Senate Bill 1508er
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1
2 An act relating to managed care organizations;
3 amending s. 641.315, F.S.; deleting provisions
4 relating to provider billings; revising
5 provisions relating to provider contracts;
6 requiring a health maintenance organization to
7 make certain disclosures to a provider;
8 providing procedures for requesting and
9 granting authorization for utilization of
10 services; creating s. 641.3154, F.S.; providing
11 that a health maintenance organization is
12 liable for payment for services rendered to
13 subscribers; prohibiting a provider from
14 billing a subscriber under specified
15 circumstances; requiring a health maintenance
16 organization and the Department of Insurance to
17 report violations to the Department of Health
18 or the Agency for Health Care Administration;
19 amending s. 641.3155, F.S.; defining the term
20 "clean claim"; specifying the basis for
21 determining when a claim is to be considered
22 clean or not clean; requiring the Department of
23 Insurance to adopt rules to establish a claim
24 form; providing requirements; authorizing the
25 Department of Insurance to adopt rules for
26 coding standards; providing requirements for
27 paying clean claims; providing requirements for
28 denying or contesting a portion of a claim;
29 providing for interest accrual and payment of
30 interest; providing an uncontestable obligation
31 to pay a claim; requiring a health maintenance
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1 organization to make a claim for overpayment;
2 prohibiting an organization from reducing
3 payment for other services; providing
4 exceptions; requiring a provider to pay a claim
5 for overpayment within a specified time;
6 providing a procedure and timeframes for a
7 provider to notify a health maintenance
8 organization that it is denying or contesting a
9 claim for overpayment; specifying when a
10 provider payment of a claim for overpayment is
11 to be considered made; providing for assessment
12 of simple interest against overdue payment of a
13 claim; specifying when interest on overdue
14 payments of claims for overpayment begins to
15 accrue; specifying a timeframe for a provider
16 to deny or contest a claim for overpayment;
17 providing an uncontestable obligation to pay a
18 claim; specifying when a provider claim that is
19 electronically transmitted or mailed is
20 considered received; specifying when a health
21 maintenance organization claim for overpayment
22 is considered received; mandating
23 acknowledgment of receipts for electronically
24 submitted provider claims; prescribing a
25 timeframe for a health maintenance organization
26 to retroactively deny a claim for services
27 provided to an ineligible subscriber; creating
28 s. 641.3156, F.S.; providing for treatment
29 authorization and payment of claims by a health
30 maintenance organization; clarifying that
31 treatment authorization and payment of a claim
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1 for emergency services is subject to specified
2 provisions of law; amending s. 641.3903, F.S.;
3 providing that downcoding with intent to deny
4 reimbursement by a health maintenance
5 organization is an unfair method of competition
6 and an unfair or deceptive act or practice;
7 amending s. 641.3909, F.S.; authorizing the
8 Department of Insurance to issue a cease and
9 desist order for a violation of s. 641.3155,
10 F.S., relating to payment of claims; amending
11 s. 641.495, F.S.; revising provisions relating
12 to treatment-authorization capabilities;
13 requiring agreement to pending authorizations
14 and tracking numbers as a precondition to such
15 an authorization; creating s. 408.7057, F.S.;
16 providing for the establishment of a statewide
17 claim-dispute-resolution program for providers
18 and managed care organizations; providing
19 rulemaking authority to the Agency for Health
20 Care Administration; amending s. 395.1065,
21 F.S., relating to criminal and administrative
22 penalties for health care providers;
23 authorizing administrative sanctions against a
24 hospital's license for improper subscriber
25 billing and violations of requirements relating
26 to claims payment; amending s. 631.818, F.S.,
27 relating to the health maintenance organization
28 consumer assistance plan; conforming provisions
29 to changes made by the act; amending s.
30 817.234, F.S.; providing that certain actions
31 by a provider are punishable under s. 641.52,
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1 F.S., in addition to any other provision of
2 law; amending s. 817.50, F.S., relating to
3 fraud against hospitals; expanding
4 applicability to health care providers;
5 amending s. 641.31, F.S., relating to health
6 maintenance contracts; conforming a
7 cross-reference to changes made by the act;
8 providing applicability; providing an
9 appropriation; providing an effective date.
10
11 Be It Enacted by the Legislature of the State of Florida:
12
13 Section 1. Section 641.315, Florida Statutes, is
14 amended to read:
15 641.315 Provider contracts.--
16 (1) Whenever a contract exists between a health
17 maintenance organization and a provider and the organization
18 fails to meet its obligations to pay fees for services already
19 rendered to a subscriber, the health maintenance organization
20 shall be liable for such fee or fees rather than the
21 subscriber; and the contract shall so state.
22 (2) No subscriber of an HMO shall be liable to any
23 provider of health care services for any services covered by
24 the HMO.
25 (3) No provider of services or any representative of
26 such provider shall collect or attempt to collect from an HMO
27 subscriber any money for services covered by an HMO and no
28 provider or representative of such provider may maintain any
29 action at law against a subscriber of an HMO to collect money
30 owed to such provider by an HMO.
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1 (1)(4) Each Every contract between a health
2 maintenance organization an HMO and a provider of health care
3 services must shall be in writing and must shall contain a
4 provision that the subscriber is shall not be liable to the
5 provider for any services for which the health maintenance
6 organization is liable as specified in s. 641.3154 covered by
7 the subscriber's contract with the HMO.
8 (5) The provisions of this section shall not be
9 construed to apply to the amount of any deductible or
10 copayment which is not covered by the contract of the HMO.
11 (2)(6)(a) For all provider contracts executed after
12 October 1, 1991, and within 180 days after October 1, 1991,
13 for contracts in existence as of October 1, 1991:
14 1. The contracts must require provide that the
15 provider to give shall provide 60 days' advance written notice
16 to the health maintenance organization and the department
17 before canceling the contract with the health maintenance
18 organization for any reason; and
19 2. The contract must also provide that nonpayment for
20 goods or services rendered by the provider to the health
21 maintenance organization is shall not be a valid reason for
22 avoiding the 60-day advance notice of cancellation.
23 (b) For All provider contracts executed after October
24 1, 1996, and within 180 days after October 1, 1996, for
25 contracts in existence as of October 1, 1996, the contracts
26 must provide that the health maintenance organization will
27 provide 60 days' advance written notice to the provider and
28 the department before canceling, without cause, the contract
29 with the provider, except in a case in which a patient's
30 health is subject to imminent danger or a physician's ability
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1 to practice medicine is effectively impaired by an action by
2 the Board of Medicine or other governmental agency.
3 (3)(7) Upon receipt by the health maintenance
4 organization of a 60-day cancellation notice, the health
5 maintenance organization may, if requested by the provider,
6 terminate the contract in less than 60 days if the health
7 maintenance organization is not financially impaired or
8 insolvent.
9 (4) Whenever a contract exists between a health
10 maintenance organization and a provider, the health
11 maintenance organization shall disclose to the provider:
12 (a) The mailing address or electronic address where
13 claims should be sent for processing;
14 (b) The telephone number that a provider may call to
15 have questions and concerns regarding claims addressed; and
16 (c) The address of any separate claims-processing
17 centers for specific types of services.
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19 A health maintenance organization shall provide to its
20 contracted providers no less than 30 calendar days' prior
21 written notice of any changes in the information required in
22 this subsection.
23 (5)(8) A contract between a health maintenance
24 organization and a provider of health care services shall not
25 contain any provision restricting the provider's ability to
26 communicate information to the provider's patient regarding
27 medical care or treatment options for the patient when the
28 provider deems knowledge of such information by the patient to
29 be in the best interest of the health of the patient.
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1 (6)(9) A contract between a health maintenance
2 organization and a provider of health care services may not
3 contain any provision that in any way prohibits or restricts:
4 (a) The health care provider from entering into a
5 commercial contract with any other health maintenance
6 organization; or
7 (b) The health maintenance organization from entering
8 into a commercial contract with any other health care
9 provider.
10 (7)(10) A health maintenance organization or health
11 care provider may not terminate a contract with a health care
12 provider or health maintenance organization unless the party
13 terminating the contract provides the terminated party with a
14 written reason for the contract termination, which may include
15 termination for business reasons of the terminating party. The
16 reason provided in the notice required in this section or any
17 other information relating to the reason for termination does
18 not create any new administrative or civil action and may not
19 be used as substantive evidence in any such action, but may be
20 used for impeachment purposes. As used in this subsection, the
21 term "health care provider" means a physician licensed under
22 chapter 458, chapter 459, chapter 460, or chapter 461, or a
23 dentist licensed under chapter 466.
24 (8) The health maintenance organization must establish
25 written procedures for a contract provider to request and the
26 health maintenance organization to grant authorization for
27 utilization of health care services. The health maintenance
28 organization must give written notice to the contract provider
29 prior to any change in these procedures.
30 Section 2. Section 641.3154, Florida Statutes, is
31 created to read:
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1 641.3154 Organization liability; provider billing
2 prohibited.--
3 (1) If a health maintenance organization is liable for
4 services rendered to a subscriber by a provider, regardless of
5 whether a contract exists between the organization and the
6 provider, the organization is liable for payment of fees to
7 the provider and the subscriber is not liable for payment of
8 fees to the provider.
9 (2) For purposes of this section, a health maintenance
10 organization is liable for services rendered to an eligible
11 subscriber by a provider if the provider follows the health
12 maintenance organization's authorization procedures and
13 receives authorization for a covered service for an eligible
14 subscriber, unless the provider provided information to the
15 health maintenance organization with the willful intention to
16 misinform the health maintenance organization.
17 (3) The liability of an organization for payment of
18 fees for services is not affected by any contract the
19 organization has with a third party for the functions of
20 authorizing, processing, or paying claims.
21 (4) A provider or any representative of a provider,
22 regardless of whether the provider is under contract with the
23 health maintenance organization, may not collect or attempt to
24 collect money from, maintain any action at law against, or
25 report to a credit agency a subscriber of an organization for
26 payment of services for which the organization is liable, if
27 the provider in good faith knows or should know that the
28 organization is liable. This prohibition applies during the
29 pendency of any claim for payment made by the provider to the
30 organization for payment of the services and any legal
31 proceedings or dispute-resolution process to determine whether
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1 the organization is liable for the services if the provider is
2 informed that such proceedings are taking place. It is
3 presumed that a provider does not know and should not know
4 that an organization is liable unless:
5 (a) The provider is informed by the organization that
6 it accepts liability;
7 (b) A court of competent jurisdiction determines that
8 the organization is liable; or
9 (c) The department or agency makes a final
10 determination that the organization is required to pay for
11 such services subsequent to a recommendation made by the
12 Statewide Provider and Subscriber Assistance Panel pursuant to
13 s. 408.7056.
14 (5) An organization and the department shall report
15 any suspected violation of this section by a health care
16 practitioner to the Department of Health and by a facility to
17 the agency, which shall take such action as authorized by law.
18 Section 3. Section 641.3155, Florida Statutes, is
19 amended to read:
20 641.3155 Provider contracts; Payment of claims.--
21 (1)(a) As used in this section, the term "clean claim"
22 for a noninstitutional provider means a claim submitted on a
23 HCFA 1500 form which has no defect or impropriety, including
24 lack of required substantiating documentation for
25 noncontracted providers and suppliers, or particular
26 circumstances requiring special treatment which prevent timely
27 payment from being made on the claim. A claim may not be
28 considered not clean solely because a health maintenance
29 organization refers the claim to a medical specialist within
30 the health maintenance organization for examination. If
31 additional substantiating documentation, such as the medical
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1 record or encounter data, is required from a source outside
2 the health maintenance organization, the claim is considered
3 not clean. This definition of "clean claim" is repealed on the
4 effective date of rules adopted by the department which define
5 the term "clean claim."
6 (b) Absent a written definition that is agreed upon
7 through contract, the term "clean claim" for an institutional
8 claim is a properly and accurately completed paper or
9 electronic billing instrument that consists of the UB-92 data
10 set or its successor with entries stated as mandatory by the
11 National Uniform Billing Committee.
12 (c) The department shall adopt rules to establish
13 claim forms consistent with federal claim-filing standards for
14 health maintenance organizations required by the federal
15 Health Care Financing Administration. The department may adopt
16 rules relating to coding standards consistent with Medicare
17 coding standards adopted by the federal Health Care Financing
18 Administration.
19 (2)(1)(a) A health maintenance organization shall pay
20 any clean claim or any portion of a clean claim made by a
21 contract provider for services or goods provided under a
22 contract with the health maintenance organization or a clean
23 claim made by a noncontract provider which the organization
24 does not contest or deny within 35 days after receipt of the
25 claim by the health maintenance organization which is mailed
26 or electronically transferred by the provider.
27 (b) A health maintenance organization that denies or
28 contests a provider's claim or any portion of a claim shall
29 notify the contract provider, in writing, within 35 days after
30 receipt of the claim by the health maintenance organization
31 receives the claim that the claim is contested or denied. The
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1 notice that the claim is denied or contested must identify the
2 contested portion of the claim and the specific reason for
3 contesting or denying the claim, and, if contested, must may
4 include a request for additional information. If the provider
5 submits health maintenance organization requests additional
6 information, the provider must shall, within 35 days after
7 receipt of the such request, mail or electronically transfer
8 the information to the health maintenance organization. The
9 health maintenance organization shall pay or deny the claim or
10 portion of the claim within 45 days after receipt of the
11 information.
12 (3)(2) Payment of a claim is considered made on the
13 date the payment was received or electronically transferred or
14 otherwise delivered. An overdue payment of a claim bears
15 simple interest at the rate of 10 percent per year. Interest
16 on an overdue payment for a clean claim or for any uncontested
17 portion of a clean claim begins to accrue on the 36th day
18 after the claim has been received. The interest is payable
19 with the payment of the claim.
20 (4)(3) A health maintenance organization shall pay or
21 deny any claim no later than 120 days after receiving the
22 claim. Failure to do so creates an uncontestable obligation
23 for the health maintenance organization to pay the claim to
24 the provider.
25 (5)(a) If, as a result of retroactive review of
26 coverage decisions or payment levels, a health maintenance
27 organization determines that it has made an overpayment to a
28 provider for services rendered to a subscriber, the
29 organization must make a claim for such overpayment. The
30 organization may not reduce payment to that provider for other
31 services unless the provider agrees to the reduction or fails
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1 to respond to the organization's claim as required in this
2 subsection.
3 (b) A provider shall pay a claim for an overpayment
4 made by a health maintenance organization which the provider
5 does not contest or deny within 35 days after receipt of the
6 claim that is mailed or electronically transferred to the
7 provider.
8 (c) A provider that denies or contests an
9 organization's claim for overpayment or any portion of a claim
10 shall notify the organization, in writing, within 35 days
11 after the provider receives the claim that the claim for
12 overpayment is contested or denied. The notice that the claim
13 for overpayment is denied or contested must identify the
14 contested portion of the claim and the specific reason for
15 contesting or denying the claim, and, if contested, must
16 include a request for additional information. If the
17 organization submits additional information, the organization
18 must, within 35 days after receipt of the request, mail or
19 electronically transfer the information to the provider. The
20 provider shall pay or deny the claim for overpayment within 45
21 days after receipt of the information.
22 (d) Payment of a claim for overpayment is considered
23 made on the date payment was received or electronically
24 transferred or otherwise delivered to the organization, or the
25 date that the provider receives a payment from the
26 organization that reduces or deducts the overpayment. An
27 overdue payment of a claim bears simple interest at the rate
28 of 10 percent a year. Interest on an overdue payment of a
29 claim for overpayment or for any uncontested portion of a
30 claim for overpayment begins to accrue on the 36th day after
31 the claim for overpayment has been received.
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1 (e) A provider shall pay or deny any claim for
2 overpayment no later than 120 days after receiving the claim.
3 Failure to do so creates an uncontestable obligation for the
4 provider to pay the claim to the organization.
5 (6)(4) Any retroactive reductions of payments or
6 demands for refund of previous overpayments which are due to
7 retroactive review-of-coverage decisions or payment levels
8 must be reconciled to specific claims unless the parties agree
9 to other reconciliation methods and terms. Any retroactive
10 demands by providers for payment due to underpayments or
11 nonpayments for covered services must be reconciled to
12 specific claims unless the parties agree to other
13 reconciliation methods and terms. The look-back period may be
14 specified by the terms of the contract.
15 (7)(a) A provider claim for payment shall be
16 considered received by the health maintenance organization, if
17 the claim has been electronically transmitted to the health
18 maintenance organization, when receipt is verified
19 electronically or, if the claim is mailed to the address
20 disclosed by the organization, on the date indicated on the
21 return receipt. A provider must wait 45 days following receipt
22 of a claim before submitting a duplicate claim.
23 (b) A health maintenance organization claim for
24 overpayment shall be considered received by a provider, if the
25 claim has been electronically transmitted to the provider,
26 when receipt is verified electronically or, if the claim is
27 mailed to the address disclosed by the provider, on the date
28 indicated on the return receipt. An organization must wait 45
29 days following the provider's receipt of a claim for
30 overpayment before submitting a duplicate claim.
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1 (c) This section does not preclude the health
2 maintenance organization and provider from agreeing to other
3 methods of transmission and receipt of claims.
4 (8) A provider, or the provider's designee, who bills
5 electronically is entitled to electronic acknowledgement of
6 the receipt of a claim within 72 hours.
7 (9) A health maintenance organization may not
8 retroactively deny a claim because of subscriber ineligibility
9 more than 1 year after the date of payment of the clean claim.
10 Section 4. Section 641.3156, Florida Statutes, is
11 created to read:
12 641.3156 Treatment authorization; payment of claims.--
13 (1) A health maintenance organization must pay any
14 hospital-service or referral-service claim for treatment for
15 an eligible subscriber which was authorized by a provider
16 empowered by contract with the health maintenance organization
17 to authorize or direct the patient's utilization of health
18 care services and which was also authorized in accordance with
19 the health maintenance organization's current and communicated
20 procedures, unless the provider provided information to the
21 health maintenance organization with the willful intention to
22 misinform the health maintenance organization.
23 (2) A claim for treatment may not be denied if a
24 provider follows the health maintenance organization's
25 authorization procedures and receives authorization for a
26 covered service for an eligible subscriber, unless the
27 provider provided information to the health maintenance
28 organization with the willful intention to misinform the
29 health maintenance organization.
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1 (3) Emergency services are subject to the provisions
2 of s. 641.513 and are not subject to the provisions of this
3 section.
4 Section 5. Subsection (5) of section 641.3903, Florida
5 Statutes, is amended to read:
6 641.3903 Unfair methods of competition and unfair or
7 deceptive acts or practices defined.--The following are
8 defined as unfair methods of competition and unfair or
9 deceptive acts or practices:
10 (5) UNFAIR CLAIM SETTLEMENT PRACTICES.--
11 (a) Attempting to settle claims on the basis of an
12 application or any other material document which was altered
13 without notice to, or knowledge or consent of, the subscriber
14 or group of subscribers to a health maintenance organization;
15 (b) Making a material misrepresentation to the
16 subscriber for the purpose and with the intent of effecting
17 settlement of claims, loss, or damage under a health
18 maintenance contract on less favorable terms than those
19 provided in, and contemplated by, the contract; or
20 (c) Committing or performing with such frequency as to
21 indicate a general business practice any of the following:
22 1. Failing to adopt and implement standards for the
23 proper investigation of claims;
24 2. Misrepresenting pertinent facts or contract
25 provisions relating to coverage at issue;
26 3. Failing to acknowledge and act promptly upon
27 communications with respect to claims;
28 4. Denying of claims without conducting reasonable
29 investigations based upon available information;
30 5. Failing to affirm or deny coverage of claims upon
31 written request of the subscriber within a reasonable time not
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1 to exceed 30 days after a claim or proof-of-loss statements
2 have been completed and documents pertinent to the claim have
3 been requested in a timely manner and received by the health
4 maintenance organization;
5 6. Failing to promptly provide a reasonable
6 explanation in writing to the subscriber of the basis in the
7 health maintenance contract in relation to the facts or
8 applicable law for denial of a claim or for the offer of a
9 compromise settlement;
10 7. Failing to provide, upon written request of a
11 subscriber, itemized statements verifying that services and
12 supplies were furnished, where such statement is necessary for
13 the submission of other insurance claims covered by individual
14 specified disease or limited benefit policies, provided that
15 the organization may receive from the subscriber a reasonable
16 administrative charge for the cost of preparing such
17 statement; or
18 8. Failing to provide any subscriber with services,
19 care, or treatment contracted for pursuant to any health
20 maintenance contract without a reasonable basis to believe
21 that a legitimate defense exists for not providing such
22 services, care, or treatment. To the extent that a national
23 disaster, war, riot, civil insurrection, epidemic, or any
24 other emergency or similar event not within the control of the
25 health maintenance organization results in the inability of
26 the facilities, personnel, or financial resources of the
27 health maintenance organization to provide or arrange for
28 provision of a health service in accordance with requirements
29 of this part, the health maintenance organization is required
30 only to make a good faith effort to provide or arrange for
31 provision of the service, taking into account the impact of
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1 the event. For the purposes of this paragraph, an event is
2 not within the control of the health maintenance organization
3 if the health maintenance organization cannot exercise
4 influence or dominion over its occurrence; or.
5 9. Systematic downcoding with the intent to deny
6 reimbursement otherwise due.
7 Section 6. Section 641.3909, Florida Statutes, is
8 amended to read:
9 641.3909 Cease and desist and penalty orders.--After
10 the hearing provided in s. 641.3907, the department shall
11 enter a final order in accordance with s. 120.569. If it is
12 determined that the person, entity, or health maintenance
13 organization charged has engaged in an unfair or deceptive act
14 or practice or the unlawful operation of a health maintenance
15 organization without a subsisting certificate of authority,
16 the department shall also issue an order requiring the
17 violator to cease and desist from engaging in such method of
18 competition, act, or practice or unlawful operation of a
19 health maintenance organization. Further, if the act or
20 practice constitutes a violation of s. 641.3155, s. 641.3901,
21 or s. 641.3903, the department may, at its discretion, order
22 any one or more of the following:
23 (1) Suspension or revocation of the health maintenance
24 organization's certificate of authority if it knew, or
25 reasonably should have known, it was in violation of this
26 part.
27 (2) If it is determined that the person or entity
28 charged has engaged in the business of operating a health
29 maintenance organization without a certificate of authority,
30 an administrative penalty not to exceed $1,000 for each health
31 maintenance contract offered or effectuated.
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1 Section 7. Subsection (4) of section 641.495, Florida
2 Statutes, is amended to read:
3 641.495 Requirements for issuance and maintenance of
4 certificate.--
5 (4) The organization shall ensure that the health care
6 services it provides to subscribers, including physician
7 services as required by s. 641.19(13)(d) and (e), are
8 accessible to the subscribers, with reasonable promptness,
9 with respect to geographic location, hours of operation,
10 provision of after-hours service, and staffing patterns within
11 generally accepted industry norms for meeting the projected
12 subscriber needs. The health maintenance organization must
13 provide treatment authorization 24 hours a day, 7 days a week.
14 Requests for treatment authorization may not be held pending
15 unless the requesting provider contractually agrees to take a
16 pending or tracking number.
17 Section 8. Section 408.7057, Florida Statutes, is
18 created to read:
19 408.7057 Statewide provider and managed care
20 organization claim dispute resolution program.--
21 (1) As used in this section, the term:
22 (a) "Managed care organization" means a health
23 maintenance organization or a prepaid health clinic certified
24 under chapter 641, a prepaid health plan authorized under s.
25 409.912, or an exclusive provider organization certified under
26 s. 627.6472.
27 (b) "Resolution organization" means a qualified
28 independent third-party claim-dispute-resolution entity
29 selected by and contracted with the Agency for Health Care
30 Administration.
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1 (2)(a) The Agency for Health Care Administration shall
2 establish a program by January 1, 2001, to provide assistance
3 to contracted and noncontracted providers and managed care
4 organizations for resolution of claim disputes that are not
5 resolved by the provider and the managed care organization.
6 The agency shall contract with a resolution organization to
7 timely review and consider claim disputes submitted by
8 providers and managed care organizations and recommend to the
9 agency an appropriate resolution of those disputes. The agency
10 shall establish by rule jurisdictional amounts and methods of
11 aggregation for claim disputes that may be considered by the
12 resolution organization.
13 (b) The resolution organization shall review claim
14 disputes filed by contracted and noncontracted providers and
15 managed care organizations unless the disputed claim:
16 1. Is related to interest payment;
17 2. Does not meet the jurisdictional amounts or the
18 methods of aggregation established by agency rule, as provided
19 in paragraph (a);
20 3. Is part of an internal grievance in a Medicare
21 managed care organization or a reconsideration appeal through
22 the Medicare appeals process;
23 4. Is related to a health plan that is not regulated
24 by the state;
25 5. Is part of a Medicaid fair hearing pursued under 42
26 C.F.R. ss. 431.220 et seq.;
27 6. Is the basis for an action pending in state or
28 federal court; or
29 7. Is subject to a binding claim-dispute-resolution
30 process provided by contract entered into prior to October 1,
31 2000, between the provider and the managed care organization.
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1 (c) Contracts entered into or renewed on or after
2 October 1, 2000, may require exhaustion of an internal
3 dispute-resolution process as a prerequisite to the submission
4 of a claim by a provider or health maintenance organization to
5 the resolution organization when the dispute-resolution
6 program becomes effective.
7 (d) A contracted or noncontracted provider or health
8 maintenance organization may not file a claim dispute with the
9 resolution organization more than 12 months after a final
10 determination has been made on a claim by a health maintenance
11 organization.
12 (3) The agency shall adopt rules to establish a
13 process to be used by the resolution organization in
14 considering claim disputes submitted by a provider or managed
15 care organization which must include the issuance by the
16 resolution organization of a written recommendation, supported
17 by findings of fact, to the agency within 60 days after
18 receipt of the claim dispute submission.
19 (4) Within 30 days after receipt of the recommendation
20 of the resolution organization, the agency shall adopt the
21 recommendation as a final order.
22 (5) The entity that does not prevail in the agency's
23 order must pay a review cost to the review organization, as
24 determined by agency rule. Such rule must provide for an
25 apportionment of the review fee in any case in which both
26 parties prevail in part. If the nonprevailing party fails to
27 pay the ordered review cost within 35 days after the agency's
28 order, the nonpaying party is subject to a penalty of not more
29 than $500 per day until the penalty is paid.
30 (6) The Agency for Health Care Administration may
31 adopt rules to administer this section.
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1 Section 9. Paragraph (a) of subsection (2) of section
2 395.1065, Florida Statutes, is amended, and paragraph (d) is
3 added to that subsection, to read:
4 395.1065 Criminal and administrative penalties;
5 injunctions; emergency orders; moratorium.--
6 (2)(a) The agency may deny, revoke, or suspend a
7 license or impose an administrative fine, not to exceed $1,000
8 per violation, per day, for the violation of any provision of
9 this part or rules adopted under this part promulgated
10 hereunder. Each day of violation constitutes a separate
11 violation and is subject to a separate fine.
12 (d) The agency may impose an administrative fine for
13 the violation of s. 641.3154 or, if sufficient claims due to a
14 provider from a health maintenance organization do not exist
15 to enable the take-back of an overpayment, as provided under
16 s. 641.3155(5), for the violation of s. 641.3155(5). The
17 administrative fine for a violation cited in this paragraph
18 shall be in the amounts specified in s. 641.52(5) and the
19 provisions of paragraph (a) do not apply.
20 Section 10. Paragraph (c) of subsection (1) of section
21 631.818, Florida Statutes, is amended to read:
22 631.818 Powers and duties of the plan.--
23 (1) In the event that an HMO is insolvent, the plan
24 shall:
25 (c) Defend any claim filed contrary to the provisions
26 of s. 641.315 or s. 641.3154 against a subscriber of an
27 insolvent HMO asserted by a health care provider for services
28 covered by the HMO contract. In the event that a provider
29 obtains a judgment despite the provisions of s. 641.315 or s.
30 641.3154, the plan shall pay the judgment. If a provider
31 fails to obtain a judgment as to such claim, the plan shall be
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1 entitled to recover its reasonable costs and attorney's fees
2 incurred in defending the claim.
3 Section 11. Subsection (2) of section 817.234, Florida
4 Statutes, is amended, and subsection (11) of that section is
5 reenacted, to read:
6 817.234 False and fraudulent insurance claims.--
7 (2)(a) Any physician licensed under chapter 458,
8 osteopathic physician licensed under chapter 459, chiropractic
9 physician licensed under chapter 460, or other practitioner
10 licensed under the laws of this state who knowingly and
11 willfully assists, conspires with, or urges any insured party
12 to fraudulently violate any of the provisions of this section
13 or part XI of chapter 627, or any person who, due to such
14 assistance, conspiracy, or urging by said physician,
15 osteopathic physician, chiropractic physician, or
16 practitioner, knowingly and willfully benefits from the
17 proceeds derived from the use of such fraud, commits insurance
18 fraud, punishable as provided in subsection (11). In the event
19 that a physician, osteopathic physician, chiropractic
20 physician, or practitioner is adjudicated guilty of a
21 violation of this section, the Board of Medicine as set forth
22 in chapter 458, the Board of Osteopathic Medicine as set forth
23 in chapter 459, the Board of Chiropractic Medicine as set
24 forth in chapter 460, or other appropriate licensing authority
25 shall hold an administrative hearing to consider the
26 imposition of administrative sanctions as provided by law
27 against said physician, osteopathic physician, chiropractic
28 physician, or practitioner.
29 (b) In addition to any other provision of law,
30 systematic upcoding by a provider, as defined in s.
31 641.19(15), with the intent to obtain reimbursement otherwise
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1 not due from an insurer is punishable as provided in s.
2 641.52(5).
3 (11) If the value of any property involved in a
4 violation of this section:
5 (a) Is less than $20,000, the offender commits a
6 felony of the third degree, punishable as provided in s.
7 775.082, s. 775.083, or s. 775.084.
8 (b) Is $20,000 or more, but less than $100,000, the
9 offender commits a felony of the second degree, punishable as
10 provided in s. 775.082, s. 775.083, or s. 775.084.
11 (c) Is $100,000 or more, the offender commits a felony
12 of the first degree, punishable as provided in s. 775.082, s.
13 775.083, or s. 775.084.
14 Section 12. Section 817.50, Florida Statutes, is
15 amended to read:
16 817.50 Fraudulently obtaining goods, services, etc.,
17 from a health care provider hospital.--
18 (1) Whoever shall, willfully and with intent to
19 defraud, obtain or attempt to obtain goods, products,
20 merchandise, or services from any health care provider
21 hospital in this state, as defined in s. 641.19(15), commits
22 shall be guilty of a misdemeanor of the second degree,
23 punishable as provided in s. 775.082 or s. 775.083.
24 (2) If any person gives to any health care provider
25 hospital in this state a false or fictitious name or a false
26 or fictitious address or assigns to any health care provider
27 hospital the proceeds of any health maintenance contract or
28 insurance contract, then knowing that such contract is no
29 longer in force, is invalid, or is void for any reason, such
30 action shall be prima facie evidence of the intent of such
31 person to defraud the health care provider such hospital.
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1 Section 13. Paragraph (d) of subsection (38) of
2 section 641.31, Florida Statutes, is amended to read:
3 641.31 Health maintenance contracts.--
4 (38)
5 (d) Notwithstanding the limitations of deductibles and
6 copayment provisions in this part, a point-of-service rider
7 may require the subscriber to pay a reasonable copayment for
8 each visit for services provided by a noncontracted provider
9 chosen at the time of the service. The copayment by the
10 subscriber may either be a specific dollar amount or a
11 percentage of the reimbursable provider charges covered by the
12 contract and must be paid by the subscriber to the
13 noncontracted provider upon receipt of covered services. The
14 point-of-service rider may require that a reasonable annual
15 deductible for the expenses associated with the
16 point-of-service rider be met and may include a lifetime
17 maximum benefit amount. The rider must include the language
18 required by s. 627.6044 and must comply with copayment limits
19 described in s. 627.6471. Section 641.3154 641.315(2) and (3)
20 does not apply to a point-of-service rider authorized under
21 this subsection.
22 Section 14. The sum of $38,928 is appropriated from
23 the Health Care Trust Fund and one position to the Agency for
24 Health Care Administration for the purposes of carrying out
25 the provisions of this act during the 2000-2001 fiscal year.
26 Section 15. This act shall take effect October 1,
27 2000, and shall apply to claims for services rendered after
28 such date and to all requests for claim-dispute resolution
29 which are submitted by a provider or managed care organization
30 60 days after the effective date of the contract between the
31 resolution organization and the agency.
24