((LATE FILED FOR: 4/21/2008 2:00:00 PM))Amendment
Bill No. CS/CS/HB 405
Amendment No. 718453
CHAMBER ACTION
Senate House
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1Representative Galvano offered the following:
2
3     Amendment (with title amendment)
4     Remove lines 52-155 and insert:
5     Section 2.  Subsections (18) and (19) are added to section
6627.6131, Florida Statutes, to read:
7     627.6131  Payment of claims.--
8     (18)  Notwithstanding the 30-month period provided in
9subsection (6), all claims for overpayment submitted to a
10provider licensed under chapter 458, chapter 459, chapter 460,
11chapter 461, or chapter 466 must be submitted to the provider
12within 12 months after the health insurer's payment of the
13claim. A claim for overpayment shall not be permitted beyond 12
14months after the health insurer's payment of a claim, except
15that claims for overpayment may be sought beyond that time from
16providers convicted of fraud pursuant to s. 817.234.
17     (19)  Notwithstanding any other provision of this section,
18all claims for underpayment from a provider licensed under
19chapter 458, chapter 459, chapter 460, chapter 461, or chapter
20466 must be submitted to the insurer within 12 months after the
21health insurer's payment of the claim. A claim for underpayment
22shall not be permitted beyond 12 months after the health
23insurer's payment of a claim.
24     Section 3.  Section 627.638, Florida Statutes, is amended
25to read:
26     627.638  Direct payment for hospital, medical services.--
27     (1)  Any health insurance policy insuring against loss or
28expense due to hospital confinement or to medical and related
29services may provide for payment of benefits directly to any
30recognized hospital, licensed ambulance provider, doctor, or
31other person who provided the services, in accordance with the
32provisions of the policy. To comply with this section, the words
33"or to the hospital, licensed ambulance provider, doctor, or
34person rendering services covered by this policy," or similar
35words appropriate to the terms of the policy, shall be added to
36applicable provisions of the policy.
37     (2)  Whenever, in any health insurance claim form, an
38insured specifically authorizes payment of benefits directly to
39any recognized hospital, licensed ambulance provider, physician,
40or dentist, the insurer shall make such payment to the
41designated provider of such services, unless otherwise provided
42in the insurance contract. The insurance contract may not
43prohibit, and claims forms must provide an option for, the
44payment of benefits directly to a licensed hospital, licensed
45ambulance provider, physician, or dentist for care provided
46pursuant to s. 395.1041 or part III of chapter 401. The insurer
47may require written attestation of assignment of benefits.
48Payment to the provider from the insurer may not be more than
49the amount that the insurer would otherwise have paid without
50the assignment.
51     (3)  Any insurer that has contracted with a preferred
52provider as defined in s. 627.6471(1)(b) for the delivery of
53health care services to its insureds shall make payments
54directly to the preferred provider for such services.
55     Section 4.  Section 627.64731, Florida Statutes, is created
56to read:
57     627.64731  Leasing, renting, or granting access to a
58participating provider.--
59     (1)  As used in this section:
60     (a)  "Contracting entity" means any person or entity that
61is engaged in the act of contracting with participating
62providers and has a direct contract with a participating
63provider for the delivery of health care services or the selling
64or assigning of physicians or physician panels to other health
65care entities.
66     (b)  "Participating provider" means a physician licensed
67under chapter 458, chapter 459, chapter 460, chapter 461, or
68chapter 466 or a physician group practice that has a health care
69contract with a contracting entity and is entitled to
70reimbursement for health care services rendered to an enrollee
71under the health care contract and includes both preferred
72providers as defined in s. 627.6471 and exclusive providers as
73defined in s. 627.6472.
74     (2)  A contracting entity may not sell, lease, rent, or
75otherwise grant access to the health care services of a
76participating provider under a health care contract unless
77expressly authorized by the health care contract. At the time a
78health care contract is entered into with a participating
79provider, the contracting entity shall, to the extent possible,
80identify any third party to which the contracting entity has
81granted access to the health care services of the participating
82provider.
83     (3)  Upon a request by a participating provider, a
84contracting entity must provide the identity of any third party
85that has been granted access to the health care services of the
86participating provider.
87     (4)  A contracting entity that leases, rents, or otherwise
88grants access to the health care services of a participating
89provider must maintain an Internet website or a toll-free
90telephone number through which the provider may obtain a
91listing, updated at least every 90 days, of the third parties
92that have been granted access to the provider's health care
93services.
94     (5)  A contracting entity that leases, rents, or otherwise
95grants access to a participating provider's health care services
96must ensure that an explanation of benefits or remittance advice
97furnished to the participating provider that delivers health
98care services under the health care contract identifies the
99contractual source of any applicable discount.
100     (6)  Subject to applicable continuity of care laws, the
101right of a third party to exercise the rights and
102responsibilities of a contracting entity under a health care
103contract terminates on the day after the termination of the
104participating provider's contract with the contracting entity.
105     (7)  The provisions of this section do not apply if the
106third party that is granted access to a participating provider's
107health care services under a health care contract is:
108     (a)  An employer or other entity providing coverage for
109health care services to the employer's employees or the entity's
110members and the employer or entity has a contract with the
111contracting entity or the contracting entity's affiliate for the
112administration or processing of claims for payment or services
113provided under the health care contract;
114     (b)  An entity providing administrative services to, or
115receiving administrative services from, the contracting entity
116or the contracting entity's affiliate or subsidiary; or
117     (c)  An affiliate or a subsidiary of a contracting entity
118or other entity if operating under the same brand licensee
119program as the contracting entity.
120     (8)  A health care contract may provide for arbitration of
121disputes arising under this section.
122     (9)  A contracting entity shall ensure that all third
123parties to which the contracting entity has sold, rented,
124assigned, or otherwise given access to the participating
125provider's discounted rate comply with the physician contract,
126including all requirements to encourage access to the
127participating provider, and pay the provider pursuant to the
128rates of payment and methodology set forth in that contract,
129unless otherwise agreed to by a participating provider.
130     (10)  Notwithstanding any other provision of this section,
131no contracting entity shall sell, rent, lease, or give a third
132party the contracting entity's rights to a participating
133provider's services pursuant to the contracting entity's health
134care contract with the participating provider unless one of the
135following applies:
136     (a)  The third party accessing the participating provider's
137services under the health care contract is an employer or other
138entity providing coverage for health care services to its
139employees or members, and that employer or entity has a contract
140with the contracting entity or its affiliate for the
141administration or processing of claims for payment for services
142provided pursuant to the health care contract with the
143participating provider.
144     (b)  The third party accessing the participating provider's
145services under the health care contract is an affiliate or
146subsidiary of the contracting entity, is an entity operating
147under the same brand licensee program as the contracting entity,
148or is providing administrative services to or receiving
149administrative services from the contracting entity or an
150affiliate or subsidiary of the contracting entity.
151     (c)  The health care contract specifically provides that it
152applies to network rental arrangements and states that one
153purpose of the contract is selling, renting, or giving the
154contracting entity's rights to the services of the participating
155provider, including other preferred provider organizations, and
156the third party accessing the participating provider's services
157is:
158     1.  A payor or a third-party administrator or other entity
159responsible for administering claims on behalf of the payor;
160     2.  A preferred provider organization or preferred provider
161network that receives access to the participating provider's
162services pursuant to an arrangement with the preferred provider
163organization or preferred provider network in a contract with
164the participating provider and is required to comply with all of
165the terms, conditions, and affirmative obligations to which the
166originally contracted primary participating provider network is
167bound under its contract with the participating provider,
168including, but not limited to, obligations concerning patient
169steerage and the timeliness and manner of reimbursement; or
170     3.  An entity that is engaged in the business of providing
171electronic claims transport between the contracting entity and
172the payor or third-party administrator and complies with all of
173the applicable terms, conditions, and affirmative obligations of
174the contracting entity's contract with the participating
175provider, including, but not limited to, obligations concerning
176patient steerage and the timeliness and manner of reimbursement.
177     (11)  A contracting entity is deemed in compliance with
178this section when the insured's identification card provides,
179written or electronically, information that identifies the
180preferred provider network or networks to be utilized to
181reimburse the provider for covered services.
182     (12)  This section shall not apply to a contract between a
183contracting entity and a discount medical plan organization
184licensed or exempt under part II of chapter 636.
185     Section 5.  Subsections (11), (12), and (13) of section
186627.662, Florida Statutes, are renumbered as subsections (12),
187(13), and (14), respectively, and a new subsection (11) is added
188to that section to read:
189     627.662  Other provisions applicable.--The following
190provisions apply to group health insurance, blanket health
191insurance, and franchise health insurance:
192     (11)  Section 627.64731, relating to leasing, renting, or
193granting access to a participating provider.
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T I T L E  A M E N D M E N T
200     Remove lines 7-33 and insert:
201circumstances; amending s. 627.6131, F.S.; providing
202requirements for and prohibitions against certain claims for
203overpayment and claims for underpayment; amending s. 627.638,
204F.S.; revising provisions providing for direct payment to
205certain providers for certain services to include licensed
206ambulance providers; requiring certain insurers to make payments
207directly to contracted preferred providers for certain services;
208creating s. 627.64731, F.S.; providing definitions; providing
209requirements, limitations, and procedures for leasing, renting,
210or granting access to participating providers by third parties;
211providing exceptions; providing for arbitration; prohibiting
212third party access to certain services under certain
213circumstances; providing exceptions; providing application;
214amending s. 627.662, F.S.; expanding the list of applicable
215sections to certain types of insurance; amending s.


CODING: Words stricken are deletions; words underlined are additions.