Not a Lexis Advance subscriber? Try it out for free.

Baker County Med. Servs. v. Aetna Health Mgmt., LLC

Court of Appeal of Florida, First District

February 24, 2010, Opinion Filed

CASE NO. 1D08-0067

Opinion

 [*843]  ROBERTS, J.

Baker County Medical Services, Inc. (BCMS), appeals a final judgment interpreting section 641.513(5)(b), Florida Statutes (2006). BCMS raises two issues on appeal. First, BCMS argues that the trial court erred in ruling that the term "provider" in section 641.513(5)(b) is not limited to any specific type of provider. We disagree and affirm on the first issue. Second, BCMS argues that the trial  [**2] court erred in ruling that the phrase "usual and customary provider charges" in section 641.513(5)(b) includes consideration of the amounts billed by providers, as well as the amounts accepted by providers as payment. We agree in part and reverse with directions on the second issue.

BCMS operates a rural, not-for-profit hospital in Baker County, Florida, and provides emergency medical services to patients who come or are brought in to its emergency room. Under state and federal law, BCMS is required to provide emergency medical services to every person in need of such care. BCMS receives payment for those services from a variety of sources, including, but not limited to: the patients themselves, Medicaid and Medicare, health insurance, and health maintenance organizations (HMOs).

There are a variety of ways that prices are set for emergency medical services including, but not limited to, the following. First, hospitals are required to maintain, post, and file a list of their maximum prices with the Agency for Health Care Administration (AHCA). See § 408.061, Fla. Stat.  [*844]  (2006). The list is referred to as a hospital's "charge master." Patients paying for their own emergency medical services  [**3] are typically billed the charge master price although hospitals often accept a lower payment in full satisfaction of the debt. Indigent patients are also typically billed the charge master price, but those costs are written off by the hospital, so the price to the patient is effectively zero. Second, hospitals often contract with health insurance companies and HMOs for a negotiated rate for services. Third, for patients covered by Medicare or Medicaid, the reimbursement rate is set by the government agency administering those programs.

] Reimbursement to hospitals providing emergency medical services to patients who subscribe to an HMO that does not have a contract with the hospital is determined according to section 641.513(5), Florida Statutes (2006), which provides:

Read The Full CaseNot a Lexis Advance subscriber? Try it out for free.

Full case includes Shepard's, Headnotes, Legal Analytics from Lex Machina, and more.

31 So. 3d 842 *; 2010 Fla. App. LEXIS 2089 **; 35 Fla. L. Weekly D 438

BAKER COUNTY MEDICAL SERVICES, INC. D/B/A ED FRASER MEMORIAL HOSPITAL, Appellant, v. AETNA HEALTH MANAGEMENT, LLC, A DELAWARE LIMITED LIABILITY COMPANY, AND HUMANA MEDICAL PLAN, INC., A FLORIDA FOR-PROFIT CORPORATION, Appellees.

Subsequent History: Released for Publication April 23, 2010

Rehearing denied by Baker County Med. Servs. v. Aetna Health Mgmt., 2010 Fla. App. LEXIS 5814 (Fla. Dist. Ct. App. 1st Dist., Apr. 7, 2010)

Review denied by Baker County Med. Servs. v. Aetna Health Mgmt., 2010 Fla. LEXIS 1493 (Fla., Aug. 27, 2010)

Prior History:  [**1] An appeal from the Circuit Court for Baker County. Mark W. Moseley, Judge.

CORE TERMS

provider, customary, billed, charges, patients, amounts, emergency medical services, similar services, trial court, reimbursement

Business & Corporate Compliance, Healthcare Law, Managed Healthcare, Health Maintenance Organizations, Governments, Legislation, Interpretation, Healthcare Law, General Overview