CS/HB 405

1	A bill to be entitled
2	An act relating to health insurance claims payments;
3	amending s. 627.638, F.S.; including licensed ambulance
4	providers under provisions for direct payment for certain
5	services; deleting an insurance contract limitation on
6	payment of benefits directly to providers; authorizing
7	attestations assigning benefits; providing for transfer of
8	attestations electronically; requiring insurers to make
9	payments directly to preferred providers under certain
10	circumstances; providing an insurance contract prohibition
11	and claims form requirement relating to payment of
12	benefits directly to providers; providing a payment
13	limitation; amending s. 627.6471, F.S.; prohibiting
14	insurers and plan administrators from reimbursing
15	preferred providers at an alternative or reduced rate for
16	covered services under certain circumstances; providing
17	exceptions; prohibiting preferred provider contract
18	parties from selling, leasing, or transferring contract
19	payment or reimbursement terms information under certain
20	circumstances; amending s. 641.31, F.S.; requiring health
21	maintenance organizations to pay benefits directly to
22	certain providers under certain circumstances; prohibiting
23	health maintenance contracts from prohibiting and
24	requiring claims form to provide the option for payment of
25	benefits directly to certain providers; amending s.
26	641.315, F.S.; prohibiting health maintenance
27	organizations from selling, leasing, or transferring
28	contract payment or reimbursement terms information under
29	certain circumstances; amending s. 641.3155, F.S.;
30	decreasing the period of time authorized for overpayment
31	claims of health maintenance organizations against
32	providers; providing an effective date.
33
34	Be It Enacted by the Legislature of the State of Florida:
35
36	Section 1.  Section 627.638, Florida Statutes, is amended
37	to read:
38	627.638  Direct payment for hospital, ambulance, and
39	medical services.--
40	(1)  Any health insurance policy insuring against loss or
41	expense due to hospital confinement or to medical and related
42	services may provide for payment of benefits directly to any
43	recognized hospital, licensed ambulance provider, doctor, or
44	other person who provided the services, in accordance with the
45	provisions of the policy. To comply with this section, the words
46	"or to the hospital, licensed ambulance provider, doctor, or
47	person rendering services covered by this policy," or similar
48	words appropriate to the terms of the policy, shall be added to
49	applicable provisions of the policy.
50	(2)  Whenever, in any health insurance claim form, an
51	insured specifically authorizes payment of benefits directly to
52	any recognized hospital, licensed ambulance provider, physician,
53	or dentist, or other person who provided the services, in
54	accordance with the provisions of the policy, the insurer shall
55	make such payment to the designated provider of such services,
56	unless otherwise provided in the insurance contract. The
57	insurance contract may not prohibit, and claims forms must
58	provide an option for, the payment of benefits directly to a
59	licensed hospital, licensed ambulance provider, physician, or
60	dentist, or other person who provided services for care provided
61	pursuant to s. 395.1041 or part III of chapter 401. The insurer
62	may require an written attestation assigning of assignment of
63	benefits, which attestation may be in written or electronic
64	form, at the discretion of the insured. If the attestation is in
65	electronic form, the attestation may be transferred to the
66	insurer electronically. An insurer may not require an
67	attestation in both electronic and written form. Payment to the
68	provider from the insurer may not be more than the amount that
69	the insurer would otherwise have paid without the assignment.
70	(3)  Whenever, in any health insurance claim form, an
71	insured specifically authorizes payment of benefits directly to
72	a preferred provider as defined in s. 627.6471(1)(b), the
73	insurer shall make such payment to the preferred provider. The
74	insurance contract may not prohibit, and claims forms must
75	provide an option for, the payment of benefits directly to the
76	preferred provider. An attestation assigning benefits may be
77	transferred to the insurer in electronic form. Payment to the
78	provider from the insurer may not be more than the amount that
79	the insurer would otherwise have paid without the assignment.
80	(4)  Notwithstanding the provisions of subsections (2) and
81	(3), if an insured authorizes payment of benefits directly to a
82	licensed hospital for health care services provided pursuant to
83	s. 395.1041, the insurer shall make such payment to the
84	designated provider of such services. The insurer shall accept a
85	provider's claim form that properly indicates that the insured
86	has assigned payment of benefits directly to the hospital.
87	Payment to the hospital from the insurer may not be more than
88	the amount the insurer would otherwise have paid without the
89	assignment.
90	Section 2.  Subsection (7) is added to section 627.6471,
91	Florida Statutes, to read:
92	627.6471  Contracts for reduced rates of payment;
93	limitations; coinsurance and deductibles.--
94	(7)(a)  An insurer or an administrator may not reimburse a
95	preferred provider at an alternative or a reduced rate of
96	payment for covered services that are provided to an insured
97	unless:
98	1.  The insurer or administrator has contracted with the
99	preferred provider and has agreed to provide coverage for those
100	health care services under the health insurance policy.
101	2.  The preferred provider has agreed to the contract and
102	to provide health care services under the terms of the contract.
103	(b)  A party to a preferred provider contract may not sell,
104	lease, or otherwise transfer information regarding the payment
105	or reimbursement terms of the contract without the express
106	authority of and prior adequate notification to the other
107	contracting parties.
108	Section 3.  Subsection (41) is added to section 641.31,
109	Florida Statutes, to read:
110	641.31  Health maintenance contracts.--
111	(41)  Whenever, in any health maintenance organization
112	claim form, a subscriber specifically authorizes payment of
113	benefits directly to any hospital, ambulance provider,
114	physician, or dentist, the health maintenance organization shall
115	make such payment to the designated provider of such services,
116	provided any benefits are due to the subscriber under the terms
117	of the agreement between the subscriber and the health
118	maintenance organization. The health maintenance organization
119	contract may not prohibit, and claims forms must provide an
120	option for, the payment of benefits directly to a licensed
121	hospital, ambulance provider, physician, or dentist for covered
122	services provided, for services provided pursuant to s.
123	395.1041, and for ambulance transport and treatment provided
124	pursuant to part III of chapter 401. The attestation of
125	assignment of benefits may be in written or electronic form.
126	Payment to the provider from the health maintenance organization
127	may not be more than the amount that the insurer would otherwise
128	have paid without the assignment. Nothing in this subsection
129	affects the applicability of ss. 641.3154 and 641.513 with
130	respect to services provided and payment for such services
131	provided pursuant to this subsection.
132	Section 4.  Subsection (11) is added to section 641.315,
133	Florida Statutes, to read:
134	641.315  Provider contracts.--
135	(11)  A health maintenance organization may not sell,
136	lease, or otherwise transfer information regarding the payment
137	of reimbursement terms of a contract with a health care
138	practitioner without the express authority of and prior adequate
139	notification to the contracting parties.
140	Section 5.  Subsection (5) of section 641.3155, Florida
141	Statutes, is amended to read:
142	641.3155  Prompt payment of claims.--
143	(5)  If a health maintenance organization determines that
144	it has made an overpayment to a provider for services rendered
145	to a subscriber, the health maintenance organization must make a
146	claim for such overpayment to the provider's designated
147	location. A health maintenance organization that makes a claim
148	for overpayment to a provider under this section shall give the
149	provider a written or electronic statement specifying the basis
150	for the retroactive denial or payment adjustment. The health
151	maintenance organization must identify the claim or claims, or
152	overpayment claim portion thereof, for which a claim for
153	overpayment is submitted.
154	(a)  If an overpayment determination is the result of
155	retroactive review or audit of coverage decisions or payment
156	levels not related to fraud, a health maintenance organization
157	shall adhere to the following procedures:
158	1.  All claims for overpayment must be submitted to a
159	provider within 12 30 months after the health maintenance
160	organization's payment of the claim. A provider must pay, deny,
161	or contest the health maintenance organization's claim for
162	overpayment within 40 days after the receipt of the claim. All
163	contested claims for overpayment must be paid or denied within
164	120 days after receipt of the claim. Failure to pay or deny
165	overpayment and claim within 140 days after receipt creates an
166	uncontestable obligation to pay the claim.
167	2.  A provider that denies or contests a health maintenance
168	organization's claim for overpayment or any portion of a claim
169	shall notify the organization, in writing, within 35 days after
170	the provider receives the claim that the claim for overpayment
171	is contested or denied. The notice that the claim for
172	overpayment is denied or contested must identify the contested
173	portion of the claim and the specific reason for contesting or
174	denying the claim and, if contested, must include a request for
175	additional information. If the organization submits additional
176	information, the organization must, within 35 days after receipt
177	of the request, mail or electronically transfer the information
178	to the provider. The provider shall pay or deny the claim for
179	overpayment within 45 days after receipt of the information. The
180	notice is considered made on the date the notice is mailed or
181	electronically transferred by the provider.
182	3.  The health maintenance organization may not reduce
183	payment to the provider for other services unless the provider
184	agrees to the reduction in writing or fails to respond to the
185	health maintenance organization's overpayment claim as required
186	by this paragraph.
187	4.  Payment of an overpayment claim is considered made on
188	the date the payment was mailed or electronically transferred.
189	An overdue payment of a claim bears simple interest at the rate
190	of 12 percent per year. Interest on an overdue payment for a
191	claim for an overpayment payment begins to accrue when the claim
192	should have been paid, denied, or contested.
193	(b)  A claim for overpayment shall not be permitted beyond
194	12 30 months after the health maintenance organization's payment
195	of a claim, except that claims for overpayment may be sought
196	beyond that time from providers convicted of fraud pursuant to
197	s. 817.234.
198	Section 6.  This act shall take effect July 1, 2008.

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