Senate Bill sb1880c1
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Florida Senate - 2007 CS for SB 1880
By the Committee on Banking and Insurance; and Senator Posey
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1 A bill to be entitled
2 An act relating to motor vehicle insurance;
3 amending s. 627.736, F.S.; allowing insurers to
4 limit payments for treatment, care, procedures,
5 or services for bodily injury covered by
6 personal injury protection insurance to a
7 specified percentage of the reimbursement
8 allowed under the Medicare fee schedule;
9 allowing payment to be limited to the maximum
10 allowance under workers' compensation if such
11 treatment, care, procedure, or service is not
12 reimbursable under Medicare; prohibiting a
13 provider from billing or attempting to collect
14 from an insured amounts in excess of such fee
15 limitations; repealing s. 19 of chapter
16 2003-411, Laws of Florida; abrogating the
17 repeal of the Florida Motor Vehicle No-Fault
18 Law as provided for in that section; reenacting
19 ss. 627.730, 627.731, 627.732, 627.733,
20 627.734, 627.736, 627.737, 627.739, 627.7401,
21 627.7403, and 627.7405, F.S., the Florida Motor
22 Vehicle No-Fault Law, and providing for future
23 review and repeal; providing for application of
24 the act; providing an effective date.
25
26 Be It Enacted by the Legislature of the State of Florida:
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28 Section 1. Subsection (5) of section 627.736, Florida
29 Statutes, is amended to read:
30 627.736 Required personal injury protection benefits;
31 exclusions; priority; claims.--
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1 (5) CHARGES FOR TREATMENT OF INJURED PERSONS.--
2 (a)1. Any physician, hospital, clinic, or other person
3 or institution lawfully rendering treatment to an injured
4 person for a bodily injury covered by personal injury
5 protection insurance may charge the insurer and injured party
6 only a reasonable amount pursuant to this section for the
7 services and supplies rendered, and the insurer providing such
8 coverage may pay for such charges directly to such person or
9 institution lawfully rendering such treatment, if the insured
10 receiving such treatment or his or her guardian has
11 countersigned the properly completed invoice, bill, or claim
12 form approved by the office upon which such charges are to be
13 paid for as having actually been rendered, to the best
14 knowledge of the insured or his or her guardian. In no event,
15 however, may such a charge be in excess of the amount the
16 person or institution customarily charges for like services or
17 supplies. With respect to a determination of whether a charge
18 for a particular service, treatment, or otherwise is
19 reasonable, consideration may be given to evidence of usual
20 and customary charges and payments accepted by the provider
21 involved in the dispute, and reimbursement levels in the
22 community and various federal and state medical fee schedules
23 applicable to automobile and other insurance coverages, and
24 other information relevant to the reasonableness of the
25 reimbursement for the service, treatment, or supply.
26 2. The insurer may apply a maximum limit on charges
27 which is equal to 200 percent of the reimbursement allowed for
28 the applicable procedure code as set forth in the Medicare
29 Part A or Medicare Part B participating fee schedule in effect
30 at the time for the region where the treatment, care,
31 procedure, or service is provided. However, if such treatment,
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1 care, procedure, or service is not reimbursable under the
2 Medicare Part A or Medicare Part B participating fee schedule,
3 the insurer may apply a maximum limitation that is equal to
4 the maximum reimbursable allowance under workers'
5 compensation, as determined under s. 440.13 and rules adopted
6 thereunder, which are in effect at the time such treatment,
7 care, procedure, or service is performed. A treatment, care,
8 procedure, or service that is not reimbursable under the
9 Medicare fee schedules or that is not reimbursable under
10 workers' compensation is not reimbursable by the insurer.
11 However, this subparagraph does not allow the insurer to apply
12 any limitation on the number of treatments or other
13 utilization limits that apply under Medicare or workers'
14 compensation. If an insurer limits payment as authorized by
15 this subparagraph, the person providing such treatment, care,
16 procedure, or service may not bill or attempt to collect from
17 the insured any amounts in excess of such limits, other than
18 amounts that are not covered by the insured's personal injury
19 protection coverage due to the deductible, coinsurance amount,
20 or maximum policy limits.
21 (b)1. An insurer or insured is not required to pay a
22 claim or charges:
23 a. Made by a broker or by a person making a claim on
24 behalf of a broker;
25 b. For any service or treatment that was not lawful at
26 the time rendered;
27 c. To any person who knowingly submits a false or
28 misleading statement relating to the claim or charges;
29 d. With respect to a bill or statement that does not
30 substantially meet the applicable requirements of paragraph
31 (d);
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1 e. For any treatment or service that is upcoded, or
2 that is unbundled when such treatment or services should be
3 bundled, in accordance with paragraph (d). To facilitate
4 prompt payment of lawful services, an insurer may change codes
5 that it determines to have been improperly or incorrectly
6 upcoded or unbundled, and may make payment based on the
7 changed codes, without affecting the right of the provider to
8 dispute the change by the insurer, provided that before doing
9 so, the insurer must contact the health care provider and
10 discuss the reasons for the insurer's change and the health
11 care provider's reason for the coding, or make a reasonable
12 good faith effort to do so, as documented in the insurer's
13 file; and
14 f. For medical services or treatment billed by a
15 physician and not provided in a hospital unless such services
16 are rendered by the physician or are incident to his or her
17 professional services and are included on the physician's
18 bill, including documentation verifying that the physician is
19 responsible for the medical services that were rendered and
20 billed.
21 2. Charges for medically necessary cephalic
22 thermograms, peripheral thermograms, spinal ultrasounds,
23 extremity ultrasounds, video fluoroscopy, and surface
24 electromyography shall not exceed the maximum reimbursement
25 allowance for such procedures as set forth in the applicable
26 fee schedule or other payment methodology established pursuant
27 to s. 440.13.
28 3. Allowable amounts that may be charged to a personal
29 injury protection insurance insurer and insured for medically
30 necessary nerve conduction testing when done in conjunction
31 with a needle electromyography procedure and both are
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1 performed and billed solely by a physician licensed under
2 chapter 458, chapter 459, chapter 460, or chapter 461 who is
3 also certified by the American Board of Electrodiagnostic
4 Medicine or by a board recognized by the American Board of
5 Medical Specialties or the American Osteopathic Association or
6 who holds diplomate status with the American Chiropractic
7 Neurology Board or its predecessors shall not exceed 200
8 percent of the allowable amount under the participating
9 physician fee schedule of Medicare Part B for year 2001, for
10 the area in which the treatment was rendered, adjusted
11 annually on August 1 to reflect the prior calendar year's
12 changes in the annual Medical Care Item of the Consumer Price
13 Index for All Urban Consumers in the South Region as
14 determined by the Bureau of Labor Statistics of the United
15 States Department of Labor.
16 4. Allowable amounts that may be charged to a personal
17 injury protection insurance insurer and insured for medically
18 necessary nerve conduction testing that does not meet the
19 requirements of subparagraph 3. shall not exceed the
20 applicable fee schedule or other payment methodology
21 established pursuant to s. 440.13.
22 5. Allowable amounts that may be charged to a personal
23 injury protection insurance insurer and insured for magnetic
24 resonance imaging services shall not exceed 175 percent of the
25 allowable amount under the participating physician fee
26 schedule of Medicare Part B for year 2001, for the area in
27 which the treatment was rendered, adjusted annually on August
28 1 to reflect the prior calendar year's changes in the annual
29 Medical Care Item of the Consumer Price Index for All Urban
30 Consumers in the South Region as determined by the Bureau of
31 Labor Statistics of the United States Department of Labor for
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1 the 12-month period ending June 30 of that year, except that
2 allowable amounts that may be charged to a personal injury
3 protection insurance insurer and insured for magnetic
4 resonance imaging services provided in facilities accredited
5 by the Accreditation Association for Ambulatory Health Care,
6 the American College of Radiology, or the Joint Commission on
7 Accreditation of Healthcare Organizations shall not exceed 200
8 percent of the allowable amount under the participating
9 physician fee schedule of Medicare Part B for year 2001, for
10 the area in which the treatment was rendered, adjusted
11 annually on August 1 to reflect the prior calendar year's
12 changes in the annual Medical Care Item of the Consumer Price
13 Index for All Urban Consumers in the South Region as
14 determined by the Bureau of Labor Statistics of the United
15 States Department of Labor for the 12-month period ending June
16 30 of that year. This paragraph does not apply to charges for
17 magnetic resonance imaging services and nerve conduction
18 testing for inpatients and emergency services and care as
19 defined in chapter 395 rendered by facilities licensed under
20 chapter 395.
21 2.6. The Department of Health, in consultation with
22 the appropriate professional licensing boards, shall adopt, by
23 rule, a list of diagnostic tests deemed not to be medically
24 necessary for use in the treatment of persons sustaining
25 bodily injury covered by personal injury protection benefits
26 under this section. The initial list shall be adopted by
27 January 1, 2004, and shall be revised from time to time as
28 determined by the Department of Health, in consultation with
29 the respective professional licensing boards. Inclusion of a
30 test on the list of invalid diagnostic tests shall be based on
31 lack of demonstrated medical value and a level of general
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1 acceptance by the relevant provider community and shall not be
2 dependent for results entirely upon subjective patient
3 response. Notwithstanding its inclusion on a fee schedule in
4 this subsection, an insurer or insured is not required to pay
5 any charges or reimburse claims for any invalid diagnostic
6 test as determined by the Department of Health.
7 (c)1. With respect to any treatment or service, other
8 than medical services billed by a hospital or other provider
9 for emergency services as defined in s. 395.002 or inpatient
10 services rendered at a hospital-owned facility, the statement
11 of charges must be furnished to the insurer by the provider
12 and may not include, and the insurer is not required to pay,
13 charges for treatment or services rendered more than 35 days
14 before the postmark date of the statement, except for past due
15 amounts previously billed on a timely basis under this
16 paragraph, and except that, if the provider submits to the
17 insurer a notice of initiation of treatment within 21 days
18 after its first examination or treatment of the claimant, the
19 statement may include charges for treatment or services
20 rendered up to, but not more than, 75 days before the postmark
21 date of the statement. The injured party is not liable for,
22 and the provider shall not bill the injured party for, charges
23 that are unpaid because of the provider's failure to comply
24 with this paragraph. Any agreement requiring the injured
25 person or insured to pay for such charges is unenforceable.
26 2. If, however, the insured fails to furnish the
27 provider with the correct name and address of the insured's
28 personal injury protection insurer, the provider has 35 days
29 from the date the provider obtains the correct information to
30 furnish the insurer with a statement of the charges. The
31 insurer is not required to pay for such charges unless the
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1 provider includes with the statement documentary evidence that
2 was provided by the insured during the 35-day period
3 demonstrating that the provider reasonably relied on erroneous
4 information from the insured and either:
5 a. A denial letter from the incorrect insurer; or
6 b. Proof of mailing, which may include an affidavit
7 under penalty of perjury, reflecting timely mailing to the
8 incorrect address or insurer.
9 3. For emergency services and care as defined in s.
10 395.002 rendered in a hospital emergency department or for
11 transport and treatment rendered by an ambulance provider
12 licensed pursuant to part III of chapter 401, the provider is
13 not required to furnish the statement of charges within the
14 time periods established by this paragraph; and the insurer
15 shall not be considered to have been furnished with notice of
16 the amount of covered loss for purposes of paragraph (4)(b)
17 until it receives a statement complying with paragraph (d), or
18 copy thereof, which specifically identifies the place of
19 service to be a hospital emergency department or an ambulance
20 in accordance with billing standards recognized by the Health
21 Care Finance Administration.
22 4. Each notice of insured's rights under s. 627.7401
23 must include the following statement in type no smaller than
24 12 points:
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26 BILLING REQUIREMENTS.--Florida Statutes provide
27 that with respect to any treatment or services,
28 other than certain hospital and emergency
29 services, the statement of charges furnished to
30 the insurer by the provider may not include,
31 and the insurer and the injured party are not
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1 required to pay, charges for treatment or
2 services rendered more than 35 days before the
3 postmark date of the statement, except for past
4 due amounts previously billed on a timely
5 basis, and except that, if the provider submits
6 to the insurer a notice of initiation of
7 treatment within 21 days after its first
8 examination or treatment of the claimant, the
9 statement may include charges for treatment or
10 services rendered up to, but not more than, 75
11 days before the postmark date of the statement.
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13 (d) All statements and bills for medical services
14 rendered by any physician, hospital, clinic, or other person
15 or institution shall be submitted to the insurer on a properly
16 completed Centers for Medicare and Medicaid Services (CMS)
17 1500 form, UB 92 forms, or any other standard form approved by
18 the office or adopted by the commission for purposes of this
19 paragraph. All billings for such services rendered by
20 providers shall, to the extent applicable, follow the
21 Physicians' Current Procedural Terminology (CPT) or Healthcare
22 Correct Procedural Coding System (HCPCS), or ICD-9 in effect
23 for the year in which services are rendered and comply with
24 the Centers for Medicare and Medicaid Services (CMS) 1500 form
25 instructions and the American Medical Association Current
26 Procedural Terminology (CPT) Editorial Panel and Healthcare
27 Correct Procedural Coding System (HCPCS). All providers other
28 than hospitals shall include on the applicable claim form the
29 professional license number of the provider in the line or
30 space provided for "Signature of Physician or Supplier,
31 Including Degrees or Credentials." In determining compliance
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1 with applicable CPT and HCPCS coding, guidance shall be
2 provided by the Physicians' Current Procedural Terminology
3 (CPT) or the Healthcare Correct Procedural Coding System
4 (HCPCS) in effect for the year in which services were
5 rendered, the Office of the Inspector General (OIG),
6 Physicians Compliance Guidelines, and other authoritative
7 treatises designated by rule by the Agency for Health Care
8 Administration. No statement of medical services may include
9 charges for medical services of a person or entity that
10 performed such services without possessing the valid licenses
11 required to perform such services. For purposes of paragraph
12 (4)(b), an insurer shall not be considered to have been
13 furnished with notice of the amount of covered loss or medical
14 bills due unless the statements or bills comply with this
15 paragraph, and unless the statements or bills are properly
16 completed in their entirety as to all material provisions,
17 with all relevant information being provided therein.
18 (e)1. At the initial treatment or service provided,
19 each physician, other licensed professional, clinic, or other
20 medical institution providing medical services upon which a
21 claim for personal injury protection benefits is based shall
22 require an insured person, or his or her guardian, to execute
23 a disclosure and acknowledgment form, which reflects at a
24 minimum that:
25 a. The insured, or his or her guardian, must
26 countersign the form attesting to the fact that the services
27 set forth therein were actually rendered;
28 b. The insured, or his or her guardian, has both the
29 right and affirmative duty to confirm that the services were
30 actually rendered;
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1 c. The insured, or his or her guardian, was not
2 solicited by any person to seek any services from the medical
3 provider;
4 d. That the physician, other licensed professional,
5 clinic, or other medical institution rendering services for
6 which payment is being claimed explained the services to the
7 insured or his or her guardian; and
8 e. If the insured notifies the insurer in writing of a
9 billing error, the insured may be entitled to a certain
10 percentage of a reduction in the amounts paid by the insured's
11 motor vehicle insurer.
12 2. The physician, other licensed professional, clinic,
13 or other medical institution rendering services for which
14 payment is being claimed has the affirmative duty to explain
15 the services rendered to the insured, or his or her guardian,
16 so that the insured, or his or her guardian, countersigns the
17 form with informed consent.
18 3. Countersignature by the insured, or his or her
19 guardian, is not required for the reading of diagnostic tests
20 or other services that are of such a nature that they are not
21 required to be performed in the presence of the insured.
22 4. The licensed medical professional rendering
23 treatment for which payment is being claimed must sign, by his
24 or her own hand, the form complying with this paragraph.
25 5. The original completed disclosure and
26 acknowledgment form shall be furnished to the insurer pursuant
27 to paragraph (4)(b) and may not be electronically furnished.
28 6. This disclosure and acknowledgment form is not
29 required for services billed by a provider for emergency
30 services as defined in s. 395.002, for emergency services and
31 care as defined in s. 395.002 rendered in a hospital emergency
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1 department, or for transport and treatment rendered by an
2 ambulance provider licensed pursuant to part III of chapter
3 401.
4 7. The Financial Services Commission shall adopt, by
5 rule, a standard disclosure and acknowledgment form that shall
6 be used to fulfill the requirements of this paragraph,
7 effective 90 days after such form is adopted and becomes
8 final. The commission shall adopt a proposed rule by October
9 1, 2003. Until the rule is final, the provider may use a form
10 of its own which otherwise complies with the requirements of
11 this paragraph.
12 8. As used in this paragraph, "countersigned" means a
13 second or verifying signature, as on a previously signed
14 document, and is not satisfied by the statement "signature on
15 file" or any similar statement.
16 9. The requirements of this paragraph apply only with
17 respect to the initial treatment or service of the insured by
18 a provider. For subsequent treatments or service, the provider
19 must maintain a patient log signed by the patient, in
20 chronological order by date of service, that is consistent
21 with the services being rendered to the patient as claimed.
22 The requirements of this subparagraph for maintaining a
23 patient log signed by the patient may be met by a hospital
24 that maintains medical records as required by s. 395.3025 and
25 applicable rules and makes such records available to the
26 insurer upon request.
27 (f) Upon written notification by any person, an
28 insurer shall investigate any claim of improper billing by a
29 physician or other medical provider. The insurer shall
30 determine if the insured was properly billed for only those
31 services and treatments that the insured actually received. If
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1 the insurer determines that the insured has been improperly
2 billed, the insurer shall notify the insured, the person
3 making the written notification and the provider of its
4 findings and shall reduce the amount of payment to the
5 provider by the amount determined to be improperly billed. If
6 a reduction is made due to such written notification by any
7 person, the insurer shall pay to the person 20 percent of the
8 amount of the reduction, up to $500. If the provider is
9 arrested due to the improper billing, then the insurer shall
10 pay to the person 40 percent of the amount of the reduction,
11 up to $500.
12 (g) An insurer may not systematically downcode with
13 the intent to deny reimbursement otherwise due. Such action
14 constitutes a material misrepresentation under s.
15 626.9541(1)(i)2.
16 Section 2. Effective January 1, 2009, sections
17 627.730, 627.731, 627.732, 627.733, 627.734, 627.736, 627.737,
18 627.739, 627.7401, 627.7403, and 627.7405, Florida Statutes,
19 constituting the Florida Motor Vehicle No-Fault Law, are
20 repealed unless reviewed and reenacted by the Legislature
21 before that date.
22 Section 3. Section 19 of chapter 2003-411, Laws of
23 Florida, is repealed, and sections 627.730, 627.731, 627.732,
24 627.733, 627.734, 627.736, 627.737, 627.739, 627.7401,
25 627.7403, and 627.7405, Florida Statutes, are reenacted and
26 shall not stand repealed on October 1, 2007, as provided for
27 in that section.
28 Section 4. This act shall take effect July 1, 2007,
29 and shall apply to treatment, care, procedures, or services
30 rendered or performed on or after that date.
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1 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
2 Senate Bill 1880
3
4 The committee substitute provides the following changes:
5 1. Reenacts the no-fault law, subject to repeal on January
1, 2009.
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2. Allows a personal injury protection (PIP) insurer to
7 apply a limit on medical charges for services equal to
200 percent of the Medicare fee schedule.
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3. Provides that if a service is not covered under Medicare,
9 the charge is subject to the maximum amount that is
reimbursed under workers' compensation.
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4. Provides that if a service is not reimbursed under either
11 Medicare or workers' compensation, it is not reimbursable
by the insurer.
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5. Prohibits a provider from billing or attempting to
13 collect from an insured any amount in excess of the fee
schedule payment limit, other than amounts not covered by
14 the insured's PIP coverage due to deductibles,
coinsurance amounts, or maximum policy limits.
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6. Removes existing fee schedules for specified medical
16 procedures.
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