healthcare industry when it comes to patients, mostly because health insurers have unfettered discretion to make decisions. Without this option, patients would not be able to hire a lawyer unless they are independently wealthy and would have no recourse against the health insurance companies when faced with a denial that directly impacts their health and well-being. Patients would suffer without necessary healthcare services and hospitals and medical providers would be burdened with additional issues that should be the responsibility of health insurers.

As a result of the foregoing, HB837/236 should carve out an exception of the applicability of Section 627.428 to health insurance and/or a new section should be created as part of HB837/S236 to ensure that patients are able to seek legal counsel to represent them when it matters most, their health.

WHAT IS THE SOLUTION?

HB837 should carve out an exception of the applicability of Section 627.428 to health insurance and/or a new section should be created as part of HB837 to ensure that patients who have health insurance are able to seek legal counsel to represent them when it matters most, their health. For example, the bill can state that if an insured patient has to sue, as applied to health insurance,

1. the prevailing party can recover fees and costs,

2. a patient fund can be established to allows patients to seek representation when necessary to obtain medical treatment

3. health insurance policies can be exempt from the repeal of 627.428.

Respectfully, 

Concerned Constituent