HB 405

1	A bill to be entitled
2	An act relating to health insurance claims payments;
3	amending ss. 627.6131 and 641.31, F.S.; prohibiting health
4	insurance contracts and health maintenance contracts from
5	prohibiting or restricting insureds from assigning plan
6	benefits to certain noncontract providers for certain
7	covered services; requiring payment by an insurer of plan
8	benefits under assignment and acceptance by noncontract
9	providers; requiring noncontract providers accepting such
10	assignments to accept any payments from plan benefit
11	insurers and prohibiting such providers from collecting
12	any balances from insureds; amending s. 627.6471, F.S.;
13	prohibiting insurers and plan administrators from
14	reimbursing preferred providers at alternative or reduced
15	rates for covered services under certain circumstances;
16	providing exceptions; prohibiting preferred provider
17	contract parties from selling, leasing, or transferring
18	contract payment or reimbursement terms information under
19	certain circumstances; amending s. 641.315, F.S.;
20	prohibiting health maintenance organizations from selling,
21	leasing, or transferring contract payment or reimbursement
22	terms information under certain circumstances; amending s.
23	641.3155, F.S.; decreasing the period of time authorized
24	for overpayment claims of health maintenance organizations
25	against providers; providing an effective date.
26
27	Be It Enacted by the Legislature of the State of Florida:
28
29	Section 1.  Subsection (18) is added to section 627.6131,
30	Florida Statutes, to read:
31	627.6131  Payment of claims.--
32	(18)(a)  A contract with a health insurer may not prohibit
33	or restrict an insured from assigning plan benefits to providers
34	not under contract with the insurer for covered health care
35	services rendered by the provider to the insured.
36	(b)  Any assignment by an insured of plan benefits which
37	designates that the assignment has been accepted by a provider
38	not under contract with the health insurer must be paid to the
39	provider pursuant to this section.
40	(c)  Except for providers who are providing services
41	pursuant to ss. 395.1041 and 401.45, any provider who accepts an
42	assignment pursuant to this subsection agrees, by submitting the
43	claim to the health insurer, to accept the amount paid by the
44	health insurer as payment in full for the health care services
45	provided and to not collect any balance from the insured.
46	Section 2.  Subsection (7) is added to section 627.6471,
47	Florida Statutes, to read:
48	627.6471  Contracts for reduced rates of payment;
49	limitations; coinsurance and deductibles.--
50	(7)(a)  An insurer or an administrator may not reimburse a
51	preferred provider at an alternative or a reduced rate of
52	payment for covered services that are provided to an insured
53	unless:
54	1.  The insurer or administrator has contracted with the
55	preferred provider and has agreed to provide coverage for those
56	health care services under the health insurance policy.
57	2.  The preferred provider has agreed to the contract and
58	to provide health care services under the terms of the contract.
59	(b)  A party to a preferred provider contract may not sell,
60	lease, or otherwise transfer information regarding the payment
61	or reimbursement terms of the contract without the express
62	authority of and prior adequate notification to the other
63	contracting parties.
64	Section 3.  Subsection (41) is added to section 641.31,
65	Florida Statutes, to read:
66	641.31  Health maintenance contracts.--
67	(41)(a)  A health maintenance organization contract may not
68	prohibit or restrict a subscriber from assigning plan benefits
69	to providers not under contract with the organization for
70	covered health care services rendered by the provider to the
71	subscriber.
72	(b)  Any assignment by a subscriber of plan benefits which
73	designates that the assignment has been accepted by a provider
74	not under contract with the organization must be paid to the
75	provider pursuant to s. 641.3155.
76	(c)  Except for providers providing service pursuant to s.
77	641.513, any provider who accepts an assignment pursuant to this
78	subsection agrees, by submitting the claim to the health
79	maintenance organization, to accept the amount paid by the
80	health maintenance organization as payment in full for the
81	health care services provided and to not collect any balance
82	from the subscriber.
83	Section 4.  Subsection (11) is added to section 641.315,
84	Florida Statutes, to read:
85	641.315  Provider contracts.--
86	(11)  A health maintenance organization may not sell,
87	lease, or otherwise transfer information regarding the payment
88	of reimbursement terms of a contract with a health care
89	practitioner without the express authority of and prior adequate
90	notification to the contracting parties.
91	Section 5.  Subsection (5) of section 641.3155, Florida
92	Statutes, is amended to read:
93	641.3155  Prompt payment of claims.--
94	(5)  If a health maintenance organization determines that
95	it has made an overpayment to a provider for services rendered
96	to a subscriber, the health maintenance organization must make a
97	claim for such overpayment to the provider's designated
98	location. A health maintenance organization that makes a claim
99	for overpayment to a provider under this section shall give the
100	provider a written or electronic statement specifying the basis
101	for the retroactive denial or payment adjustment. The health
102	maintenance organization must identify the claim or claims, or
103	overpayment claim portion thereof, for which a claim for
104	overpayment is submitted.
105	(a)  If an overpayment determination is the result of
106	retroactive review or audit of coverage decisions or payment
107	levels not related to fraud, a health maintenance organization
108	shall adhere to the following procedures:
109	1.  All claims for overpayment must be submitted to a
110	provider within 6 30 months after the health maintenance
111	organization's payment of the claim. A provider must pay, deny,
112	or contest the health maintenance organization's claim for
113	overpayment within 40 days after the receipt of the claim. All
114	contested claims for overpayment must be paid or denied within
115	120 days after receipt of the claim. Failure to pay or deny
116	overpayment and claim within 140 days after receipt creates an
117	uncontestable obligation to pay the claim.
118	2.  A provider that denies or contests a health maintenance
119	organization's claim for overpayment or any portion of a claim
120	shall notify the organization, in writing, within 35 days after
121	the provider receives the claim that the claim for overpayment
122	is contested or denied. The notice that the claim for
123	overpayment is denied or contested must identify the contested
124	portion of the claim and the specific reason for contesting or
125	denying the claim and, if contested, must include a request for
126	additional information. If the organization submits additional
127	information, the organization must, within 35 days after receipt
128	of the request, mail or electronically transfer the information
129	to the provider. The provider shall pay or deny the claim for
130	overpayment within 45 days after receipt of the information. The
131	notice is considered made on the date the notice is mailed or
132	electronically transferred by the provider.
133	3.  The health maintenance organization may not reduce
134	payment to the provider for other services unless the provider
135	agrees to the reduction in writing or fails to respond to the
136	health maintenance organization's overpayment claim as required
137	by this paragraph.
138	4.  Payment of an overpayment claim is considered made on
139	the date the payment was mailed or electronically transferred.
140	An overdue payment of a claim bears simple interest at the rate
141	of 12 percent per year. Interest on an overdue payment for a
142	claim for an overpayment payment begins to accrue when the claim
143	should have been paid, denied, or contested.
144	(b)  A claim for overpayment shall not be permitted beyond
145	6 30 months after the health maintenance organization's payment
146	of a claim, except that claims for overpayment may be sought
147	beyond that time from providers convicted of fraud pursuant to
148	s. 817.234.
149	Section 6.  This act shall take effect July 1, 2008.

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