Source: https://lawsofflorida.com/services/hospital-lien/
Timestamp: 2019-04-23 02:08:36+00:00

Document:
I designed this page to provide helpful information to costumers, patients, and attorneys regarding hospital liens. Unlike other states, Florida’s hospital liens are created by special acts and local ordinances in select counties so there is no state-wide regulation. For this reason, and others, there seem to be more questions than answers and clear guidance on this topic.
This page contains the following information: A Flow Chart with links to determine if a lien is valid; a summary of hospital liens by county with links; a Law Digest of topics and statutes and cases as authority to help attorneys; and, a summary of causes of action that attorneys can use in lawsuits against hospitals.
If you have any questions, comments, or new cases that would be part of this website, please email me or post a question or comment on the BLOG.
Please help others by sending this link to anyone who may benefit from this information.
Was Lien files by a Hospital in the county official records?
Liens must be files to be perfected. Go online to the official records of the county in which the hospital is located to verify the existence of the lien. The lien will be filed in the name of the patient or the patient’s parent or guardian, and the name of the hospital after the date of discharge. NOTE: Only hospitals can file liens pursuants a lien law; if a private physician files a lien purporting to be the pursuants to a lien law it is valid.
Only some counties have enacted lien ordinances. See chart below. If the county has a lien ordinance, verify that the hospital is covered by the Lien ordinance.
Does the County have a Hospital lien ordinance?
Is the hospital covered by the ordinance?
Hospitals use treatment codes to identify patients believed to be victim of an accident for which the patient may make a claim, if the treatment is unrelated to an accident, the lien is invalid. If no claim can be made, such as situations where the patient is responsible for causing their own accident, the lien is invalid.
Is the patient’s treatment covered by Worker’s Compensation?
See section on Balance Billing: HMO below in Hospital Lien Digest.
Is the patient HMO Insured?
Has the hospital’s bill been paid in full by auto No-Fault/Medical Payments insurance?
See section on Balance Billing: Private Health Insurance below in Hospital Lien Digest.
Does the patient have health insurance whereby the hospital is a participating provider/In-network?
Did hospital bill and accept payment from Medicaid?
See Section on Balance Billing: Medicaid below in Hospital Lien Digest.
Balance billing occurs when a hospital bills the patient for the difference between the amount of their charges and the amount that has been paid by an insurance company. When the hospital is subject to a fee schedule by statute or contract for which the patient is a third party beneficiary, balance billing the patient is prohibited. Illegal balance billing occurs by virtue of filing a hospital lien for the full amount of the hospital’s charges when the hospital is limited by statute or contract in the amount it can collect from the patient. Most health insurance policies dictate the amount that the hospital must accept as payment in full, and the hospital must write off the remaining balance, only collecting a copayment from the payment. If the hospital attempts to collect additional charges from the patient in violation of the limitation imposed by statute or contract, such as filing a hospital lien for the full amount of the charges, the hospital is in violation of the balance billing prohibition.
Hospitals that accepts Medicaid must comply with Federal regulations including 42 C.F. R. Sec. 447.15 which in effect require hospitals to accept, as payment in full, the amounts paid by the Medicaid. A hospital that accepts Medicaid may not bill the patient except copayments, coinsurance, or deductibles. Hospitals are prohibited from billing or collecting from the patient the full amount of their total charges, making the filing of a hospital lien illegal. See F.S. 409.907(3)(j). Public Health Trust Co. V. Dade County School Bd., 693 So. 2d 562 (Fla. 3d DCA 1996); see also Mally v. Public Health Trust of Dade County, 88 F. Supp. 2d 1376 (S.D. Fla. 2000).
Florida Statute 440.13(14)(a) state that health care provider may not collect or receive a fee from an injured employee. Filing a hospital lien is balance billing and illegal for patients covered by workers’ compensation.
Florida Statutes 641.315 and 641.3154 make it clear that a hospital may not attempt to collect any charges from the patient. The patient’s insurer, not the patient, is responsible for the medical expenses. The hospital cannot refuse to bill the patient’s HMO or bill the patient which would constitute illegal balance billing. Filing a hospital lien against a HMO insured patient violates Florida statutes and is illegal.
Most agreements between an insurer and a hospital contain Member Protection language which typically read, “in no event, including non payment by Health Plan, Health Plan’s insolvency or breach of this agreement, shall a Provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against any Member or persons other than Health Plan acting on Member’s behalf, for amounts that are the legal obligation of Health Plan.” This language is similar to the protections afforded by the HMO statutes. In other words, the insurer, and not the patient, is obligated to the hospital, and the hospital cannot seek to collect any money from the patient other than copayments. Because liens filed by hospitals state the total charges, the liens violate the language of the contact to which the patient is a third party beneficiary, and the liens are invalid.
Assuming it is proper to file a lien, a hospital lien attaches when the patient enters the hospital, and the lien is perfected by filing the lien within the time frame provided in the law. Therefore, the lien attaches to a BI settlement.
The Florida Supreme Court in 2012 in Shands Teaching Hosp. & Clinics, Inc. v. Mercury Ins. Co. of Fla., 97 So.3d 204 (Fla. 2012) held that the Alachua County lien law created by a special act of the legislature was an unconstitutional under Article III Sec. 11(a)(9) of the Florida Constitution which prohibits “special laws pertaining to liens based on private contracts,” however the adoption of a parallel county ordinance creating such a lien in favor of a local hospital was within the county’s broad powers of local self government.
Florida Statute 627.4235 provides for coordination of benefit rules. Hospital liens and third party claims are not part of COB. COB is not permitted against an indemnity-type policy.
Some counties have enacted lien laws entirely by county ordinance, without relying on any special act of the Legislature. These ordinances would not be affected by the constitutional analysis of the Florida Supreme Court’s decision in Shands Teaching Hospital and Clinics, Inc. v. Mercury Ins. Co. of Florida.
Check the language of the lien ordinance carefully. Courts are not authorized to reduce a lien based on equitable considerations or through apportionment. Most liens state that the lien is for 100% of reasonable hospital charges, therefore the lien attaches to the entire amount of the recovery from the tortfeasor or other responsible party. The court has no discretion to pare down the line based on equitable considerations. Dade County v. Bodie, 237 So. 2d 553 (Fla. 3d DCA 1970). Similarly, the court may not reduce the amount of the hospital’s or lienholder’s recovery on its lien by ordering an equitable distribution of the settlement proceeds or allocating only a portion of a settlement to medical expenses. See, Public Health Trust of Dade County v. O’Neal, 348 So. 2d 377 (Fla. 3d DCA 1977); Dade County v. Perez, 237 So. 2d 781 (Fla. 3d DCA 1970).
Most hospital lien laws state that no release, settlement, or satisfaction of judgment shall be effective against the lienholder unless the lienholder has joined therein or executed a release of its lien prior to the payment of any proceeds. They also typically state that any acceptance of a release, settlement agreement, or satisfaction of judgment absent the release or satisfaction of the lien shall prima facie constitute an impairment of the lien. The Hospital may bring a cause of action for impairment of its lien to recover the full amount of its charges and, if it prevails, an award of attorney’s fees for bringing the action. Attorneys must be careful to always resolve any lien issues before settling the case.
This is an issue of election of payers by the hospital. MSP regulations require Medicare to be the payer of last resort. A hospital may bill and receive payment from Medicare and return payment to Medicare under 42 C.F.R. Sec. 411.20 et seq. to bill and seek payment from the third party liability carrier if the liability insurer pays within 120 days after the earlier of: a) the date the provider files claim or places lien with liability insurer, or b) date services were provided or discharge for in-patient. Wentz v. Kindred Hospital East, LLC, 333 F. Supp. 2d 1298 (S.D. Fla. 2004).
Medicaid is a payer of last resort like Medicare. But, once a hospital bills and accepts payment from Medicaid, it cannot maintain its hospital lien. Public Health Trust of Dade County v. Dade County School Board, 693 So. 2d 562 (Fla. 3rd DCA 1996). If hospital does not bill Medicaid, the hospital may not be able to collect more than the Medicaid would have paid. Mallo v. Public Health Trust of Dade County, 88 F. Supp. 2d 1376 (S.D. Fla. 2000). Practitioner tip: Florida participates in the Medicaid program, its medical assistance plan must comply with federal Medicaid statutes and regulations. 42 C.F.R. § 447.15 requires each state plan to provide that its Medicaid agency limit participation in the plan to providers that accept, as payment in full, the amount paid by the agency, plus any deductible, co-insurance, or co-payment required by the plan. Accordingly, section 409.907(3)(j), Florida Statutes (2013) states that the provider agreement shall require the provider to: “prohibit the provider 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.” Therefore, any hospital that accepts payment from Medicaid may not balance bill.
Late filing does not invalidate the lien, but only leaves the hospital in the status of an unsecured creditor until the notice is filed. Public Health Trust of Dade County v. Carroll, 509 So. 2d 1232, 1234 (Fla. 4th DCA 1987).
A hospital lien takes priority over benefits for funeral expenses and lost wages. Fernandez v. South Carolina Ins. Co., 408 So. 2d 753 (Fla. 3d DCA 1982).; Dade County vs. Pavon, 266 So.2d 94 (Fla. 3rd DCA 1972).
There are no statutes or cases regarding PPO health insurance and hospital liens. Therefore, the terms of the provider agreement between the hospital, if any, and the insurer will control. Most agreements between an insurer and a hospital contain Member Protection language which typically read, “in no event, including non payment by Health Plan, Health Plan’s insolvency or breach of this agreement, shall a Provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against any Member or persons other than Health Plan acting on Member’s behalf, for amounts that are the legal obligation of Health Plan.” This language is similar to the protections afforded by the HMO statutes. In other words, the insurer, and not the patient, is obligated to the hospital, and the hospital cannot seek to collect any money from the patient other than copayments. Liens filed against patients who are subject to this Member Protection language are mostly likely invalid. See generally, Winans v. Webber, 979 So.2d 269 (Fla. 2d DCA 2007).
The specific language of the lien law controls. Unless the county lien law specifically refers to “public hospitals,” then the lien will apply to all hospitals in the county.
A public hospital is one that is sustained by public funds. Schwartz v. GEICO, 712 So. 2d. 773 (Fla. 4th DCA 1998).
The patient can challenge the amount hospital’s charges as unreasonable. Evidence that the hospital has entered into contracts with managed care payers which provide contractual discounts for plan members is insufficient, standing alone, to establish that the hospital’s charges are unreasonable. See, Hillsborough County Hospital Authority v. Fernandez, 664 So. 2d 1071 (Fla. 2d DCA 1995).
Florida courts have not directly addressed whether it is permissible for a hospital to pursue a hospital lien instead of billing Medicare. Courts in other jurisdictions have held that a hospital has a right to seek full payment of its charges through a lien rather than bill Medicare. See, e.g., Parkview Hosp., Inc. v. Roese, 750 N.E.2d 384, 390 – 91 (Ind. App. 2001); Joiner v. Med. Ctr. East, Inc., 709 So. 2d 1209 (Ala. 1998).
If hospital does not bill Medicaid, the hospital may not be able to collect more than the Medicaid would have paid. Mallo v. Public Health Trust of Dade County, 88 F. Supp. 2d 1376 (S.D. Fla. 2000).
There are no Florida cases on whether a hospital can refuse to bill Medicare in favor of pursuing a hospital lien. Two federal cases filed in Florida alleged that a hospital’s hospital liens violated the balance billing provisions of Medicare. Neither case directly stated that a hospital cannot refuse to bill Medicare. Wentz v. Kindred Hospital East, LLC, 333 F. Supp. 2d 1298 (S.D. Fla. 2004); Massey v. Health First, Inc., 2005 WL 1243772 (M.D. Fla. May 25, 2005).
A hospital lien is extinguished by operation of law when the patient settles the account with the hospital which is the basis of the lien. Maxwell v. South Miami Hospital Foundation, 385 So.2d 127 (Fla. 3d DCA 1980).
No Florida cases on SOL.
Late filed lien is still an effective lien. Public Health Trust of Dade County v. Carroll, 509 So.2d 1232 (Fla. 4th DCA 1987). The court held that lien attached the minute the patient entered the hospital. Perfection impacted only competing lienholders. See also, Roster v. Public Health Trust of Dade County, 657 So.2d 1274 (Fla. 4th DCA 1995).
A hospital lien can attach to the proceeds of an uninsured motorist policy. Dade County v. Pavon, 266 So. 2d 94, 97 (Fla. 3d DCA 1972).
Hospital liens do not apply to accidents or injuries within the purview of the Workers’ Compensation Law. Any lien filed against an injured worker is invalid.
A hospital lien cannot attach to the claims of the survivors of the decedent in a wrongful death action. Orlando Regional Medical Center v. Estate of Heron, 596 So. 2d 1078 (Fla. 5th DCA 1992). The court explained, “Proceeds from a wrongful death action are not, and should not be, included within the ordinance establishing the lien rights. The simple reason is that the elements of a wrongful death action do not include an award for medical expenses and thus the proceeds of such settlement do not include money for that. A wrongful death action is not to collect for injuries to or expenses of the decedent; it is to recompense the survivor for their own losses, separate from their departed loved-one.” 596 So. 2d at 1079.
Hospital liens may attach to the claims of the estate in a wrongful death action. University Medical Center v. Zeiler, 625 So. 2d 120 (Fla. 5th DCA 1993).
A hospital lien takes priority over funeral expenses, lost wages, and loss of earning capacity for the purpose of PIP benefits. Fernandez v. South Carolina Ins. Co., 408 So. 2d 753 (Fla. 3d DCA 1982).
Hospitals do not notify or warn patients that it will file a hospital lien. In fact, most hospital admitting representatives will explain that the hospital will bill PIP (in auto accident cases) as primary and health insurance as secondary. After that patient is discharged, the hospital files the lien which comes as a surprise to the patient. This practice is a deceptive practice. The lien names the patient as the debtor, when the insurance company is actually the entity that is most often indebted to the hospital. Some hospitals seek to avoid billing health insurance to avoid the lower reimbursement rate in favor or enforcing the lien against the patient’s personal injury claim. These and other practices are deceptive and unfair, and violation of the contract between the hospital and the patient’s health insurer. Attorney fees are recoverable under Fla. Stat. 521.2105. Update: The 1st DCA on July 5, 2013 issued its opinion on Baker v. Baptist Hospital, Inc. 38 Fla. L. Weekly D1488a holding that filing of a hospital lien is the pursuit of a legal remedy and does not meet the definition of “trade or commerce” for purposes of Ch. 501. The opinion did not reveal whether the patients/class members where HMO or PPO insureds which would make the liens invalid.
The filing of a lien is the public records of the county is publication and an attempt to collect a debt. The lien is in the name of the patient and claims the patient is indebted to the hospital. The hospital knows or should know that the lien is invalid when: the patient is an HMO insured whereby the HMO is the only entity is financially obligated to the hospital; the patient has health insurance whereby the contract has hold harmless provisions protecting the patient from financially responsibility to the hospital; the hospital’s bill has been paid or partially paid and the lien reflects the total amount due. Attorney fees are recoverable under F.S. 559.77.
If the patient has health insurance and there is a contract between the hospital and the health insurer, that contract (provider agreement) contains language to protect the insured patient. The elements of a case or breach of third party beneficiary contract are: 1) existence of a contract, 2) the clear or manifest intent of the contracting parties that the contract primarily and directly benefits the patient, 3) the breach of the contract by the hospital, and 4) damages to the patient.If the patient is an HMO insured, this cause of action is especially effective.
Breach of Third Party Beneficiary Contact If the patient has health insurance and there is a contract between the hospital and the health insurer, that contract (provider agreement) contains language to protect the insured patient. The elements of a case or breach of third party beneficiary contract are: 1) existence of a contract, 2) the clear or manifest intent of the contracting parties that the contract primarily and directly benefits the patient, 3) the breach of the contract by the hospital, and 4) damages to the patient.
If the patient is an HMO insured, this cause of action is especially effective. Every provider agreement between a hospital and a health insurer contains this language: Member Protections: In no event, including non payment by Health Plan, Health Plan’s insolvency or breach of this agreement, shall a Provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against any Member or persons other than Health Plan acting on Member’s behalf, for amounts that are the legal obligation of Health Plan. This provision shall survive termination or expiration of this Agreement regardless of the cause giving rise to termination or expiration, shall be construed for the benefit of Members, does not prohibit collection of Member Expenses where lawfully permitted or required, and supersedes any oral or written agreement to the contrary now existing or hereafter entered into between a Provider and Members or persons acting on their behalf.” This language is tracts the HMO Act Provider Contract mandate under F.S. 641.315 that says each contract between a HMO and a provider must contain a provision that the subscriber is not liable to the provider for any services for which the health maintenance organization is liable. This language is breached by the hospital when they file a lien claiming the patient is obligated to pay full charges of the hospital. The health insurer’s contract limits the amount the hospital can charge its members; the hospital’s lien claims the patient is indebted for the usual and customary fees which violates the contract. Attorneys should examine the Coordination of Benefits provisions for additional violations.
If the patient is insured health insurance and the hospital has an agreement with the patient’s health insurer, the contract has specific Member Protection language (see above). This cause of action is similar to breach of a third party beneficiary contract. The violation occurs when the hospital refuses to bill the patient’s health insurance or violates the Member Protection language.
Fla. Stat. 86.021 provides for the right to a declaratory judgment when the elements of such a claim are pled and proven. The purpose of a declaratory judgment is to afford the parties relief from their uncertainty with respects to their rights, status, and other legal relations. The elements of this cause of action are: 1) there is bona fide, actual, present and practical need for the declaration, 2) the declaration deals with a present, ascertained or ascertainable state of facts or present controversy as to a state of facts, 3) some immunity, power, privilege or right of the complaining party is dependent upon the facts or the law applicable to the facts, 4) there is some person or persons who have, or reasonably may have an actual, present, adverse and antagonistic interest in the subject matter, either in fact or law, 5) the antagonistic and adverse interests are all before the court by proper process or class representative, and 6) relief is sought is not merely giving of legal advice by the courts or the answer to questions propounded from curiosity.
The admission agreement signed by the patient may provide for attorney fees if there is a dispute. This may be a basis to recovery attorney fees from this cause of action. The court’s ruling on the declaratory action in summary judgment will determine the course of the other cause of actions in the lawsuit. The patient’s lawyer should evaluate whether the patient executed an assignment of benefits which determines whether the patient has standing.

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