1 | Representative Galvano offered the following: |
2 |
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3 | Amendment (with title amendment) |
4 | Remove lines 52-155 and insert: |
5 | Section 2. Subsections (18) and (19) are added to section |
6 | 627.6131, Florida Statutes, to read: |
7 | 627.6131 Payment of claims.-- |
8 | (18) Notwithstanding the 30-month period provided in |
9 | subsection (6), all claims for overpayment submitted to a |
10 | provider licensed under chapter 458, chapter 459, chapter 460, |
11 | chapter 461, or chapter 466 must be submitted to the provider |
12 | within 12 months after the health insurer's payment of the |
13 | claim. A claim for overpayment shall not be permitted beyond 12 |
14 | months after the health insurer's payment of a claim, except |
15 | that claims for overpayment may be sought beyond that time from |
16 | providers convicted of fraud pursuant to s. 817.234. |
17 | (19) Notwithstanding any other provision of this section, |
18 | all claims for underpayment from a provider licensed under |
19 | chapter 458, chapter 459, chapter 460, chapter 461, or chapter |
20 | 466 must be submitted to the insurer within 12 months after the |
21 | health insurer's payment of the claim. A claim for underpayment |
22 | shall not be permitted beyond 12 months after the health |
23 | insurer's payment of a claim. |
24 | Section 3. Section 627.638, Florida Statutes, is amended |
25 | to read: |
26 | 627.638 Direct payment for hospital, medical services.-- |
27 | (1) Any health insurance policy insuring against loss or |
28 | expense due to hospital confinement or to medical and related |
29 | services may provide for payment of benefits directly to any |
30 | recognized hospital, licensed ambulance provider, doctor, or |
31 | other person who provided the services, in accordance with the |
32 | provisions of the policy. To comply with this section, the words |
33 | "or to the hospital, licensed ambulance provider, doctor, or |
34 | person rendering services covered by this policy," or similar |
35 | words appropriate to the terms of the policy, shall be added to |
36 | applicable provisions of the policy. |
37 | (2) Whenever, in any health insurance claim form, an |
38 | insured specifically authorizes payment of benefits directly to |
39 | any recognized hospital, licensed ambulance provider, physician, |
40 | or dentist, the insurer shall make such payment to the |
41 | designated provider of such services, unless otherwise provided |
42 | in the insurance contract. The insurance contract may not |
43 | prohibit, and claims forms must provide an option for, the |
44 | payment of benefits directly to a licensed hospital, licensed |
45 | ambulance provider, physician, or dentist for care provided |
46 | pursuant to s. 395.1041 or part III of chapter 401. The insurer |
47 | may require written attestation of assignment of benefits. |
48 | Payment to the provider from the insurer may not be more than |
49 | the amount that the insurer would otherwise have paid without |
50 | the assignment. |
51 | (3) Any insurer that has contracted with a preferred |
52 | provider as defined in s. 627.6471(1)(b) for the delivery of |
53 | health care services to its insureds shall make payments |
54 | directly to the preferred provider for such services. |
55 | Section 4. Section 627.64731, Florida Statutes, is created |
56 | to read: |
57 | 627.64731 Leasing, renting, or granting access to a |
58 | participating provider.-- |
59 | (1) As used in this section: |
60 | (a) "Contracting entity" means any person or entity that |
61 | is engaged in the act of contracting with participating |
62 | providers and has a direct contract with a participating |
63 | provider for the delivery of health care services or the selling |
64 | or assigning of physicians or physician panels to other health |
65 | care entities. |
66 | (b) "Participating provider" means a physician licensed |
67 | under chapter 458, chapter 459, chapter 460, chapter 461, or |
68 | chapter 466 or a physician group practice that has a health care |
69 | contract with a contracting entity and is entitled to |
70 | reimbursement for health care services rendered to an enrollee |
71 | under the health care contract and includes both preferred |
72 | providers as defined in s. 627.6471 and exclusive providers as |
73 | defined in s. 627.6472. |
74 | (2) A contracting entity may not sell, lease, rent, or |
75 | otherwise grant access to the health care services of a |
76 | participating provider under a health care contract unless |
77 | expressly authorized by the health care contract. At the time a |
78 | health care contract is entered into with a participating |
79 | provider, the contracting entity shall, to the extent possible, |
80 | identify any third party to which the contracting entity has |
81 | granted access to the health care services of the participating |
82 | provider. |
83 | (3) Upon a request by a participating provider, a |
84 | contracting entity must provide the identity of any third party |
85 | that has been granted access to the health care services of the |
86 | participating provider. |
87 | (4) A contracting entity that leases, rents, or otherwise |
88 | grants access to the health care services of a participating |
89 | provider must maintain an Internet website or a toll-free |
90 | telephone number through which the provider may obtain a |
91 | listing, updated at least every 90 days, of the third parties |
92 | that have been granted access to the provider's health care |
93 | services. |
94 | (5) A contracting entity that leases, rents, or otherwise |
95 | grants access to a participating provider's health care services |
96 | must ensure that an explanation of benefits or remittance advice |
97 | furnished to the participating provider that delivers health |
98 | care services under the health care contract identifies the |
99 | contractual source of any applicable discount. |
100 | (6) Subject to applicable continuity of care laws, the |
101 | right of a third party to exercise the rights and |
102 | responsibilities of a contracting entity under a health care |
103 | contract terminates on the day after the termination of the |
104 | participating provider's contract with the contracting entity. |
105 | (7) The provisions of this section do not apply if the |
106 | third party that is granted access to a participating provider's |
107 | health care services under a health care contract is: |
108 | (a) An employer or other entity providing coverage for |
109 | health care services to the employer's employees or the entity's |
110 | members and the employer or entity has a contract with the |
111 | contracting entity or the contracting entity's affiliate for the |
112 | administration or processing of claims for payment or services |
113 | provided under the health care contract; |
114 | (b) An entity providing administrative services to, or |
115 | receiving administrative services from, the contracting entity |
116 | or the contracting entity's affiliate or subsidiary; or |
117 | (c) An affiliate or a subsidiary of a contracting entity |
118 | or other entity if operating under the same brand licensee |
119 | program as the contracting entity. |
120 | (8) A health care contract may provide for arbitration of |
121 | disputes arising under this section. |
122 | (9) A contracting entity shall ensure that all third |
123 | parties to which the contracting entity has sold, rented, |
124 | assigned, or otherwise given access to the participating |
125 | provider's discounted rate comply with the physician contract, |
126 | including all requirements to encourage access to the |
127 | participating provider, and pay the provider pursuant to the |
128 | rates of payment and methodology set forth in that contract, |
129 | unless otherwise agreed to by a participating provider. |
130 | (10) Notwithstanding any other provision of this section, |
131 | no contracting entity shall sell, rent, lease, or give a third |
132 | party the contracting entity's rights to a participating |
133 | provider's services pursuant to the contracting entity's health |
134 | care contract with the participating provider unless one of the |
135 | following applies: |
136 | (a) The third party accessing the participating provider's |
137 | services under the health care contract is an employer or other |
138 | entity providing coverage for health care services to its |
139 | employees or members, and that employer or entity has a contract |
140 | with the contracting entity or its affiliate for the |
141 | administration or processing of claims for payment for services |
142 | provided pursuant to the health care contract with the |
143 | participating provider. |
144 | (b) The third party accessing the participating provider's |
145 | services under the health care contract is an affiliate or |
146 | subsidiary of the contracting entity, is an entity operating |
147 | under the same brand licensee program as the contracting entity, |
148 | or is providing administrative services to or receiving |
149 | administrative services from the contracting entity or an |
150 | affiliate or subsidiary of the contracting entity. |
151 | (c) The health care contract specifically provides that it |
152 | applies to network rental arrangements and states that one |
153 | purpose of the contract is selling, renting, or giving the |
154 | contracting entity's rights to the services of the participating |
155 | provider, including other preferred provider organizations, and |
156 | the third party accessing the participating provider's services |
157 | is: |
158 | 1. A payor or a third-party administrator or other entity |
159 | responsible for administering claims on behalf of the payor; |
160 | 2. A preferred provider organization or preferred provider |
161 | network that receives access to the participating provider's |
162 | services pursuant to an arrangement with the preferred provider |
163 | organization or preferred provider network in a contract with |
164 | the participating provider and is required to comply with all of |
165 | the terms, conditions, and affirmative obligations to which the |
166 | originally contracted primary participating provider network is |
167 | bound under its contract with the participating provider, |
168 | including, but not limited to, obligations concerning patient |
169 | steerage and the timeliness and manner of reimbursement; or |
170 | 3. An entity that is engaged in the business of providing |
171 | electronic claims transport between the contracting entity and |
172 | the payor or third-party administrator and complies with all of |
173 | the applicable terms, conditions, and affirmative obligations of |
174 | the contracting entity's contract with the participating |
175 | provider, including, but not limited to, obligations concerning |
176 | patient steerage and the timeliness and manner of reimbursement. |
177 | (11) A contracting entity is deemed in compliance with |
178 | this section when the insured's identification card provides, |
179 | written or electronically, information that identifies the |
180 | preferred provider network or networks to be utilized to |
181 | reimburse the provider for covered services. |
182 | (12) This section shall not apply to a contract between a |
183 | contracting entity and a discount medical plan organization |
184 | licensed or exempt under part II of chapter 636. |
185 | Section 5. Subsections (11), (12), and (13) of section |
186 | 627.662, Florida Statutes, are renumbered as subsections (12), |
187 | (13), and (14), respectively, and a new subsection (11) is added |
188 | to that section to read: |
189 | 627.662 Other provisions applicable.--The following |
190 | provisions apply to group health insurance, blanket health |
191 | insurance, and franchise health insurance: |
192 | (11) Section 627.64731, relating to leasing, renting, or |
193 | granting access to a participating provider. |
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198 | ----------------------------------------------------- |
199 | T I T L E A M E N D M E N T |
200 | Remove lines 7-33 and insert: |
201 | circumstances; amending s. 627.6131, F.S.; providing |
202 | requirements for and prohibitions against certain claims for |
203 | overpayment and claims for underpayment; amending s. 627.638, |
204 | F.S.; revising provisions providing for direct payment to |
205 | certain providers for certain services to include licensed |
206 | ambulance providers; requiring certain insurers to make payments |
207 | directly to contracted preferred providers for certain services; |
208 | creating s. 627.64731, F.S.; providing definitions; providing |
209 | requirements, limitations, and procedures for leasing, renting, |
210 | or granting access to participating providers by third parties; |
211 | providing exceptions; providing for arbitration; prohibiting |
212 | third party access to certain services under certain |
213 | circumstances; providing exceptions; providing application; |
214 | amending s. 627.662, F.S.; expanding the list of applicable |
215 | sections to certain types of insurance; amending s. |