Florida Senate - 2012 SB 1860
By Senator Negron
28-00905-12 20121860__
1 A bill to be entitled
2 An act relating to motor vehicle personal injury
3 protection insurance; amending s. 316.066, F.S.;
4 revising the conditions for completing the long-form
5 traffic crash report; revising the information
6 contained in the long-form and the short-form reports;
7 limiting the inclusion of telephone numbers in crash
8 reports; authorizing an investigating officer to
9 testify at trial or provide an affidavit regarding a
10 crash; amending s. 400.9905, F.S.; providing that
11 certain entities exempt from licensure as a health
12 care clinic must nonetheless be licensed in order to
13 receive reimbursement for the provision of personal
14 injury protection benefits; amending s. 400.991, F.S.;
15 requiring that an application for licensure, or
16 exemption from licensure, as a health care clinic
17 include a statement regarding insurance fraud;
18 amending s. 626.989, F.S.; providing that knowingly
19 submitting false, misleading, or fraudulent documents
20 relating to licensure as a health care clinic, or
21 submitting a claim for personal injury protection
22 relating to clinic licensure documents, is a
23 fraudulent insurance act under certain conditions;
24 amending s. 626.9894, F.S.; conforming provisions to
25 changes made by act; creating s. 626.9895, F.S.;
26 providing definitions; authorizing the Division of
27 Insurance Fraud of the Department of Financial
28 Services to establish a direct-support organization
29 for the purpose of prosecuting, investigating, and
30 preventing motor vehicle insurance fraud; providing
31 requirements for, and duties of, the organization;
32 requiring that the organization operate pursuant to a
33 contract with the division; providing for the
34 requirements of the contract; providing for a board of
35 directors; authorizing the organization to use the
36 division’s property and facilities subject to certain
37 requirements; requiring that the department adopt
38 rules relating to procedures for the organization’s
39 governance and relating to conditions for the use of
40 the division’s property or facilities; authorizing
41 contributions from insurers; authorizing any moneys
42 received by the organization to be held in a separate
43 depository account in the name of the organization;
44 requiring that the division deposit certain proceeds
45 into the Insurance Regulatory Trust Fund; amending s.
46 627.0651, F.S.; prohibiting attorney fees awarded to
47 plaintiffs in claims for benefits under the motor
48 vehicle no-fault law from being included in insurance
49 rates; amending s. 627.736, F.S.; excluding massage
50 and acupuncture from medical benefits that may be
51 reimbursed under the motor vehicle no-fault law;
52 requiring that an insurer give priority to the payment
53 of death benefits under certain conditions; requiring
54 that an insurer repay any benefits covered by the
55 Medicaid program; requiring that an insurer provide a
56 claimant an opportunity to revise claims that contain
57 errors; including hospitals within a requirement for
58 insurers to reserve a portion of personal injury
59 protection benefits; requiring that an insurer create
60 and maintain a log of personal injury protection
61 benefits paid and that the insurer provide to the
62 insured or an assignee of the insured, upon request, a
63 copy of the log; revising the Medicare fee schedules
64 that an insurer may use as a basis for limiting
65 reimbursement of personal injury protection benefits;
66 providing that the Medicare fee schedule in effect on
67 a specific date applies for purposes of limiting such
68 reimbursement; authorizing insurers to apply certain
69 Medicare coding policies and payment methodologies;
70 requiring that an insurer that limits payments based
71 on the statutory fee schedule include a notice in
72 insurance policies at the time of issuance or renewal;
73 deleting obsolete provisions; providing that certain
74 entities exempt from licensure as a clinic must
75 nonetheless be licensed to receive reimbursement for
76 the provision of personal injury protection benefits;
77 providing exceptions; requiring that an insurer notify
78 parties in disputes over personal injury protection
79 claims when policy limits are reached; consolidating
80 provisions relating to unfair or deceptive practices
81 under certain conditions; eliminating a requirement
82 that all parties mutually and expressly agree for the
83 use of electronic transmission of data; amending s.
84 817.234, F.S.; providing that it is insurance fraud to
85 present a claim for personal injury protection
86 benefits payable to a person or entity that knowingly
87 submitted false, misleading, or fraudulent documents
88 relating to licensure as a health care clinic;
89 providing that a licensed health care practitioner
90 guilty of certain insurance fraud loses his or her
91 license and may not receive personal injury protection
92 benefits for a specified period; defining the term
93 “insurer”; amending s. 316.065, F.S.; conforming a
94 cross-reference; requiring that the Office of
95 Insurance Regulation perform a data call relating to
96 personal injury protection; prescribing required
97 elements of the data call; providing for severability;
98 providing effective dates.
99
100 Be It Enacted by the Legislature of the State of Florida:
101
102 Section 1. Subsection (1) of section 316.066, Florida
103 Statutes, is amended to read:
104 316.066 Written reports of crashes.—
105 (1)(a) A Florida Traffic Crash Report, Long Form, must is
106 required to be completed and submitted to the department within
107 10 days after completing an investigation is completed by the
108 every law enforcement officer who in the regular course of duty
109 investigates a motor vehicle crash that:
110 1. Resulted in death, or personal injury, or any complaint
111 of pain or discomfort by any of the parties or passengers
112 involved in the crash;.
113 2. Involved one or more passengers in any vehicle involved
114 in the crash, other than the driver of the vehicle; or
115 3.2. Involved a violation of s. 316.061(1) or s. 316.193.
116 (b) In any every crash for which a Florida Traffic Crash
117 Report, Long Form, is not required by this section, the law
118 enforcement officer may complete a short-form crash report or
119 provide a driver exchange-of-information form to be completed by
120 each party involved in the crash. The agency that employs the
121 law enforcement officer who prepares the short-form crash report
122 shall maintain the report.
123 (c) The long-form and the short-form reports report must
124 include:
125 1. The date, time, and location of the crash.
126 2. A description of the vehicles involved.
127 3. The names and addresses of the parties involved,
128 including all drivers and passengers, with each party clearly
129 identified as a driver or passenger and the vehicle that he or
130 she occupied.
131 4. The names and addresses of witnesses.
132 5. The name, badge number, and law enforcement agency of
133 the officer investigating the crash.
134 6. The names of the insurance companies for the respective
135 parties involved in the crash.
136
137 Except for a crash in which a party is charged with a criminal
138 traffic offense, a long-form or short-form crash report may not
139 include the telephone number of a party involved in the crash.
140 (d)(c) Each party to the crash must provide the law
141 enforcement officer with proof of insurance, which must be
142 documented in the crash report. If a law enforcement officer
143 submits a report on the crash, proof of insurance must be
144 provided to the officer by each party involved in the crash. Any
145 party who fails to provide the required information commits a
146 noncriminal traffic infraction, punishable as a nonmoving
147 violation as provided in chapter 318, unless the officer
148 determines that due to injuries or other special circumstances
149 such insurance information cannot be provided immediately. If,
150 within 24 hours after the crash, the person provides the law
151 enforcement agency with, within 24 hours after the crash, proof
152 of insurance that was valid at the time of the crash, the law
153 enforcement agency may void the citation.
154 (e)(d) The driver of a vehicle that was in any manner
155 involved in a crash resulting in damage to any vehicle or other
156 property in an amount of $500 or more which was not investigated
157 by a law enforcement agency, shall, within 10 days after the
158 crash, submit a written report of the crash to the department.
159 The entity receiving the report may require witnesses of the
160 crash to render reports and may require the any driver of a
161 vehicle involved in a crash of which a written report must be
162 made to file supplemental written reports if the original report
163 is deemed insufficient by the receiving entity.
164 (f) The law enforcement officer who investigates a crash
165 may testify at trial, provide a deposition for use at trial, or
166 provide a signed affidavit to confirm or supplement information
167 included in the long-form or short-form crash report.
168 (e) Short-form crash reports prepared by law enforcement
169 shall be maintained by the law enforcement officer’s agency.
170 Section 2. Subsection (4) of section 400.9905, Florida
171 Statutes, is amended to read:
172 400.9905 Definitions.—
173 (4) “Clinic” means an entity where at which health care
174 services are provided to individuals and which tenders charges
175 for reimbursement for such services, including a mobile clinic
176 and a portable equipment provider. As used in For purposes of
177 this part, the term does not include and the licensure
178 requirements of this part do not apply to:
179 (a) Entities licensed or registered by the state under
180 chapter 395; or entities licensed or registered by the state and
181 providing only health care services within the scope of services
182 authorized under their respective licenses granted under ss.
183 383.30-383.335, chapter 390, chapter 394, chapter 397, this
184 chapter except part X, chapter 429, chapter 463, chapter 465,
185 chapter 466, chapter 478, part I of chapter 483, chapter 484, or
186 chapter 651; end-stage renal disease providers authorized under
187 42 C.F.R. part 405, subpart U; or providers certified under 42
188 C.F.R. part 485, subpart B or subpart H; or any entity that
189 provides neonatal or pediatric hospital-based health care
190 services or other health care services by licensed practitioners
191 solely within a hospital licensed under chapter 395.
192 (b) Entities that own, directly or indirectly, entities
193 licensed or registered by the state pursuant to chapter 395; or
194 entities that own, directly or indirectly, entities licensed or
195 registered by the state and providing only health care services
196 within the scope of services authorized pursuant to their
197 respective licenses granted under ss. 383.30-383.335, chapter
198 390, chapter 394, chapter 397, this chapter except part X,
199 chapter 429, chapter 463, chapter 465, chapter 466, chapter 478,
200 part I of chapter 483, chapter 484, chapter 651; end-stage renal
201 disease providers authorized under 42 C.F.R. part 405, subpart
202 U; or providers certified under 42 C.F.R. part 485, subpart B or
203 subpart H; or any entity that provides neonatal or pediatric
204 hospital-based health care services by licensed practitioners
205 solely within a hospital licensed under chapter 395.
206 (c) Entities that are owned, directly or indirectly, by an
207 entity licensed or registered by the state pursuant to chapter
208 395; or entities that are owned, directly or indirectly, by an
209 entity licensed or registered by the state and providing only
210 health care services within the scope of services authorized
211 pursuant to their respective licenses granted under ss. 383.30
212 383.335, chapter 390, chapter 394, chapter 397, this chapter
213 except part X, chapter 429, chapter 463, chapter 465, chapter
214 466, chapter 478, part I of chapter 483, chapter 484, or chapter
215 651; end-stage renal disease providers authorized under 42
216 C.F.R. part 405, subpart U; or providers certified under 42
217 C.F.R. part 485, subpart B or subpart H; or any entity that
218 provides neonatal or pediatric hospital-based health care
219 services by licensed practitioners solely within a hospital
220 under chapter 395.
221 (d) Entities that are under common ownership, directly or
222 indirectly, with an entity licensed or registered by the state
223 pursuant to chapter 395; or entities that are under common
224 ownership, directly or indirectly, with an entity licensed or
225 registered by the state and providing only health care services
226 within the scope of services authorized pursuant to their
227 respective licenses granted under ss. 383.30-383.335, chapter
228 390, chapter 394, chapter 397, this chapter except part X,
229 chapter 429, chapter 463, chapter 465, chapter 466, chapter 478,
230 part I of chapter 483, chapter 484, or chapter 651; end-stage
231 renal disease providers authorized under 42 C.F.R. part 405,
232 subpart U; or providers certified under 42 C.F.R. part 485,
233 subpart B or subpart H; or any entity that provides neonatal or
234 pediatric hospital-based health care services by licensed
235 practitioners solely within a hospital licensed under chapter
236 395.
237 (e) An entity that is exempt from federal taxation under 26
238 U.S.C. s. 501(c)(3) or (4), an employee stock ownership plan
239 under 26 U.S.C. s. 409 that has a board of trustees at least not
240 less than two-thirds of which are Florida-licensed health care
241 practitioners and provides only physical therapy services under
242 physician orders, any community college or university clinic,
243 and any entity owned or operated by the federal or state
244 government, including agencies, subdivisions, or municipalities
245 thereof.
246 (f) A sole proprietorship, group practice, partnership, or
247 corporation that provides health care services by physicians
248 covered by s. 627.419, that is directly supervised by one or
249 more of such physicians, and that is wholly owned by one or more
250 of those physicians or by a physician and the spouse, parent,
251 child, or sibling of that physician.
252 (g) A sole proprietorship, group practice, partnership, or
253 corporation that provides health care services by licensed
254 health care practitioners under chapter 457, chapter 458,
255 chapter 459, chapter 460, chapter 461, chapter 462, chapter 463,
256 chapter 466, chapter 467, chapter 480, chapter 484, chapter 486,
257 chapter 490, chapter 491, or part I, part III, part X, part
258 XIII, or part XIV of chapter 468, or s. 464.012, and that is
259 which are wholly owned by one or more licensed health care
260 practitioners, or the licensed health care practitioners set
261 forth in this paragraph and the spouse, parent, child, or
262 sibling of a licensed health care practitioner if, so long as
263 one of the owners who is a licensed health care practitioner is
264 supervising the business activities and is legally responsible
265 for the entity’s compliance with all federal and state laws.
266 However, a health care practitioner may not supervise services
267 beyond the scope of the practitioner’s license, except that, for
268 the purposes of this part, a clinic owned by a licensee in s.
269 456.053(3)(b) which that provides only services authorized
270 pursuant to s. 456.053(3)(b) may be supervised by a licensee
271 specified in s. 456.053(3)(b).
272 (h) Clinical facilities affiliated with an accredited
273 medical school at which training is provided for medical
274 students, residents, or fellows.
275 (i) Entities that provide only oncology or radiation
276 therapy services by physicians licensed under chapter 458 or
277 chapter 459 or entities that provide oncology or radiation
278 therapy services by physicians licensed under chapter 458 or
279 chapter 459 which are owned by a corporation whose shares are
280 publicly traded on a recognized stock exchange.
281 (j) Clinical facilities affiliated with a college of
282 chiropractic accredited by the Council on Chiropractic Education
283 at which training is provided for chiropractic students.
284 (k) Entities that provide licensed practitioners to staff
285 emergency departments or to deliver anesthesia services in
286 facilities licensed under chapter 395 and that derive at least
287 90 percent of their gross annual revenues from the provision of
288 such services. Entities claiming an exemption from licensure
289 under this paragraph must provide documentation demonstrating
290 compliance.
291 (l) Orthotic or prosthetic clinical facilities that are a
292 publicly traded corporation or that are wholly owned, directly
293 or indirectly, by a publicly traded corporation. As used in this
294 paragraph, a publicly traded corporation is a corporation that
295 issues securities traded on an exchange registered with the
296 United States Securities and Exchange Commission as a national
297 securities exchange.
298
299 Notwithstanding this subsection, an entity shall be deemed a
300 clinic and must be licensed under this part in order to receive
301 reimbursement under the Florida Motor Vehicle No-Fault Law, ss.
302 627.730-627.7405, unless exempted under s. 627.736(5)(h).
303 Section 3. Subsection (6) is added to section 400.991,
304 Florida Statutes, to read:
305 400.991 License requirements; background screenings;
306 prohibitions.—
307 (6) All agency forms for licensure application or exemption
308 from licensure under this part must contain the following
309 statement:
310
311 INSURANCE FRAUD NOTICE.—A person who knowingly submits
312 a false, misleading, or fraudulent application or
313 other document when applying for licensure as a health
314 care clinic, seeking an exemption from licensure as a
315 health care clinic, or demonstrating compliance with
316 part X of chapter 400, Florida Statutes, with the
317 intent to use the license, exemption from licensure,
318 or demonstration of compliance to provide services or
319 seek reimbursement under the Florida Motor Vehicle No
320 Fault Law, commits a fraudulent insurance act, as
321 defined in s. 626.989, Florida Statutes. A person who
322 presents a claim for personal injury protection
323 benefits knowing that the payee knowingly submitted
324 such health care clinic application or document,
325 commits insurance fraud, as defined in s. 817.234,
326 Florida Statutes.
327 Section 4. Subsection (1) of section 626.989, Florida
328 Statutes, is amended to read:
329 626.989 Investigation by department or Division of
330 Insurance Fraud; compliance; immunity; confidential information;
331 reports to division; division investigator’s power of arrest.—
332 (1) For the purposes of this section:,
333 (a) A person commits a “fraudulent insurance act” if the
334 person:
335 1. Knowingly and with intent to defraud presents, causes to
336 be presented, or prepares with knowledge or belief that it will
337 be presented, to or by an insurer, self-insurer, self-insurance
338 fund, servicing corporation, purported insurer, broker, or any
339 agent thereof, any written statement as part of, or in support
340 of, an application for the issuance of, or the rating of, any
341 insurance policy, or a claim for payment or other benefit
342 pursuant to any insurance policy, which the person knows to
343 contain materially false information concerning any fact
344 material thereto or if the person conceals, for the purpose of
345 misleading another, information concerning any fact material
346 thereto.
347 2. Knowingly submits:
348 a. A false, misleading, or fraudulent application or other
349 document when applying for licensure as a health care clinic,
350 seeking an exemption from licensure as a health care clinic, or
351 demonstrating compliance with part X of chapter 400 with an
352 intent to use the license, exemption from licensure, or
353 demonstration of compliance to provide services or seek
354 reimbursement under the Florida Motor Vehicle No-Fault Law.
355 b. A claim for payment or other benefit pursuant to a
356 personal injury protection insurance policy under the Florida
357 Motor Vehicle No-Fault Law if the person knows that the payee
358 knowingly submitted a false, misleading, or fraudulent
359 application or other document when applying for licensure as a
360 health care clinic, seeking an exemption from licensure as a
361 health care clinic, or demonstrating compliance with part X of
362 chapter 400. For the purposes of this section,
363 (b) The term “insurer” also includes a any health
364 maintenance organization, and the term “insurance policy” also
365 includes a health maintenance organization subscriber contract.
366 Section 5. Subsection (5) of section 626.9894, Florida
367 Statutes, is amended to read:
368 626.9894 Gifts and grants.—
369 (5) Notwithstanding the provisions of s. 216.301 and
370 pursuant to s. 216.351, any balance of moneys deposited into the
371 Insurance Regulatory Trust Fund pursuant to this section or s.
372 626.9895 remaining at the end of any fiscal year is shall be
373 available for carrying out the duties and responsibilities of
374 the division. The department may request annual appropriations
375 from the grants and donations received pursuant to this section
376 or s. 626.9895 and cash balances in the Insurance Regulatory
377 Trust Fund for the purpose of carrying out its duties and
378 responsibilities related to the division’s anti-fraud efforts,
379 including the funding of dedicated prosecutors and related
380 personnel.
381 Section 6. Section 626.9895, Florida Statutes, is created
382 to read:
383 626.9895 Motor vehicle insurance fraud direct-support
384 organization.—
385 (1) DEFINITIONS.—As used in this section, the term:
386 (a) “Division” means the Division of Insurance Fraud of the
387 Department of Financial Services.
388 (b) “Motor vehicle insurance fraud” means any act defined
389 as a “fraudulent insurance act” under s. 626.989, which relates
390 to the coverage of motor vehicle insurance as described in part
391 XI of chapter 627.
392 (c) “Organization” means the direct-support organization
393 established under this section.
394 (2) ORGANIZATION ESTABLISHED.—The division may establish a
395 direct-support organization, to be known as the “Automobile
396 Insurance Fraud Strike Force,” whose sole purpose is to support
397 the prosecution, investigation, and prevention of motor vehicle
398 insurance fraud. The organization shall:
399 (a) Be a not-for-profit corporation incorporated under
400 chapter 617 and approved by the Department of State.
401 (b) Be organized and operated to conduct programs and
402 activities; raise funds; request and receive grants, gifts, and
403 bequests of money; acquire, receive, hold, invest, and
404 administer, in its own name, securities, funds, objects of
405 value, or other property, real or personal; and make grants and
406 expenditures to or for the direct or indirect benefit of the
407 division, state attorneys’ offices, the statewide prosecutor,
408 the Agency for Health Care Administration, and the Department of
409 Health to the extent that such grants and expenditures are used
410 exclusively to advance the prosecution, investigation, or
411 prevention of motor vehicle insurance fraud. Grants and
412 expenditures may include the cost of salaries or benefits of
413 motor vehicle insurance fraud investigators, prosecutors, or
414 support personnel if such grants and expenditures do not
415 interfere with prosecutorial independence or otherwise create
416 conflicts of interest which threaten the success of
417 prosecutions.
418 (c) Be determined by the division to operate in a manner
419 that promotes the goals of laws relating to motor vehicle
420 insurance fraud, that is in the best interest of the state, and
421 that is in accordance with the adopted goals and mission of the
422 division.
423 (d) Use all of its grants and expenditures solely for the
424 purpose of preventing and decreasing motor vehicle insurance
425 fraud, and not for the purpose of lobbying as defined in s.
426 11.045.
427 (e) Be subject to an annual financial audit in accordance
428 with s. 215.981.
429 (3) CONTRACT.—The organization shall operate under written
430 contract with the division. The contract must provide for:
431 (a) Approval of the articles of incorporation and bylaws of
432 the organization by the division.
433 (b) Submission of an annual budget for approval of the
434 division. The budget must require the organization to minimize
435 costs to the division and its members at all times by using
436 existing personnel and property and allowing for telephonic
437 meetings if appropriate.
438 (c) Certification by the division that the organization is
439 complying with the terms of the contract and in a manner
440 consistent with the goals and purposes of the department and in
441 the best interest of the state. Such certification must be made
442 annually and reported in the official minutes of a meeting of
443 the organization.
444 (d) Allocation of funds to address motor vehicle insurance
445 fraud.
446 (e) Reversion of moneys and property held in trust by the
447 organization for motor vehicle insurance fraud prosecution,
448 investigation, and prevention to the division if the
449 organization is no longer approved to operate for the department
450 or if the organization ceases to exist, or to the state if the
451 division ceases to exist.
452 (f) Specific criteria to be used by the organization’s
453 board of directors to evaluate the effectiveness of funding used
454 to combat motor vehicle insurance fraud.
455 (g) The fiscal year of the organization, which begins July
456 1 of each year and ends June 30 of the following year.
457 (h) Disclosure of the material provisions of the contract,
458 and distinguishing between the department and the organization
459 to donors of gifts, contributions, or bequests, including
460 providing such disclosure on all promotional and fundraising
461 publications.
462 (4) BOARD OF DIRECTORS.—
463 (a) The board of directors of the organization shall
464 consist of the following eleven members:
465 1. The Chief Financial Officer, or designee, who shall
466 serve as chair.
467 2. Two state attorneys, one of whom shall be appointed by
468 the Chief Financial Officer and one of whom shall be appointed
469 by the Attorney General.
470 3. Two representatives of motor vehicle insurers appointed
471 by the Chief Financial Officer.
472 4. Two representatives of local law enforcement agencies,
473 one of whom shall be appointed by the Chief Financial Officer
474 and one of whom shall be appointed by the Attorney General.
475 5. Two representatives of the types of health care
476 providers who regularly make claims for benefits under ss.
477 627.730-627.7405, one of whom shall be appointed by the
478 President of the Senate and one of whom shall be appointed by
479 the Speaker of the House of Representatives. The appointees may
480 not represent the same type of health care provider.
481 6. A private attorney that has experience in representing
482 claimants in actions for benefits under ss. 627.730-627.7405,
483 who shall be appointed by the President of the Senate.
484 7. A private attorney who has experience in representing
485 insurers in actions for benefits under ss. 627.730-627.7405, who
486 shall be appointed by the Speaker of the House of
487 Representatives.
488 (b) The officer who appointed a member of the board may
489 remove that member for cause. The term of office of an appointed
490 member expires at the same time as the term of the officer who
491 appointed him or her or at such earlier time as the person
492 ceases to be qualified.
493 (5) USE OF PROPERTY.—The department may authorize, without
494 charge, appropriate use of fixed property and facilities of the
495 division by the organization, subject to this subsection.
496 (a) The department may prescribe any condition with which
497 the organization must comply in order to use the division’s
498 property or facilities.
499 (b) The department may not authorize the use of the
500 division’s property or facilities if the organization does not
501 provide equal membership and employment opportunities to all
502 persons regardless of race, religion, sex, age, or national
503 origin.
504 (c) The department shall adopt rules prescribing the
505 procedures by which the organization is governed and any
506 conditions with which the organization must comply to use the
507 division’s property or facilities.
508 (6) CONTRIBUTIONS FROM INSURERS.—Contributions from an
509 insurer to the organization shall be allowed as an appropriate
510 business expense of the insurer for all regulatory purposes.
511 (7) DEPOSITORY ACCOUNT.—Any moneys received by the
512 organization may be held in a separate depository account in the
513 name of the organization and subject to the contract with the
514 division.
515 (8) DIVISION’S RECEIPT OF PROCEEDS.—Proceeds received by
516 the division from the organization shall be deposited into the
517 Insurance Regulatory Trust Fund.
518 Section 7. Subsection (12) of section 627.0651, Florida
519 Statutes, is amended to read:
520 627.0651 Making and use of rates for motor vehicle
521 insurance.—
522 (12)(a) Any portion of a judgment entered as a result of a
523 statutory or common-law bad faith action and any portion of a
524 judgment entered which awards punitive damages against an
525 insurer may shall not be included in the insurer’s rate base,
526 and shall not be used to justify a rate or rate change. Any
527 portion of a settlement entered as a result of a statutory or
528 common-law bad faith action identified as such and any portion
529 of a settlement wherein an insurer agrees to pay specific
530 punitive damages may shall not be used to justify a rate or rate
531 change. The portion of the taxable costs and attorney attorney’s
532 fees which is identified as being related to the bad faith and
533 punitive damages in these judgments and settlements may shall
534 not be included in the insurer’s rate base and used shall not be
535 utilized to justify a rate or rate change.
536 (b) Any portion of a judgment or settlement for taxable
537 costs and attorney fees in favor of a prevailing plaintiff
538 against an insurer in a claim for benefits under ss. 627.730
539 627.7405, the Florida Motor Vehicle No-Fault Law, may not be
540 included in the insurer’s rate base and used to justify a rate
541 or rate change.
542 Section 8. Subsections (1), (4), (5), (6), (8), (9), (10),
543 and (11) of section 627.736, Florida Statutes, are amended to
544 read:
545 627.736 Required personal injury protection benefits;
546 exclusions; priority; claims.—
547 (1) REQUIRED BENEFITS.—An Every insurance policy complying
548 with the security requirements of s. 627.733 must shall provide
549 personal injury protection to the named insured, relatives
550 residing in the same household, persons operating the insured
551 motor vehicle, passengers in the such motor vehicle, and other
552 persons struck by the such motor vehicle and suffering bodily
553 injury while not an occupant of a self-propelled vehicle,
554 subject to the provisions of subsection (2) and paragraph
555 (4)(e), to a limit of $10,000 for loss sustained by any such
556 person as a result of bodily injury, sickness, disease, or death
557 arising out of the ownership, maintenance, or use of a motor
558 vehicle as follows:
559 (a) Medical benefits.—Eighty percent of all reasonable
560 expenses for medically necessary medical, surgical, X-ray,
561 dental, and rehabilitative services, including prosthetic
562 devices, and medically necessary ambulance, hospital, and
563 nursing services. Medical benefits do not includes massage as
564 defined in s. 480.033 or acupuncture as defined in s. 457.102.
565 However, The medical benefits shall provide reimbursement only
566 for such services and care that are lawfully provided,
567 supervised, ordered, or prescribed by a physician licensed under
568 chapter 458 or chapter 459, a dentist licensed under chapter
569 466, or a chiropractic physician licensed under chapter 460 or
570 that are provided by any of the following persons or entities:
571 1. A hospital or ambulatory surgical center licensed under
572 chapter 395.
573 2. A person or entity licensed under part III of chapter
574 401 which ss. 401.2101-401.45 that provides emergency
575 transportation and treatment.
576 3. An entity wholly owned by one or more physicians
577 licensed under chapter 458 or chapter 459, chiropractic
578 physicians licensed under chapter 460, or dentists licensed
579 under chapter 466 or by such practitioner or practitioners and
580 the spouse, parent, child, or sibling of such that practitioner
581 or those practitioners.
582 4. An entity wholly owned, directly or indirectly, by a
583 hospital or hospitals.
584 5. A health care clinic licensed under part X of chapter
585 400 which ss. 400.990-400.995 that is:
586 a. A health care clinic accredited by the Joint Commission
587 on Accreditation of Healthcare Organizations, the American
588 Osteopathic Association, the Commission on Accreditation of
589 Rehabilitation Facilities, or the Accreditation Association for
590 Ambulatory Health Care, Inc.; or
591 b. A health care clinic that:
592 (I) Has a medical director licensed under chapter 458,
593 chapter 459, or chapter 460;
594 (II) Has been continuously licensed for more than 3 years
595 or is a publicly traded corporation that issues securities
596 traded on an exchange registered with the United States
597 Securities and Exchange Commission as a national securities
598 exchange; and
599 (III) Provides at least four of the following medical
600 specialties:
601 (A) General medicine.
602 (B) Radiography.
603 (C) Orthopedic medicine.
604 (D) Physical medicine.
605 (E) Physical therapy.
606 (F) Physical rehabilitation.
607 (G) Prescribing or dispensing outpatient prescription
608 medication.
609 (H) Laboratory services.
610
611 The Financial Services Commission shall adopt by rule the form
612 that must be used by an insurer and a health care provider
613 specified in subparagraph 3., subparagraph 4., or subparagraph
614 5. to document that the health care provider meets the criteria
615 of this paragraph, which rule must include a requirement for a
616 sworn statement or affidavit.
617 (b) Disability benefits.—Sixty percent of any loss of gross
618 income and loss of earning capacity per individual from
619 inability to work proximately caused by the injury sustained by
620 the injured person, plus all expenses reasonably incurred in
621 obtaining from others ordinary and necessary services in lieu of
622 those that, but for the injury, the injured person would have
623 performed without income for the benefit of his or her
624 household. All disability benefits payable under this provision
625 must shall be paid at least not less than every 2 weeks.
626 (c) Death benefits.—Death benefits equal to the lesser of
627 $5,000 or the remainder of unused personal injury protection
628 benefits per individual. The insurer shall give priority to the
629 payment of death benefits over the payment of other benefits of
630 the deceased and, upon learning of the death of the individual,
631 stop paying the other benefits until the death benefits are
632 paid. The insurer may pay death such benefits to the executor or
633 administrator of the deceased, to any of the deceased’s
634 relatives by blood, or legal adoption, or connection by
635 marriage, or to any person appearing to the insurer to be
636 equitably entitled thereto.
637
638 Only insurers writing motor vehicle liability insurance in this
639 state may provide the required benefits of this section, and no
640 such insurer may not shall require the purchase of any other
641 motor vehicle coverage other than the purchase of property
642 damage liability coverage as required by s. 627.7275 as a
643 condition for providing such required benefits. Insurers may not
644 require that property damage liability insurance in an amount
645 greater than $10,000 be purchased in conjunction with personal
646 injury protection. Such insurers shall make benefits and
647 required property damage liability insurance coverage available
648 through normal marketing channels. An Any insurer writing motor
649 vehicle liability insurance in this state who fails to comply
650 with such availability requirement as a general business
651 practice violates shall be deemed to have violated part IX of
652 chapter 626, and such violation constitutes shall constitute an
653 unfair method of competition or an unfair or deceptive act or
654 practice involving the business of insurance. An; and any such
655 insurer committing such violation is shall be subject to the
656 penalties provided under that afforded in such part, as well as
657 those provided which may be afforded elsewhere in the insurance
658 code.
659 (4) PAYMENT OF BENEFITS; WHEN DUE.—Benefits due from an
660 insurer under ss. 627.730-627.7405 are shall be primary, except
661 that benefits received under any workers’ compensation law must
662 shall be credited against the benefits provided by subsection
663 (1) and are shall be due and payable as loss accrues, upon
664 receipt of reasonable proof of such loss and the amount of
665 expenses and loss incurred which are covered by the policy
666 issued under ss. 627.730-627.7405. If When the Agency for Health
667 Care Administration provides, pays, or becomes liable for
668 medical assistance under the Medicaid program related to injury,
669 sickness, disease, or death arising out of the ownership,
670 maintenance, or use of a motor vehicle, the benefits under ss.
671 627.730-627.7405 are shall be subject to the provisions of the
672 Medicaid program. However, within 30 days after receiving notice
673 that the Medicaid program paid such benefits, the insurer shall
674 repay the full amount of the benefits to the Medicaid program.
675 (a) An insurer may require written notice to be given as
676 soon as practicable after an accident involving a motor vehicle
677 with respect to which the policy affords the security required
678 by ss. 627.730-627.7405.
679 (b) Personal injury protection insurance benefits paid
680 pursuant to this section are shall be overdue if not paid within
681 30 days after the insurer is furnished written notice of the
682 fact of a covered loss and of the amount of same. However:
683 1. If such written notice of the entire claim is not
684 furnished to the insurer as to the entire claim, any partial
685 amount supported by written notice is overdue if not paid within
686 30 days after such written notice is furnished to the insurer.
687 Any part or all of the remainder of the claim that is
688 subsequently supported by written notice is overdue if not paid
689 within 30 days after such written notice is furnished to the
690 insurer.
691 2. If When an insurer pays only a portion of a claim or
692 rejects a claim, the insurer shall provide at the time of the
693 partial payment or rejection an itemized specification of each
694 item that the insurer had reduced, omitted, or declined to pay
695 and any information that the insurer desires the claimant to
696 consider related to the medical necessity of the denied
697 treatment or to explain the reasonableness of the reduced charge
698 if, provided that this does shall not limit the introduction of
699 evidence at trial.; and The insurer must also shall include the
700 name and address of the person to whom the claimant should
701 respond and a claim number to be referenced in future
702 correspondence.
703 3. If an insurer pays only a portion of a claim or rejects
704 a claim due to an alleged error in the claim, the insurer shall
705 provide at the time of the partial payment or rejection an
706 itemized specification or explanation of benefits of the
707 specified error. Upon receiving the specification or
708 explanation, the person making the claim has, at the person’s
709 option and without waiving any other legal remedy for payment,
710 15 days to submit a revised claim, and the revised claim shall
711 be considered a timely submission of written notice of a claim.
712 4. However, Notwithstanding the fact that written notice
713 has been furnished to the insurer, any payment is shall not be
714 deemed overdue if when the insurer has reasonable proof to
715 establish that the insurer is not responsible for the payment.
716 5. For the purpose of calculating the extent to which any
717 benefits are overdue, payment shall be treated as being made on
718 the date a draft or other valid instrument that which is
719 equivalent to payment was placed in the United States mail in a
720 properly addressed, postpaid envelope or, if not so posted, on
721 the date of delivery.
722 6. This paragraph does not preclude or limit the ability of
723 the insurer to assert that the claim was unrelated, was not
724 medically necessary, or was unreasonable or that the amount of
725 the charge was in excess of that permitted under, or in
726 violation of, subsection (5). Such assertion by the insurer may
727 be made at any time, including after payment of the claim or
728 after the 30-day time period for payment set forth in this
729 paragraph.
730 (c) Upon receiving notice of an accident that is
731 potentially covered by personal injury protection benefits, the
732 insurer must reserve $5,000 of personal injury protection
733 benefits for payment to:
734 1. Physicians licensed under chapter 458 or chapter 459 or
735 dentists licensed under chapter 466 who provide emergency
736 services and care, as defined in s. 395.002(9), or who provide
737 hospital inpatient care.
738 2. Hospitals licensed under chapter 395.
739
740 The amount required to be held in reserve may be used only to
741 pay claims from such physicians, or dentists, or hospitals until
742 30 days after the date the insurer receives notice of the
743 accident. After the 30-day period, any amount of the reserve for
744 which the insurer has not received notice of such claims a claim
745 from a physician or dentist who provided emergency services and
746 care or who provided hospital inpatient care may then be used by
747 the insurer to pay other claims. The time periods specified in
748 paragraph (b) for required payment of personal injury protection
749 benefits are shall be tolled for the period of time that an
750 insurer is required by this paragraph to hold payment of a claim
751 that is not from such a physician, or dentist, or hospital who
752 provided emergency services and care or who provided hospital
753 inpatient care to the extent that the personal injury protection
754 benefits not held in reserve are insufficient to pay the claim.
755 This paragraph does not require an insurer to establish a claim
756 reserve for insurance accounting purposes.
757 (d) All overdue payments shall bear simple interest at the
758 rate established under s. 55.03 or the rate established in the
759 insurance contract, whichever is greater, for the year in which
760 the payment became overdue, calculated from the date the insurer
761 was furnished with written notice of the amount of covered loss.
762 Interest is shall be due at the time payment of the overdue
763 claim is made.
764 (e) The insurer of the owner of a motor vehicle shall pay
765 personal injury protection benefits for:
766 1. Accidental bodily injury sustained in this state by the
767 owner while occupying a motor vehicle, or while not an occupant
768 of a self-propelled vehicle if the injury is caused by physical
769 contact with a motor vehicle.
770 2. Accidental bodily injury sustained outside this state,
771 but within the United States of America or its territories or
772 possessions or Canada, by the owner while occupying the owner’s
773 motor vehicle.
774 3. Accidental bodily injury sustained by a relative of the
775 owner residing in the same household, under the circumstances
776 described in subparagraph 1. or subparagraph 2., if provided the
777 relative at the time of the accident is domiciled in the owner’s
778 household and is not himself or herself the owner of a motor
779 vehicle with respect to which security is required under ss.
780 627.730-627.7405.
781 4. Accidental bodily injury sustained in this state by any
782 other person while occupying the owner’s motor vehicle or, if a
783 resident of this state, while not an occupant of a self
784 propelled vehicle, if the injury is caused by physical contact
785 with such motor vehicle, if provided the injured person is not
786 himself or herself:
787 a. The owner of a motor vehicle with respect to which
788 security is required under ss. 627.730-627.7405; or
789 b. Entitled to personal injury benefits from the insurer of
790 the owner or owners of such a motor vehicle.
791 (f) If two or more insurers are liable for paying to pay
792 personal injury protection benefits for the same injury to any
793 one person, the maximum payable is shall be as specified in
794 subsection (1), and the any insurer paying the benefits is shall
795 be entitled to recover from each of the other insurers an
796 equitable pro rata share of the benefits paid and expenses
797 incurred in processing the claim.
798 (g) It is a violation of the insurance code for an insurer
799 to fail to timely provide benefits as required by this section
800 with such frequency as to constitute a general business
801 practice.
802 (h) Benefits are shall not be due or payable to or on the
803 behalf of an insured person if that person has committed, by a
804 material act or omission, any insurance fraud relating to
805 personal injury protection coverage under his or her policy, if
806 the fraud is admitted to in a sworn statement by the insured or
807 if it is established in a court of competent jurisdiction. Any
808 insurance fraud voids shall void all coverage arising from the
809 claim related to such fraud under the personal injury protection
810 coverage of the insured person who committed the fraud,
811 irrespective of whether a portion of the insured person’s claim
812 may be legitimate, and any benefits paid before prior to the
813 discovery of the insured person’s insurance fraud is shall be
814 recoverable by the insurer in its entirety from the person who
815 committed insurance fraud in their entirety. The prevailing
816 party is entitled to its costs and attorney attorney’s fees in
817 any action in which it prevails in an insurer’s action to
818 enforce its right of recovery under this paragraph.
819 (i) An insurer shall create and maintain for each insured a
820 log of personal injury protection benefits paid by the insurer
821 on behalf of the insured. The insurer shall provide to the
822 insured, or an assignee of the insured, a copy of the log within
823 30 days after receiving a request for the log from the insured
824 or the assignee.
825 (5) CHARGES FOR TREATMENT OF INJURED PERSONS.—
826 (a)1. A Any physician, hospital, clinic, or other person or
827 institution lawfully rendering treatment to an injured person
828 for a bodily injury covered by personal injury protection
829 insurance may charge the insurer and injured party only a
830 reasonable amount pursuant to this section for the services and
831 supplies rendered, and the insurer providing such coverage may
832 pay for such charges directly to such person or institution
833 lawfully rendering such treatment, if the insured receiving such
834 treatment or his or her guardian has countersigned the properly
835 completed invoice, bill, or claim form approved by the office
836 upon which such charges are to be paid for as having actually
837 been rendered, to the best knowledge of the insured or his or
838 her guardian. In no event, However, may such a charge may not
839 exceed be in excess of the amount the person or institution
840 customarily charges for like services or supplies. In
841 determining With respect to a determination of whether a charge
842 for a particular service, treatment, or otherwise is reasonable,
843 consideration may be given to evidence of usual and customary
844 charges and payments accepted by the provider involved in the
845 dispute, and reimbursement levels in the community and various
846 federal and state medical fee schedules applicable to motor
847 vehicle automobile and other insurance coverages, and other
848 information relevant to the reasonableness of the reimbursement
849 for the service, treatment, or supply.
850 1.2. The insurer may limit reimbursement to 80 percent of
851 the following schedule of maximum charges:
852 a. For emergency transport and treatment by providers
853 licensed under chapter 401, 200 percent of Medicare.
854 b. For emergency services and care provided by a hospital
855 licensed under chapter 395, 75 percent of the hospital’s usual
856 and customary charges.
857 c. For emergency services and care as defined by s.
858 395.002(9) provided in a facility licensed under chapter 395
859 rendered by a physician or dentist, and related hospital
860 inpatient services rendered by a physician or dentist, the usual
861 and customary charges in the community.
862 d. For hospital inpatient services, other than emergency
863 services and care, 200 percent of the Medicare Part A
864 prospective payment applicable to the specific hospital
865 providing the inpatient services.
866 e. For hospital outpatient services, other than emergency
867 services and care, 200 percent of the Medicare Part A Ambulatory
868 Payment Classification for the specific hospital providing the
869 outpatient services.
870 f. For all other medical services, supplies, and care, 200
871 percent of the allowable amount under:
872 (I) The participating physicians fee schedule of Medicare
873 Part B, except as provided in sub-sub-subparagraphs (II) and
874 (III).
875 (II) Medicare Part B, in the case of services, supplies,
876 and care provided by ambulatory surgical centers and clinical
877 laboratories.
878 (III) The Durable Medical Equipment Prosthetics/Orthotics
879 and Supplies fee schedule of Medicare Part B, in the case of
880 durable medical equipment.
881
882 However, if such services, supplies, or care is not reimbursable
883 under Medicare Part B, as provided in this sub-subparagraph, the
884 insurer may limit reimbursement to 80 percent of the maximum
885 reimbursable allowance under workers’ compensation, as
886 determined under s. 440.13 and rules adopted thereunder which
887 are in effect at the time such services, supplies, or care is
888 provided. Services, supplies, or care that is not reimbursable
889 under Medicare or workers’ compensation is not required to be
890 reimbursed by the insurer.
891 2.3. For purposes of subparagraph 1. 2., the applicable fee
892 schedule or payment limitation under Medicare is the fee
893 schedule or payment limitation in effect on January 1 of the
894 year in which at the time the services, supplies, or care is was
895 rendered and for the area in which such services, supplies, or
896 care is were rendered, and the applicable fee schedule or
897 payment limitation applies throughout the remainder of that
898 year, notwithstanding any subsequent change made to the fee
899 schedule or payment limitation, except that it may not be less
900 than the allowable amount under the applicable participating
901 physicians schedule of Medicare Part B for 2007 for medical
902 services, supplies, and care subject to Medicare Part B.
903 3.4. Subparagraph 1. 2. does not allow the insurer to apply
904 any limitation on the number of treatments or other utilization
905 limits that apply under Medicare or workers’ compensation. An
906 insurer that applies the allowable payment limitations of
907 subparagraph 1. 2. must reimburse a provider who lawfully
908 provided care or treatment under the scope of his or her
909 license, regardless of whether such provider is would be
910 entitled to reimbursement under Medicare due to restrictions or
911 limitations on the types or discipline of health care providers
912 who may be reimbursed for particular procedures or procedure
913 codes. However, subparagraph 1. does not prohibit an insurer
914 from using the Medicare coding policies and payment
915 methodologies of the federal Centers for Medicare and Medicaid
916 Services, including applicable modifiers, to determine the
917 appropriate amount of reimbursement for medical services,
918 supplies, or care if the coding policy or payment methodology
919 does not constitute a utilization limit.
920 4.5. If an insurer limits payment as authorized by
921 subparagraph 1. 2., the person providing such services,
922 supplies, or care may not bill or attempt to collect from the
923 insured any amount in excess of such limits, except for amounts
924 that are not covered by the insured’s personal injury protection
925 coverage due to the coinsurance amount or maximum policy limits.
926 5. Effective July 1, 2012, an insurer may limit payment as
927 authorized by this paragraph only if the insurance policy
928 includes a notice at the time of issuance or renewal that the
929 insurer may limit payment pursuant to the schedule of charges
930 specified in this paragraph. A policy form approved by the
931 office satisfies this requirement. If a provider submits a
932 charge for an amount less than the amount allowed under
933 subparagraph 1., the insurer may pay the amount of the charge
934 submitted.
935 (b)1. An insurer or insured is not required to pay a claim
936 or charges:
937 a. Made by a broker or by a person making a claim on behalf
938 of a broker;
939 b. For any service or treatment that was not lawful at the
940 time rendered;
941 c. To any person who knowingly submits a false or
942 misleading statement relating to the claim or charges;
943 d. With respect to a bill or statement that does not
944 substantially meet the applicable requirements of paragraph (d);
945 e. For any treatment or service that is upcoded, or that is
946 unbundled when such treatment or services should be bundled, in
947 accordance with paragraph (d). To facilitate prompt payment of
948 lawful services, an insurer may change codes that it determines
949 to have been improperly or incorrectly upcoded or unbundled, and
950 may make payment based on the changed codes, without affecting
951 the right of the provider to dispute the change by the insurer,
952 if, provided that before doing so, the insurer contacts must
953 contact the health care provider and discusses discuss the
954 reasons for the insurer’s change and the health care provider’s
955 reason for the coding, or makes make a reasonable good faith
956 effort to do so, as documented in the insurer’s file; and
957 f. For medical services or treatment billed by a physician
958 and not provided in a hospital unless such services are rendered
959 by the physician or are incident to his or her professional
960 services and are included on the physician’s bill, including
961 documentation verifying that the physician is responsible for
962 the medical services that were rendered and billed.
963 2. The Department of Health, in consultation with the
964 appropriate professional licensing boards, shall adopt, by rule,
965 a list of diagnostic tests deemed not to be medically necessary
966 for use in the treatment of persons sustaining bodily injury
967 covered by personal injury protection benefits under this
968 section. The initial list shall be adopted by January 1, 2004,
969 and shall be revised from time to time as determined by the
970 Department of Health, in consultation with the respective
971 professional licensing boards. Inclusion of a test on the list
972 of invalid diagnostic tests shall be based on lack of
973 demonstrated medical value and a level of general acceptance by
974 the relevant provider community and may shall not be dependent
975 for results entirely upon subjective patient response.
976 Notwithstanding its inclusion on a fee schedule in this
977 subsection, an insurer or insured is not required to pay any
978 charges or reimburse claims for an any invalid diagnostic test
979 as determined by the Department of Health.
980 (c)1. With respect to any treatment or service, other than
981 medical services billed by a hospital or other provider for
982 emergency services and care as defined in s. 395.002 or
983 inpatient services rendered at a hospital-owned facility, the
984 statement of charges must be furnished to the insurer by the
985 provider and may not include, and the insurer is not required to
986 pay, charges for treatment or services rendered more than 35
987 days before the postmark date or electronic transmission date of
988 the statement, except for past due amounts previously billed on
989 a timely basis under this paragraph, and except that, if the
990 provider submits to the insurer a notice of initiation of
991 treatment within 21 days after its first examination or
992 treatment of the claimant, the statement may include charges for
993 treatment or services rendered up to, but not more than, 75 days
994 before the postmark date of the statement. The injured party is
995 not liable for, and the provider may shall not bill the injured
996 party for, charges that are unpaid because of the provider’s
997 failure to comply with this paragraph. Any agreement requiring
998 the injured person or insured to pay for such charges is
999 unenforceable.
1000 1.2. If, however, the insured fails to furnish the provider
1001 with the correct name and address of the insured’s personal
1002 injury protection insurer, the provider has 35 days from the
1003 date the provider obtains the correct information to furnish the
1004 insurer with a statement of the charges. The insurer is not
1005 required to pay for such charges unless the provider includes
1006 with the statement documentary evidence that was provided by the
1007 insured during the 35-day period demonstrating that the provider
1008 reasonably relied on erroneous information from the insured and
1009 either:
1010 a. A denial letter from the incorrect insurer; or
1011 b. Proof of mailing, which may include an affidavit under
1012 penalty of perjury, reflecting timely mailing to the incorrect
1013 address or insurer.
1014 2.3. For emergency services and care as defined in s.
1015 395.002 rendered in a hospital emergency department or for
1016 transport and treatment rendered by an ambulance provider
1017 licensed pursuant to part III of chapter 401, the provider is
1018 not required to furnish the statement of charges within the time
1019 periods established by this paragraph,; and the insurer is shall
1020 not be considered to have been furnished with notice of the
1021 amount of covered loss for purposes of paragraph (4)(b) until it
1022 receives a statement complying with paragraph (d), or copy
1023 thereof, which specifically identifies the place of service to
1024 be a hospital emergency department or an ambulance in accordance
1025 with billing standards recognized by the federal Centers for
1026 Medicare and Medicaid Services Health Care Finance
1027 Administration.
1028 3.4. Each notice of the insured’s rights under s. 627.7401
1029 must include the following statement in at least 12-point type
1030 in type no smaller than 12 points:
1031
1032 BILLING REQUIREMENTS.—Florida law provides Statutes
1033 provide that with respect to any treatment or
1034 services, other than certain hospital and emergency
1035 services, the statement of charges furnished to the
1036 insurer by the provider may not include, and the
1037 insurer and the injured party are not required to pay,
1038 charges for treatment or services rendered more than
1039 35 days before the postmark date of the statement,
1040 except for past due amounts previously billed on a
1041 timely basis, and except that, if the provider submits
1042 to the insurer a notice of initiation of treatment
1043 within 21 days after its first examination or
1044 treatment of the claimant, the statement may include
1045 charges for treatment or services rendered up to, but
1046 not more than, 75 days before the postmark date of the
1047 statement.
1048
1049 (d) All statements and bills for medical services rendered
1050 by a any physician, hospital, clinic, or other person or
1051 institution shall be submitted to the insurer on a properly
1052 completed Centers for Medicare and Medicaid Services (CMS) 1500
1053 form, UB 92 forms, or any other standard form approved by the
1054 office or adopted by the commission for purposes of this
1055 paragraph. All billings for such services rendered by providers
1056 must shall, to the extent applicable, follow the Physicians’
1057 Current Procedural Terminology (CPT) or Healthcare Correct
1058 Procedural Coding System (HCPCS), or ICD-9 in effect for the
1059 year in which services are rendered and comply with the Centers
1060 for Medicare and Medicaid Services (CMS) 1500 form instructions,
1061 and the American Medical Association Current Procedural
1062 Terminology (CPT) Editorial Panel, and the Healthcare Correct
1063 Procedural Coding System (HCPCS). All providers, other than
1064 hospitals, must shall include on the applicable claim form the
1065 professional license number of the provider in the line or space
1066 provided for “Signature of Physician or Supplier, Including
1067 Degrees or Credentials.” In determining compliance with
1068 applicable CPT and HCPCS coding, guidance shall be provided by
1069 the Physicians’ Current Procedural Terminology (CPT) or the
1070 Healthcare Correct Procedural Coding System (HCPCS) in effect
1071 for the year in which services were rendered, the Office of the
1072 Inspector General (OIG), Physicians Compliance Guidelines, and
1073 other authoritative treatises designated by rule by the Agency
1074 for Health Care Administration. A No statement of medical
1075 services may not include charges for medical services of a
1076 person or entity that performed such services without possessing
1077 the valid licenses required to perform such services. For
1078 purposes of paragraph (4)(b), an insurer is shall not be
1079 considered to have been furnished with notice of the amount of
1080 covered loss or medical bills due unless the statements or bills
1081 comply with this paragraph, and unless the statements or bills
1082 are properly completed in their entirety as to all material
1083 provisions, with all relevant information being provided
1084 therein.
1085 (e)1. At the initial treatment or service provided, each
1086 physician, other licensed professional, clinic, or other medical
1087 institution providing medical services upon which a claim for
1088 personal injury protection benefits is based shall require an
1089 insured person, or his or her guardian, to execute a disclosure
1090 and acknowledgment form, which reflects at a minimum that:
1091 a. The insured, or his or her guardian, must countersign
1092 the form attesting to the fact that the services set forth
1093 therein were actually rendered;
1094 b. The insured, or his or her guardian, has both the right
1095 and affirmative duty to confirm that the services were actually
1096 rendered;
1097 c. The insured, or his or her guardian, was not solicited
1098 by any person to seek any services from the medical provider;
1099 d. The physician, other licensed professional, clinic, or
1100 other medical institution rendering services for which payment
1101 is being claimed explained the services to the insured or his or
1102 her guardian; and
1103 e. If the insured notifies the insurer in writing of a
1104 billing error, the insured may be entitled to a certain
1105 percentage of a reduction in the amounts paid by the insured’s
1106 motor vehicle insurer.
1107 2. The physician, other licensed professional, clinic, or
1108 other medical institution rendering services for which payment
1109 is being claimed has the affirmative duty to explain the
1110 services rendered to the insured, or his or her guardian, so
1111 that the insured, or his or her guardian, countersigns the form
1112 with informed consent.
1113 3. Countersignature by the insured, or his or her guardian,
1114 is not required for the reading of diagnostic tests or other
1115 services that are of such a nature that they are not required to
1116 be performed in the presence of the insured.
1117 4. The licensed medical professional rendering treatment
1118 for which payment is being claimed must sign, by his or her own
1119 hand, the form complying with this paragraph.
1120 5. The original completed disclosure and acknowledgment
1121 form shall be furnished to the insurer pursuant to paragraph
1122 (4)(b) and may not be electronically furnished.
1123 6. The This disclosure and acknowledgment form is not
1124 required for services billed by a provider for emergency
1125 services as defined in s. 395.002, for emergency services and
1126 care as defined in s. 395.002 rendered in a hospital emergency
1127 department, or for transport and treatment rendered by an
1128 ambulance provider licensed pursuant to part III of chapter 401.
1129 7. The Financial Services Commission shall adopt, by rule,
1130 a standard disclosure and acknowledgment form to that shall be
1131 used to fulfill the requirements of this paragraph, effective 90
1132 days after such form is adopted and becomes final. The
1133 commission shall adopt a proposed rule by October 1, 2003. Until
1134 the rule is final, the provider may use a form of its own which
1135 otherwise complies with the requirements of this paragraph.
1136 8. As used in this paragraph, the term “countersign” or
1137 “countersignature” “countersigned” means a second or verifying
1138 signature, as on a previously signed document, and is not
1139 satisfied by the statement “signature on file” or any similar
1140 statement.
1141 9. The requirements of this paragraph apply only with
1142 respect to the initial treatment or service of the insured by a
1143 provider. For subsequent treatments or service, the provider
1144 must maintain a patient log signed by the patient, in
1145 chronological order by date of service, which that is consistent
1146 with the services being rendered to the patient as claimed. The
1147 requirement to maintain requirements of this subparagraph for
1148 maintaining a patient log signed by the patient may be met by a
1149 hospital that maintains medical records as required by s.
1150 395.3025 and applicable rules and makes such records available
1151 to the insurer upon request.
1152 (f) Upon written notification by any person, an insurer
1153 shall investigate any claim of improper billing by a physician
1154 or other medical provider. The insurer shall determine if the
1155 insured was properly billed for only those services and
1156 treatments that the insured actually received. If the insurer
1157 determines that the insured has been improperly billed, the
1158 insurer shall notify the insured, the person making the written
1159 notification, and the provider of its findings and shall reduce
1160 the amount of payment to the provider by the amount determined
1161 to be improperly billed. If a reduction is made due to a such
1162 written notification by any person, the insurer shall pay to the
1163 person 20 percent of the amount of the reduction, up to $500. If
1164 the provider is arrested due to the improper billing, then the
1165 insurer shall pay to the person 40 percent of the amount of the
1166 reduction, up to $500.
1167 (g) An insurer may not systematically downcode with the
1168 intent to deny reimbursement otherwise due. Such action
1169 constitutes a material misrepresentation under s.
1170 626.9541(1)(i)2.
1171 (h) As provided in s. 400.9905, an entity excluded from the
1172 definition of a clinic shall be deemed a clinic and must be
1173 licensed under part X of chapter 400 in order to receive
1174 reimbursement under ss. 627.730-627.7405. However, this
1175 licensing requirement does not apply to:
1176 1. An entity wholly owned by a physician licensed under
1177 chapter 458 or chapter 459, or by the physician and the spouse,
1178 parent, child, or sibling of the physician;
1179 2. An entity wholly owned by a dentist licensed under
1180 chapter 466, or by the dentist and the spouse, parent, child, or
1181 sibling of the dentist;
1182 3. An entity wholly owned by a chiropractic physician
1183 licensed under chapter 460, or by the chiropractic physician and
1184 the spouse, parent, child, or sibling of the chiropractic
1185 physician;
1186 4. A hospital or ambulatory surgical center licensed under
1187 chapter 395; or
1188 5. An entity wholly owned, directly or indirectly, by a
1189 hospital or hospitals licensed under chapter 395.
1190 (6) DISCOVERY OF FACTS ABOUT AN INJURED PERSON; DISPUTES.—
1191 (a) Every employer shall, If a request is made by an
1192 insurer providing personal injury protection benefits under ss.
1193 627.730-627.7405 against whom a claim has been made, an employer
1194 must furnish forthwith, in a form approved by the office, a
1195 sworn statement of the earnings, since the time of the bodily
1196 injury and for a reasonable period before the injury, of the
1197 person upon whose injury the claim is based.
1198 (b) Every physician, hospital, clinic, or other medical
1199 institution providing, before or after bodily injury upon which
1200 a claim for personal injury protection insurance benefits is
1201 based, any products, services, or accommodations in relation to
1202 that or any other injury, or in relation to a condition claimed
1203 to be connected with that or any other injury, shall, if
1204 requested to do so by the insurer against whom the claim has
1205 been made, furnish forthwith a written report of the history,
1206 condition, treatment, dates, and costs of such treatment of the
1207 injured person and why the items identified by the insurer were
1208 reasonable in amount and medically necessary, together with a
1209 sworn statement that the treatment or services rendered were
1210 reasonable and necessary with respect to the bodily injury
1211 sustained and identifying which portion of the expenses for such
1212 treatment or services was incurred as a result of such bodily
1213 injury, and produce forthwith, and allow permit the inspection
1214 and copying of, his or her or its records regarding such
1215 history, condition, treatment, dates, and costs of treatment if;
1216 provided that this does shall not limit the introduction of
1217 evidence at trial. Such sworn statement must shall read as
1218 follows: “Under penalty of perjury, I declare that I have read
1219 the foregoing, and the facts alleged are true, to the best of my
1220 knowledge and belief.” A No cause of action for violation of the
1221 physician-patient privilege or invasion of the right of privacy
1222 may not be brought shall be permitted against any physician,
1223 hospital, clinic, or other medical institution complying with
1224 the provisions of this section. The person requesting such
1225 records and such sworn statement shall pay all reasonable costs
1226 connected therewith. If an insurer makes a written request for
1227 documentation or information under this paragraph within 30 days
1228 after having received notice of the amount of a covered loss
1229 under paragraph (4)(a), the amount or the partial amount that
1230 which is the subject of the insurer’s inquiry is shall become
1231 overdue if the insurer does not pay in accordance with paragraph
1232 (4)(b) or within 10 days after the insurer’s receipt of the
1233 requested documentation or information, whichever occurs later.
1234 As used in For purposes of this paragraph, the term “receipt”
1235 includes, but is not limited to, inspection and copying pursuant
1236 to this paragraph. An Any insurer that requests documentation or
1237 information pertaining to reasonableness of charges or medical
1238 necessity under this paragraph without a reasonable basis for
1239 such requests as a general business practice is engaging in an
1240 unfair trade practice under the insurance code.
1241 (c) In the event of a any dispute regarding an insurer’s
1242 right to discovery of facts under this section, the insurer may
1243 petition a court of competent jurisdiction to enter an order
1244 permitting such discovery. The order may be made only on motion
1245 for good cause shown and upon notice to all persons having an
1246 interest, and must it shall specify the time, place, manner,
1247 conditions, and scope of the discovery. Such court may, In order
1248 to protect against annoyance, embarrassment, or oppression, as
1249 justice requires, the court may enter an order refusing
1250 discovery or specifying conditions of discovery and may order
1251 payments of costs and expenses of the proceeding, including
1252 reasonable fees for the appearance of attorneys at the
1253 proceedings, as justice requires.
1254 (d) The injured person shall be furnished, upon request, a
1255 copy of all information obtained by the insurer under the
1256 provisions of this section, and shall pay a reasonable charge,
1257 if required by the insurer.
1258 (e) Notice to an insurer of the existence of a claim may
1259 shall not be unreasonably withheld by an insured.
1260 (f) In a dispute between the insured and the insurer, or
1261 between an assignee of the insured’s rights and the insurer, the
1262 insurer must notify the insured or the assignee that the policy
1263 limits under this section have been reached within 15 days after
1264 the limits have been reached.
1265 (8) APPLICABILITY OF PROVISION REGULATING ATTORNEY
1266 ATTORNEY’S FEES.—With respect to any dispute under the
1267 provisions of ss. 627.730-627.7405 between the insured and the
1268 insurer, or between an assignee of an insured’s rights and the
1269 insurer, the provisions of ss. s. 627.428 and 768.79 shall
1270 apply, except as provided in subsections (10) and (15).
1271 (9) PREFERRED PROVIDERS.—An insurer may negotiate and
1272 contract enter into contracts with preferred licensed health
1273 care providers for the benefits described in this section,
1274 referred to in this section as “preferred providers,” which
1275 shall include health care providers licensed under chapter
1276 chapters 458, chapter 459, chapter 460, chapter 461, or chapter
1277 and 463. The insurer may provide an option to an insured to use
1278 a preferred provider at the time of purchasing purchase of the
1279 policy for personal injury protection benefits, if the
1280 requirements of this subsection are met. If the insured elects
1281 to use a provider who is not a preferred provider, whether the
1282 insured purchased a preferred provider policy or a nonpreferred
1283 provider policy, the medical benefits provided by the insurer
1284 shall be as required by this section. If the insured elects to
1285 use a provider who is a preferred provider, the insurer may pay
1286 medical benefits in excess of the benefits required by this
1287 section and may waive or lower the amount of any deductible that
1288 applies to such medical benefits. If the insurer offers a
1289 preferred provider policy to a policyholder or applicant, it
1290 must also offer a nonpreferred provider policy. The insurer
1291 shall provide each insured policyholder with a current roster of
1292 preferred providers in the county in which the insured resides
1293 at the time of purchase of such policy, and shall make such list
1294 available for public inspection during regular business hours at
1295 the insurer’s principal office of the insurer within the state.
1296 (10) DEMAND LETTER.—
1297 (a) As a condition precedent to filing any action for
1298 benefits under this section, the insurer must be provided with
1299 written notice of an intent to initiate litigation must be
1300 provided to the insurer. Such notice may not be sent until the
1301 claim is overdue, including any additional time the insurer has
1302 to pay the claim pursuant to paragraph (4)(b).
1303 (b) The notice must required shall state that it is a
1304 “demand letter under s. 627.736(10)” and shall state with
1305 specificity:
1306 1. The name of the insured upon which such benefits are
1307 being sought, including a copy of the assignment giving rights
1308 to the claimant if the claimant is not the insured.
1309 2. The claim number or policy number upon which such claim
1310 was originally submitted to the insurer.
1311 3. To the extent applicable, the name of any medical
1312 provider who rendered to an insured the treatment, services,
1313 accommodations, or supplies that form the basis of such claim;
1314 and an itemized statement specifying each exact amount, the date
1315 of treatment, service, or accommodation, and the type of benefit
1316 claimed to be due. A completed form satisfying the requirements
1317 of paragraph (5)(d) or the lost-wage statement previously
1318 submitted may be used as the itemized statement. To the extent
1319 that the demand involves an insurer’s withdrawal of payment
1320 under paragraph (7)(a) for future treatment not yet rendered,
1321 the claimant shall attach a copy of the insurer’s notice
1322 withdrawing such payment and an itemized statement of the type,
1323 frequency, and duration of future treatment claimed to be
1324 reasonable and medically necessary.
1325 (c) Each notice required by this subsection must be
1326 delivered to the insurer by United States certified or
1327 registered mail, return receipt requested. Such postal costs
1328 shall be reimbursed by the insurer if so requested by the
1329 claimant in the notice, when the insurer pays the claim. Such
1330 notice must be sent to the person and address specified by the
1331 insurer for the purposes of receiving notices under this
1332 subsection. Each licensed insurer, whether domestic, foreign, or
1333 alien, shall file with the office designation of the name and
1334 address of the person to whom notices must pursuant to this
1335 subsection shall be sent which the office shall make available
1336 on its Internet website. The name and address on file with the
1337 office pursuant to s. 624.422 are shall be deemed the authorized
1338 representative to accept notice pursuant to this subsection if
1339 in the event no other designation has been made.
1340 (d) If, within 30 days after receipt of notice by the
1341 insurer, the overdue claim specified in the notice is paid by
1342 the insurer together with applicable interest and a penalty of
1343 10 percent of the overdue amount paid by the insurer, subject to
1344 a maximum penalty of $250, no action may be brought against the
1345 insurer. If the demand involves an insurer’s withdrawal of
1346 payment under paragraph (7)(a) for future treatment not yet
1347 rendered, no action may be brought against the insurer if,
1348 within 30 days after its receipt of the notice, the insurer
1349 mails to the person filing the notice a written statement of the
1350 insurer’s agreement to pay for such treatment in accordance with
1351 the notice and to pay a penalty of 10 percent, subject to a
1352 maximum penalty of $250, when it pays for such future treatment
1353 in accordance with the requirements of this section. To the
1354 extent the insurer determines not to pay any amount demanded,
1355 the penalty is shall not be payable in any subsequent action.
1356 For purposes of this subsection, payment or the insurer’s
1357 agreement shall be treated as being made on the date a draft or
1358 other valid instrument that is equivalent to payment, or the
1359 insurer’s written statement of agreement, is placed in the
1360 United States mail in a properly addressed, postpaid envelope,
1361 or if not so posted, on the date of delivery. The insurer is not
1362 obligated to pay any attorney attorney’s fees if the insurer
1363 pays the claim or mails its agreement to pay for future
1364 treatment within the time prescribed by this subsection.
1365 (e) The applicable statute of limitation for an action
1366 under this section shall be tolled for a period of 30 business
1367 days by the mailing of the notice required by this subsection.
1368 (f) Any insurer making a general business practice of not
1369 paying valid claims until receipt of the notice required by this
1370 subsection is engaging in an unfair trade practice under the
1371 insurance code.
1372 (11) FAILURE TO PAY VALID CLAIMS; UNFAIR OR DECEPTIVE
1373 PRACTICE.—
1374 (a) If An insurer fails to pay valid claims for personal
1375 injury protection with such frequency so as to indicate a
1376 general business practice, the insurer is engaging in a
1377 prohibited unfair or deceptive practice that is subject to the
1378 penalties provided in s. 626.9521 and the office has the powers
1379 and duties specified in ss. 626.9561-626.9601 if the insurer,
1380 with such frequency so as to indicate a general business
1381 practice: with respect thereto
1382 1. Fails to pay valid claims for personal injury
1383 protection; or
1384 2. Fails to pay valid claims until receipt of the notice
1385 required by subsection (10).
1386 (b) Notwithstanding s. 501.212, the Department of Legal
1387 Affairs may investigate and initiate actions for a violation of
1388 this subsection, including, but not limited to, the powers and
1389 duties specified in part II of chapter 501.
1390 Section 9. Effective December 1, 2012, subsection (16) of
1391 section 627.736, Florida Statutes, is amended to read:
1392 627.736 Required personal injury protection benefits;
1393 exclusions; priority; claims.—
1394 (16) SECURE ELECTRONIC DATA TRANSFER.—If all parties
1395 mutually and expressly agree, A notice, documentation,
1396 transmission, or communication of any kind required or
1397 authorized under ss. 627.730-627.7405 may be transmitted
1398 electronically if it is transmitted by secure electronic data
1399 transfer that is consistent with state and federal privacy and
1400 security laws.
1401 Section 10. Subsections (1), (10), and (13) of section
1402 817.234, Florida Statutes, are amended to read:
1403 817.234 False and fraudulent insurance claims.—
1404 (1)(a) A person commits insurance fraud punishable as
1405 provided in subsection (11) if that person, with the intent to
1406 injure, defraud, or deceive any insurer:
1407 1. Presents or causes to be presented any written or oral
1408 statement as part of, or in support of, a claim for payment or
1409 other benefit pursuant to an insurance policy or a health
1410 maintenance organization subscriber or provider contract,
1411 knowing that such statement contains any false, incomplete, or
1412 misleading information concerning any fact or thing material to
1413 such claim;
1414 2. Prepares or makes any written or oral statement that is
1415 intended to be presented to any insurer in connection with, or
1416 in support of, any claim for payment or other benefit pursuant
1417 to an insurance policy or a health maintenance organization
1418 subscriber or provider contract, knowing that such statement
1419 contains any false, incomplete, or misleading information
1420 concerning any fact or thing material to such claim; or
1421 3.a. Knowingly presents, causes to be presented, or
1422 prepares or makes with knowledge or belief that it will be
1423 presented to any insurer, purported insurer, servicing
1424 corporation, insurance broker, or insurance agent, or any
1425 employee or agent thereof, any false, incomplete, or misleading
1426 information or written or oral statement as part of, or in
1427 support of, an application for the issuance of, or the rating
1428 of, any insurance policy, or a health maintenance organization
1429 subscriber or provider contract; or
1430 b. Who Knowingly conceals information concerning any fact
1431 material to such application; or.
1432 4. Knowingly presents, causes to be presented, or prepares
1433 or makes with knowledge or belief that it will be presented to
1434 any insurer a claim for payment or other benefit under a
1435 personal injury protection insurance policy if the person knows
1436 that the payee knowingly submitted a false, misleading, or
1437 fraudulent application or other document when applying for
1438 licensure as a health care clinic, seeking an exemption from
1439 licensure as a health care clinic, or demonstrating compliance
1440 with part X of chapter 400.
1441 (b) All claims and application forms must shall contain a
1442 statement that is approved by the Office of Insurance Regulation
1443 of the Financial Services Commission which clearly states in
1444 substance the following: “Any person who knowingly and with
1445 intent to injure, defraud, or deceive any insurer files a
1446 statement of claim or an application containing any false,
1447 incomplete, or misleading information is guilty of a felony of
1448 the third degree.” This paragraph does shall not apply to
1449 reinsurance contracts, reinsurance agreements, or reinsurance
1450 claims transactions.
1451 (10) A licensed health care practitioner who is found
1452 guilty of insurance fraud under this section for an act relating
1453 to a personal injury protection insurance policy loses his or
1454 her license to practice for 5 years and may not receive
1455 reimbursement for personal injury protection benefits for 10
1456 years. As used in this section, the term “insurer” means any
1457 insurer, health maintenance organization, self-insurer, self
1458 insurance fund, or other similar entity or person regulated
1459 under chapter 440 or chapter 641 or by the Office of Insurance
1460 Regulation under the Florida Insurance Code.
1461 (13) As used in this section, the term:
1462 (a) “Insurer” means any insurer, health maintenance
1463 organization, self-insurer, self-insurance fund, or similar
1464 entity or person regulated under chapter 440 or chapter 641 or
1465 by the Office of Insurance Regulation under the Florida
1466 Insurance Code.
1467 (b)(a) “Property” means property as defined in s. 812.012.
1468 (c)(b) “Value” means value as defined in s. 812.012.
1469 Section 11. Subsection (4) of section 316.065, Florida
1470 Statutes, is amended to read:
1471 316.065 Crashes; reports; penalties.—
1472 (4) Any person who knowingly repairs a motor vehicle
1473 without having made a report as required by subsection (3) is
1474 guilty of a misdemeanor of the first degree, punishable as
1475 provided in s. 775.082 or s. 775.083. The owner and driver of a
1476 vehicle involved in a crash who makes a report thereof in
1477 accordance with subsection (1) or s. 316.066(1) is not liable
1478 under this section.
1479 Section 12. The Office of Insurance Regulation shall
1480 perform a comprehensive personal injury protection data call and
1481 publish the results by January 1, 2015. It is the intent of the
1482 Legislature that the office design the data call with the
1483 expectation that the Legislature will use the data to help
1484 evaluate market conditions relating to the Florida Motor Vehicle
1485 No-Fault Law and the impact on the market of reforms to the law
1486 made by this act. The elements of the data call must address,
1487 but need not be limited to, the following components of the
1488 Florida Motor Vehicle No-Fault Law:
1489 (1) Quantity of personal injury protection claims.
1490 (2) Type or nature of claimants.
1491 (3) Amount and type of personal injury protection benefits
1492 paid and expenses incurred.
1493 (4) Type and quantity of, and charges for, medical
1494 benefits.
1495 (5) Attorney fees related to bringing and defending actions
1496 for benefits.
1497 (6) Direct earned premiums for personal injury protection
1498 coverage, pure loss ratios, pure premiums, and other information
1499 related to premiums and losses.
1500 (7) Licensed drivers and accidents.
1501 (8) Fraud and enforcement.
1502 Section 13. If any provision of this act or its application
1503 to any person or circumstance is held invalid, the invalidity
1504 does not affect other provisions or applications of the act
1505 which can be given effect without the invalid provision or
1506 application, and to this end the provisions of this act are
1507 severable.
1508 Section 14. Except as otherwise expressly provided in this
1509 act, this act shall take effect July 1, 2012.