Senate Bill sb1850
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Florida Senate - 2002 SB 1850
By Senators Brown-Waite and Peaden
10-235-02
1 A bill to be entitled
2 An act relating to health care; creating s.
3 408.7058, F.S.; providing for a statewide
4 provider-qualification dispute-resolution
5 program to be established by the Agency for
6 Health Care Administration; providing
7 definitions; authorizing the agency to adopt
8 rules; providing for adoption of final orders;
9 providing for payment of costs; amending s.
10 627.6474, F.S.; providing terms and conditions
11 of contracts between a health insurer and a
12 health care provider; providing conditions for
13 terminating contracts; providing for waiver or
14 nullification of such conditions by contract of
15 the parties; amending s. 641.315, F.S.;
16 eliminating the requirement for a 60 days'
17 written notice of cancellation without cause of
18 a contract between a health maintenance
19 organization and a health care provider;
20 eliminating certain discretionary reasons for
21 terminating such contracts; prescribing new
22 procedures for terminating such contracts;
23 providing notice requirements; specifying that
24 terms and conditions to be met by health care
25 providers must be stated in the contract with
26 the health maintenance organization; providing
27 an effective date.
28
29 Be It Enacted by the Legislature of the State of Florida:
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1 Section 1. Section 408.7058, Florida Statutes, is
2 created to read:
3 408.7058 Statewide provider-qualification
4 dispute-resolution program.--
5 (1) As used in this section, the term:
6 (a) "Health care provider" means any hospital licensed
7 under chapter 395 or any health care practitioner as defined
8 by s. 456.001.
9 (b) "Health maintenance organization" or
10 "organization" means an organization certified under part I of
11 chapter 641.
12 (c) "Health insurer" means an entity licensed under
13 chapter 627.
14 (d) "Qualification dispute" means any dispute between
15 a health maintenance organization and a health care provider,
16 or a health insurer and a health care provider, as to whether
17 the provider meets the entity's written terms and conditions
18 provided to the health care provider pursuant to s. 627.6474
19 or s. 641.315(10).
20 (e) "Resolution organization" means a qualified
21 independent third-party claim-dispute-resolution entity
22 selected by and contract with the Agency for Health Care
23 Administration.
24 (2)(a) The Agency for Health Care Administration shall
25 establish a program by January 1, 2003, to provide assistance
26 to contracted and noncontracted health care providers for
27 resolution of qualification disputes that are not resolved by
28 the provider and the health maintenance organization or health
29 insurer. The agency shall contract with a resolution
30 organization to timely review and consider qualification
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1 disputes submitted by providers and recommend to the agency an
2 appropriate resolution of those disputes.
3 (b) The resolution organization shall review
4 qualification disputes filed by contracted and noncontracted
5 providers unless the dispute is the basis for an action
6 pending in state or federal court.
7 (3) The agency shall adopt rules to establish a
8 process to be used by the resolution organization in
9 considering qualification disputes submitted by a health care
10 provider which must include the issuance by the resolution
11 organization of a written recommendation, supported by
12 findings of fact, to the agency within 60 days after receipt
13 of the dispute submission. The written recommendation may
14 include a recommendation that the health care provider not be
15 terminated from the health maintenance organization or health
16 insurer.
17 (4) Within 30 days after receipt of the recommendation
18 of the resolution organization, the agency shall adopt the
19 recommendation as a final order.
20 (5) The entity that does not prevail in the agency's
21 order must pay a review cost to the review organization, as
22 determined by agency rule. If the nonprevailing party fails to
23 pay the ordered review cost within 35 days after the agency's
24 order, the nonpaying party is subject to a penalty of not more
25 than $500 per day until the penalty is paid.
26 (6) The Agency for Health Care Administration may
27 adopt rules to administer this section.
28 Section 2. Section 627.6474, Florida Statutes, is
29 amended to read:
30 627.6474 Provider contracts.--
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1 (1) A health insurer shall not require a contracted
2 health care practitioner as defined in s. 456.001(4) to accept
3 the terms of other health care practitioner contracts with the
4 insurer or any other insurer, or health maintenance
5 organization, under common management and control with the
6 insurer, including Medicare and Medicaid practitioner
7 contracts and those authorized by s. 627.6471, s. 627.6472, or
8 s. 641.315, except for a practitioner in a group practice as
9 defined in s. 456.053 who must accept the terms of a contract
10 negotiated for the practitioner by the group, as a condition
11 of continuation or renewal of the contract. Any contract
12 provision that violates this subsection section is void. A
13 violation of this subsection section is not subject to the
14 criminal penalty specified in s. 624.15.
15 (2) Each contract between a health insurer and a
16 health care provider must contain the organization's terms and
17 conditions that must be met by health care providers
18 contracting with the health insurer. The insurer's terms and
19 conditions for contracting with the health care provider may
20 not be modified or amended in any way by the health insurer
21 during the term of the contract between the health insurer and
22 the health care provider.
23 (3) A health insurer that has a market share of over
24 25 percent in a county in any of its plans may not refuse to
25 enter into or renew a contact in such plan with any licensed
26 health care provider that is willing to meet the terms and
27 conditions established by the insurer under subsection (2),
28 that practices within the geographic area served by the
29 insurer, and whose credentials are verified and examined by
30 the insurer's system for verification and examination of the
31 credentials of each of its providers.
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1 (4)(a) A health insurer or health care provider may
2 not terminate a contract with a health care provider or health
3 insurer unless the party terminating the contract provides the
4 terminated party with a written reason for the proposed
5 contract termination.
6 (b) A health insurer may terminate a contract with a
7 health care provider only if the provider fails to comply with
8 the organization's written term and conditions that have been
9 provided to the health care provider under subsection (2). If
10 a health insurer proposes to terminate a contract with a
11 health care provider, the health insurer must provide the
12 health care provider with 60 days' advance written notice of
13 its intent to terminate the provider's contract. This
14 paragraph does not apply in cased involving imminent harm to
15 patient health or a final disciplinary action by the
16 provider's licensing board or other governmental agency which
17 impairs the health care provider's ability to practice within
18 the jurisdiction.
19 (c) If a health insurer proposes to terminate a
20 contract of a health care provider, the health insurer may not
21 notify the provider's patients of the proposed termination
22 until the effective date of the termination or the conclusion
23 of the review or hearing provided in this section, whichever
24 occurs later. If a provider's contract is terminated for
25 reasons related to imminent harm to patient health or a final
26 disciplinary action by the provider's licensing board or other
27 governmental agency which impairs the health care provider's
28 ability to practice within the jurisdiction, the health
29 insurer may notify the provider's patients immediately.
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1 (d) The notice of the proposed contract termination
2 provided by the health insurer to the health care provider
3 must include:
4 1. The specific term and condition established by the
5 health insurer which the insurer alleges has been breached by
6 the health care provider and which serves as the reason for
7 the proposed termination.
8 2. Notice that the health care provider has the right
9 to request a review before the statewide provider and health
10 insurer qualification dispute-resolution program created under
11 s. 408.7058.
12 3. A time period of not less than 30 days within which
13 a health care provider may request a review.
14 (e) If the health care provider requests a review, the
15 health care provider must be given a written notice that
16 states the names of the witnesses, if any, expected to testify
17 at the hearing on behalf of the health insurer.
18 (5) The provisions of this section apply to contracts
19 entered into under ss. 627.6471 and 627.6472.
20 (6) The provisions of this section may not be waived,
21 voided, or nullified by contract.
22 Section 3. Section 641.315, Florida Statutes, is
23 amended to read:
24 641.315 Provider contracts.--
25 (1) Each contract between a health maintenance
26 organization and a provider of health care services must be in
27 writing and must contain a provision that the subscriber is
28 not liable to the provider for any services for which the
29 health maintenance organization is liable as specified in s.
30 641.3154.
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1 (2)(a) For all Provider contracts executed after
2 October 1, 1991, and within 180 days after October 1, 1991,
3 for contracts in existence as of October 1, 1991:
4 (a)1. The contracts Must require the provider to give
5 60 days' advance written notice to the health maintenance
6 organization and the department before canceling the contract
7 with the health maintenance organization for any reason; and
8 (b)2. The contract Must also provide that nonpayment
9 for goods or services rendered by the provider to the health
10 maintenance organization is not a valid reason for avoiding
11 the 60-day advance notice of cancellation.
12 (b) All provider contracts must provide that the
13 health maintenance organization will provide 60 days' advance
14 written notice to the provider and the department before
15 canceling, without cause, the contract with the provider,
16 except in a case in which a patient's health is subject to
17 imminent danger or a physician's ability to practice medicine
18 is effectively impaired by an action by the Board of Medicine
19 or other governmental agency.
20 (3) Upon receipt by the health maintenance
21 organization of a 60-day cancellation notice, the health
22 maintenance organization may, if requested by the provider,
23 terminate the contract in less than 60 days if the health
24 maintenance organization is not financially impaired or
25 insolvent.
26 (3)(4) Whenever a contract exists between a health
27 maintenance organization and a provider, the health
28 maintenance organization shall disclose to the provider:
29 (a) The mailing address or electronic address where
30 claims should be sent for processing;
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1 (b) The telephone number that a provider may call to
2 have questions and concerns regarding claims addressed; and
3 (c) The address of any separate claims-processing
4 centers for specific types of services.
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6 A health maintenance organization shall provide to its
7 contracted providers no less than 30 calendar days' prior
8 written notice of any changes in the information required in
9 this subsection.
10 (4)(5) A contract between a health maintenance
11 organization and a provider of health care services shall not
12 contain any provision restricting the provider's ability to
13 communicate information to the provider's patient regarding
14 medical care or treatment options for the patient when the
15 provider deems knowledge of such information by the patient to
16 be in the best interest of the health of the patient.
17 (5)(6) A contract between a health maintenance
18 organization and a provider of health care services may not
19 contain any provision that in any way prohibits or restricts:
20 (a) The health care provider from entering into a
21 commercial contract with any other health maintenance
22 organization; or
23 (b) The health maintenance organization from entering
24 into a commercial contract with any other health care
25 provider.
26 (6)(a)(7) A health maintenance organization or health
27 care provider may not terminate a contract with a health care
28 provider or health maintenance organization unless the party
29 terminating the contract provides the terminated party with a
30 written reason for the proposed contract termination, which
31 may include termination for business reasons of the
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1 terminating party. The reason provided in the notice required
2 in this section or any other information relating to the
3 reason for termination does not create any new administrative
4 or civil action and may not be used as substantive evidence in
5 any such action, but may be used for impeachment purposes. As
6 used in this subsection, the term "health care provider" means
7 a physician licensed under chapter 458, chapter 459, chapter
8 460, or chapter 461, or a dentist licensed under chapter 466.
9 (b) A health maintenance organization may terminate a
10 contract with a health care provider only if the provider
11 fails to comply with the organization's written terms and
12 conditions that have been provided the health care provider
13 under subsection (10). If a health maintenance organization
14 proposes to terminate a contract with a health care provider,
15 the health maintenance organization shall give the health care
16 provider 60 days' advance written notice of its intent to
17 terminate the provider's contract. This paragraph does not
18 apply in cases involving imminent harm to patient health or a
19 final disciplinary action by the provider's licensing board or
20 other governmental agency which impairs the health care
21 provider's ability to practice within the jurisdiction.
22 (c) If a health maintenance organization proposes to
23 terminate a contract of a health care provider under this
24 section, the health maintenance organization may not notify
25 the provider's patients of the proposed termination until the
26 effective date of the termination or the conclusion of the
27 review or hearing provided in this section, whichever occurs
28 later. If a provider's contract is terminated for reasons
29 related to imminent harm to patient health or a final
30 disciplinary action by the provider's licensing board or other
31 governmental agency which impairs the health care provider's
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1 ability to practice within the jurisdiction, the health
2 maintenance organization may notify the provider's patients
3 immediately.
4 (d) The notice of the proposed contract termination
5 provided by the health maintenance organization to the health
6 care provider must include:
7 1. The specific term and condition established by the
8 health maintenance organization which the organization alleges
9 has been breached by the health care provider and which serve
10 as the reason for the proposed termination.
11 2. Notice that the health care provider has the right
12 to request a review before the statewide provider and health
13 maintenance organization qualification dispute-resolution
14 program created under s. 408.7058.
15 3. A time period of not less than 30 days within which
16 a health care provider may request a review.
17 (c) If the health care provider requests a review, the
18 health care provider must be provided a written notice that
19 states the names of the witnesses, if any, expected to testify
20 at the hearing on behalf of the health maintenance
21 organization.
22 (7)(8) The health maintenance organization must
23 establish written procedures for a contract provider to
24 request and the health maintenance organization to grant
25 authorization for utilization of health care services. The
26 health maintenance organization must give written notice to
27 the contract provider prior to any change in these procedures.
28 (8)(9) A contract between a health maintenance
29 organization and a contracted primary care or admitting
30 physician may not contain any provision that prohibits such
31 physician from providing inpatient services in a contracted
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1 hospital to a subscriber if such services are determined by
2 the organization to be medically necessary and covered
3 services under the organization's contract with the contract
4 holder.
5 (9)(10) A health maintenance organization shall not
6 require a contracted health care practitioner as defined in s.
7 456.001(4) to accept the terms of other health care
8 practitioner contracts with the health maintenance
9 organization or any insurer, or other health maintenance
10 organization, under common management and control with the
11 health maintenance organization, including Medicare and
12 Medicaid practitioner contracts and those authorized by s.
13 627.6471, s. 627.6472, or s. 641.315, except for a
14 practitioner in a group practice as defined in s. 456.053 who
15 must accept the terms of a contract negotiated for the
16 practitioner by the group, as a condition of continuation or
17 renewal of the contract. Any contract provision that violates
18 this section is void. A violation of this section is not
19 subject to the criminal penalty specified in s. 624.15.
20 (10) Each contract between a health maintenance
21 organization and a health care provider must contain the
22 organization's terms and conditions that must be met by health
23 care providers contracting with the health maintenance
24 organization. The organization's terms and conditions for
25 contracting with the health maintenance organization may not
26 be modified or amended in any way by the health maintenance
27 organization during the term of the contract between the
28 health maintenance organization and the health care provider.
29 The provisions of this subsection may not be waived, voided,
30 or nullified by contract.
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1 (11) A health maintenance organization that has a
2 market share of over 25 percent in a county in any of its
3 health maintenance organization plans may not refuse to enter
4 into or renew a contract in such plan with any licensed health
5 care provider who is willing to meet the terms and conditions
6 established by the organization under subsection (10), who
7 practices within the geographic area served by the
8 organization, and whose credentials are verified and examined
9 by the organization under s. 641.495(6).
10 Section 4. This act shall take effect July 1, 2002.
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13 SENATE SUMMARY
14 Provides for the establishment by the Agency for Health
Care Administration of a statewide provider-qualification
15 dispute-resolution program. Provides the agency with
rulemaking authority. Provides for adoption of final
16 orders and payment of costs. Provides terms and
conditions to be included in contracts between health
17 insurers and health care providers. Prescribes conditions
for terminating such contracts and for waiver of such
18 conditions. Prescribes new procedures for terminating
contracts between a health maintenance organization and a
19 health care provider. Specifies that terms and conditions
to be met by a health care provider must be stated in its
20 contract with the HMO.
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