Senate Bill 1508
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Florida Senate - 2000 SB 1508
By Senator Brown-Waite
10-600-00
1 A bill to be entitled
2 An act relating to health maintenance
3 organizations; amending s. 641.315, F.S.;
4 revising provisions relating to provider
5 billing; amending s. 641.3155, F.S.; defining
6 the term "clean claim"; providing timeframes
7 for interest payment on late and overdue claim
8 payments; providing a schedule for electronic
9 billing; mandating acknowledgment of receipts
10 for electronically submitted claims; specifying
11 timeframes for duplicate billing; creating s.
12 641.3156, F.S.; providing for treatment
13 authorization and payment of claims; amending
14 s. 641.495, F.S.; revising provisions relating
15 to treatment authorization capabilities;
16 creating s. 408.7057, F.S.; providing for the
17 establishment of a statewide provider and
18 managed-care-organization claim-dispute
19 mediation panel; granting rulemaking authority
20 to the Agency for Health Care Administration;
21 providing an effective date.
22
23 Be It Enacted by the Legislature of the State of Florida:
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25 Section 1. Section 641.315, Florida Statutes, is
26 amended to read:
27 641.315 Provider contracts.--
28 (1) If Whenever a contract exists between a health
29 maintenance organization and a provider and the organization
30 fails to meet its obligations to pay fees for services already
31 rendered to a subscriber, the health maintenance organization
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1 is shall be liable for such fee or fees rather than the
2 subscriber; and the contract must shall so state.
3 (2) A No subscriber of an HMO is not shall be liable
4 to any provider of health care services for any services
5 covered by the HMO.
6 (3) A No provider of services or any representative of
7 such provider may not shall collect or attempt to collect from
8 an HMO subscriber any money for services covered by an HMO,
9 and a no provider or representative of the such provider may
10 not maintain any action at law against a subscriber of an HMO
11 to collect money owed to the such provider by an HMO. The
12 provider may not bill the subscriber during any ongoing
13 dispute-resolution process. The responsibility for claims
14 payment to providers rests with the HMO/MCO and not with any
15 party to which the HMO/MCO has delegated the functions of
16 claims or management claims processing, or both. A provider of
17 services or a representative of the provider may not report a
18 subscriber to a credit agency for unpaid claims due from an
19 HMO/MCO for covered HMO services. A violation of this
20 subsection by an individual physician or a physician practice
21 must be referred to the agency for investigation and to the
22 Board of Medicine for final disciplinary action as part of the
23 current Medical Quality Assurance Program. A violation by a
24 facility must be referred to the agency. A violation of this
25 subsection by an institutional provider must be referred to
26 the agency for investigation as part of the agency's current
27 Consumer Assistance Program.
28 (4) Each Every contract between an HMO and a provider
29 of health care services must shall be in writing and shall
30 contain a provision that the subscriber is shall not be liable
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1 to the provider for any services covered by the subscriber's
2 contract with the HMO.
3 (5) The provisions of This section does shall not be
4 construed to apply to the amount of any deductible or
5 copayment which is not covered by the contract of the HMO.
6 (6)(a) For all provider contracts executed after
7 October 1, 1991, and within 180 days after October 1, 1991,
8 for contracts in existence as of October 1, 1991:
9 1. The contracts must require provide that the
10 provider to shall provide 60 days' advance written notice to
11 the health maintenance organization and the department before
12 canceling the contract with the health maintenance
13 organization for any reason; and
14 2. The contract must also provide that nonpayment for
15 goods or services rendered by the provider to the health
16 maintenance organization is shall not be a valid reason for
17 avoiding the 60-day advance notice of cancellation.
18 (b) For all provider contracts executed after October
19 1, 1996, and within 180 days after October 1, 1996, for
20 contracts in existence as of October 1, 1996, the contracts
21 must provide that the health maintenance organization will
22 provide 60 days' advance written notice to the provider and
23 the department before canceling, without cause, the contract
24 with the provider, except in a case in which a patient's
25 health is subject to imminent danger or a physician's ability
26 to practice medicine is effectively impaired by an action by
27 the Board of Medicine or other governmental agency.
28 (7) Upon receipt by the health maintenance
29 organization of a 60-day cancellation notice, the health
30 maintenance organization may, if requested by the provider,
31 terminate the contract in less than 60 days if the health
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1 maintenance organization is not financially impaired or
2 insolvent.
3 (8) A contract between a health maintenance
4 organization and a provider of health care services may shall
5 not restrict contain any provision restricting the provider's
6 ability to communicate information to the provider's patient
7 regarding medical care or treatment options for the patient
8 when the provider deems knowledge of such information by the
9 patient to be in the best interest of the health of the
10 patient.
11 (9) A contract between a health maintenance
12 organization and a provider of health care services may not
13 contain any provision that in any way prohibits or restricts:
14 (a) The health care provider from entering into a
15 commercial contract with any other health maintenance
16 organization; or
17 (b) The health maintenance organization from entering
18 into a commercial contract with any other health care
19 provider.
20 (10) A health maintenance organization or health care
21 provider may not terminate a contract with a health care
22 provider or health maintenance organization unless the party
23 terminating the contract provides the terminated party with a
24 written reason for the contract termination, which may include
25 termination for business reasons of the terminating party. The
26 reason provided in the notice required by in this section or
27 any other information relating to the reason for termination
28 does not create any new administrative or civil action and may
29 not be used as substantive evidence in any such action, but
30 may be used for impeachment purposes. As used in this
31 subsection, the term "health care provider" means a physician
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1 licensed under chapter 458, chapter 459, chapter 460, or
2 chapter 461, or a dentist licensed under chapter 466.
3 Section 2. Section 641.3155, Florida Statutes, is
4 amended to read:
5 641.3155 Provider contracts; payment of claims.--
6 (1)(a) As used in this section, the term "clean claim"
7 means either:
8 1. An institutional claim that is a properly completed
9 billing instrument (paper or electronic), consisting of the
10 UB-92 data set or its successor, and submitted on the
11 designated paper or electronic format adopted by the National
12 Uniform Billing Committee (NUBC) with entries designated as
13 mandatory by the NUBC, together with any data required by the
14 state uniform billing committee and included in the UB-92
15 manual that is in effect at the time of service; or
16 2. The definition established within an executed and
17 current provider contract.
18 (b) The term "clean claim" as used in this section
19 does not involve coordination of benefits (COB) for
20 third-party liability or subrogation as evidenced by the
21 information provided on the claim related to COB.
22 (c) The definition prescribed in paragraph (a) is
23 inapplicable to claims against a physician's practice. With
24 respect to a physician's practice, the definition of the term
25 "clean claim" must be agreed upon by contract.
26 (2)(1)(a) A health maintenance organization shall pay
27 any clean claim or any portion of a clean claim made by a
28 contract provider for services or goods provided under a
29 contract with the health maintenance organization which the
30 organization does not contest or deny within 35 days after
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1 receipt of the claim by the health maintenance organization
2 which is mailed or electronically transferred by the provider.
3 (b) A health maintenance organization that denies or
4 contests a provider's claim or any portion of a claim shall
5 notify the contract provider, in writing, within 35 days after
6 receipt of the claim by the health maintenance organization
7 receives the claim that the claim is contested or denied. The
8 notice that the claim is denied or contested must identify the
9 contested portion of the claim and the specific reason for
10 contesting or denying the claim, and must may include a
11 request for additional information. If the provider submits
12 health maintenance organization requests additional
13 information, the provider must shall, within 35 days after
14 receipt of the such request, mail or electronically transfer
15 the information to the health maintenance organization. The
16 health maintenance organization shall pay or deny the claim or
17 portion of the claim within 45 days after receipt of the
18 information.
19 (3)(2) Payment of a claim is considered made on the
20 date the payment was received or electronically transferred or
21 otherwise delivered. An overdue payment of a claim bears
22 simple interest at the rate of 10 percent per year. Interest
23 on an overdue payment for a clean claim or for any uncontested
24 portion of a clean claim begins to accrue on the 36th day
25 after the claim has been received. The interest is payable
26 with the payment of the claim. Interest on overpayments made
27 to providers begins to accrue on the 36th day after the
28 provider receives notice of overpayment. Upon the 36th day,
29 plans must be allowed to offset any interest payment due
30 against future claims.
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1 (4)(3) A health maintenance organization shall pay or
2 deny any claim no later than 120 days after receiving the
3 claim.
4 (5)(4) Any retroactive reductions of payments or
5 demands for refund of previous overpayments which are due to
6 retroactive review-of-coverage decisions or payment levels
7 must be reconciled to specific claims unless the parties agree
8 to other reconciliation methods and terms. Any retroactive
9 demands by providers for payment due to underpayments or
10 nonpayments for covered services must be reconciled to
11 specific claims unless the parties agree to other
12 reconciliation methods and terms. The look-back period may be
13 specified by the terms of the contract.
14 (6) Providers must implement electronic billing in
15 accordance with the implementation schedule established by the
16 National Uniform Billing Committee. The department may grant
17 special consideration and variance to the implementation
18 schedule to rural hospitals and physician's practices.
19 (7) Providers who bill electronically are entitled to
20 electronic acknowledgement of receipts of claims within 48
21 hours. Providers must wait 45 days before submitting duplicate
22 bills if confirmation of receipt was received from the plan.
23 (8) The time limit for recouping or collecting
24 outstanding claims may not exceed 1 year for either a
25 contracted or a noncontracted provider.
26 Section 3. Section 641.3156, Florida Statutes, is
27 created to read:
28 641.3156 Treatment authorization; payment of claims.--
29 (1) A health maintenance organization must pay any
30 hospital-service or referral-service claim for treatment that
31 was authorized by a physician empowered by the HMO/MCO to
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1 authorize or direct the patient's utilization of health care
2 services and that was also authorized in accordance with the
3 HMO/MCO's current and communicated procedures.
4 (2) A claim for treatment that was authorized in
5 accordance with this section may not be denied retroactively
6 by the HMO/MCO unless:
7 (a) The service is not covered;
8 (b) The subscriber was ineligible at the time the
9 services were rendered; or
10 (c) The physician provided information to the health
11 maintenance organization with the willful intention to
12 misinform the health maintenance organization.
13 Section 4. Subsection (4) of section 641.495, Florida
14 Statutes, is amended to read:
15 641.495 Requirements for issuance and maintenance of
16 certificate.--
17 (4) The organization shall ensure that the health care
18 services it provides to subscribers, including physician
19 services as required by s. 641.19(13)(d) and (e), are
20 accessible to the subscribers, with reasonable promptness,
21 with respect to geographic location, hours of operation,
22 provision of after-hours service, and staffing patterns within
23 generally accepted industry norms for meeting the projected
24 subscriber needs. The health maintenance organization must be
25 able to provide treatment authorization 24 hours a day, 7 days
26 a week. Requests for treatment authorization may not be held
27 pending unless the requesting provider contractually agrees to
28 take a pending or tracking number.
29 Section 5. Section 408.7057, Florida Statutes, is
30 created to read:
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1 408.7057 Statewide provider and managed care
2 organization claim dispute mediation panel.--
3 (1) As used in this section, the term:
4 (a) "Managed care entity" means a health maintenance
5 organization or a prepaid health clinic certified under
6 chapter 641, a prepaid health plan authorized under s.
7 409.912, or an exclusive provider organization certified under
8 s. 627.6472.
9 (b) "Panel" means a statewide provider and managed
10 care claim dispute mediation panel selected as provided in
11 subsection (7).
12 (2)(a) The Agency for Health Care Administration shall
13 establish a program to provide assistance to contracting and
14 noncontracting providers and managed care organizations for
15 those claim disputes that are in violation of s. 641.3155 and
16 are not resolved by the provider and the managed care entity.
17 The program must consist of one or more panels that meet as
18 often as necessary to timely review, consider, and hear claim
19 disputes and to recommend to the agency any actions that
20 should be taken concerning individual cases heard by the
21 panel.
22 (b) The panel shall hear claim disputes filed by
23 participating and nonparticipating providers and managed care
24 organizations unless the disputed claim:
25 1. Is related to interest payment;
26 2. Is for an amount of $5,000 or less for a claim
27 against an institution or $1,000 or less for a claim against
28 an individual physician;
29 3. Is part of an internal grievance in a Medicare
30 managed care entity or a reconsideration appeal through the
31 Medicare appeals process;
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1 4. Is related to a health plan that is not regulated
2 by the state, such as an administrative services organization,
3 a third-party administrator, or a federal employee health
4 benefit program;
5 5. Is part of a Medicaid fair hearing pursued under 42
6 C.F.R. ss. 431.220 et seq.;
7 6. Is the basis for an action pending in state or
8 federal court; or
9 7. Was filed before the provider or the managed care
10 organization made a good-faith effort to resolve the dispute.
11 (c) Failure of the provider or the managed care entity
12 that is filing for claim dispute resolution to attend the
13 hearing constitutes a withdrawal of the request.
14 (3) Within 30 days after receiving a request for claim
15 dispute resolution, the agency shall review the request and
16 determine whether the grievance will be heard. Once the agency
17 notifies the panel, the provider, and the managed care entity
18 that the panel will hear the request for claim-dispute
19 resolution, the panel must hear the claim dispute, in the
20 network area or by teleconference, no later than 60 days after
21 the agency has determined that the dispute will be heard. The
22 deadline may be waived if both the provider and the managed
23 care organization consent. The agency shall notify the
24 parties, in writing, by facsimile transmission, or by phone,
25 of the time and place of the hearing. The panel may take
26 testimony under oath, request certified copies of documents,
27 and take similar actions to collect information and
28 documentation that will assist the panel in making findings of
29 fact and a recommendation. Within 30 working days after
30 hearing the claim dispute, the panel shall issue a written
31 recommendation, supported by findings of fact, to the provider
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1 and managed care entity. If at the hearing the panel requests
2 additional documentation or additional records, the time for
3 issuing a recommendation is tolled until the requested
4 information or documentation has been provided to the panel.
5 The proceedings of the panel are not subject to chapter 120.
6 (4) If, upon receiving a proper patient authorization
7 together with a properly filed grievance, the agency requests
8 medical records, billing information, or claim records from a
9 health care provider or managed care entity, the health care
10 provider or managed care entity that has custody of the
11 records must provide the records to the agency within 10 days.
12 Failure to provide requested medical records may result in the
13 imposition of a fine in an amount of no more than $500. Each
14 day that records are not produced constitutes a separate
15 violation.
16 (5) After hearing the claim dispute, the panel shall
17 make its recommendation to the agency, which may require
18 payment of the unpaid portion of any claim not paid by the
19 managed care entity. Interest payment in the amount of 10
20 percent per year accrues from the date the provider files the
21 request for a hearing under this section.
22 (6) Within 30 days after the issuance of the panel's
23 recommendation, the agency may adopt the panel's
24 recommendation or findings of fact in a final order. The
25 agency may reject all or part of the panel's recommendation.
26 (7) The panel shall consist of five members, one of
27 whom is employed by the agency and one of whom is employed by
28 the department, chosen by their respective agencies; a medical
29 director of a managed care entity that holds a current
30 certificate of authority to operate in this state; a physician
31 who represents a hospital; and a physician licensed under
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1 chapter 458 or chapter 459. Each member of the panel must be
2 proficient in coding methodology.
3 (8) The entity that does not prevail at the hearing
4 must pay the reasonable costs and attorney's fees of the
5 agency or the department which were incurred in that
6 proceeding.
7 Section 6. The Agency for Health Care Administration
8 has the authority to adopt rules necessary for administering
9 this act.
10 Section 7. This act shall take effect October 1, 2000,
11 and shall apply to all requests for claim-dispute resolution
12 which are submitted by a provider or managed care entity after
13 September 30, 2000.
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16 SENATE SUMMARY
17 Relates to health maintenance organizations. Revises
provisions relating to provider billing. Defines the term
18 "clean claim." Provides timeframes for interest payment
on late and overdue claim payments. Provides a schedule
19 for electronic billing. Mandates acknowledgment of
receipts for electronically submitted claims. Specifies
20 timeframes for duplicate billing. Provides for treatment
authorization and payment of claims. Revises provisions
21 relating to treatment authorization capabilities.
Provides for the establishment of a statewide provider
22 and managed care organization claim-dispute mediation
panel. Grants rulemaking authority to the Agency for
23 Health Care Administration.
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