Florida Senate - 2011 COMMITTEE AMENDMENT
Bill No. CS for SB 1930
Barcode 679970
LEGISLATIVE ACTION
Senate . House
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The Committee on Judiciary (Bogdanoff) recommended the
following:
1 Senate Amendment (with title amendment)
2
3 Delete everything after the enacting clause
4 and insert:
5 Section 1. Subsection (1) of section 316.066, Florida
6 Statutes, is amended to read:
7 316.066 Written reports of crashes.—
8 (1)(a) A Florida Traffic Crash Report, Long Form, must is
9 required to be completed and submitted to the department within
10 10 days after completing an investigation is completed by the
11 every law enforcement officer who in the regular course of duty
12 investigates a motor vehicle crash:
13 1. That resulted in death, or personal injury, or any
14 indication of complaints of pain or discomfort by any of the
15 parties or passengers involved in the crash;.
16 2. That involved one or more passengers, other than the
17 drivers of the vehicles, in any of the vehicles involved in the
18 crash;
19 3.2. That involved a violation of s. 316.061(1) or s.
20 316.193; or.
21 4.3. In which a vehicle was rendered inoperative to a
22 degree that required a wrecker to remove it from traffic, if
23 such action is appropriate, in the officer’s discretion.
24 (b) In every crash for which a Florida Traffic Crash
25 Report, Long Form, is not required by this section, the law
26 enforcement officer may complete a short-form crash report or
27 provide a short-form crash report to be completed by each party
28 involved in the crash. Short-form crash reports prepared by the
29 law enforcement officer shall be maintained by the officer’s
30 agency.
31 (c) The long-form and the short-form report must include:
32 1. The date, time, and location of the crash.
33 2. A description of the vehicles involved.
34 3. The names and addresses of the parties involved.
35 4. The names and addresses of all passengers in all
36 vehicles involved in the crash, each clearly identified as being
37 a passenger, and the identification of the vehicle in which they
38 were a passenger.
39 5.4. The names and addresses of witnesses.
40 6.5. The name, badge number, and law enforcement agency of
41 the officer investigating the crash.
42 7.6. The names of the insurance companies for the
43 respective parties involved in the crash.
44 (d)(c) Each party to the crash must shall provide the law
45 enforcement officer with proof of insurance, which must to be
46 included in the crash report. If a law enforcement officer
47 submits a report on the accident, proof of insurance must be
48 provided to the officer by each party involved in the crash. Any
49 party who fails to provide the required information commits a
50 noncriminal traffic infraction, punishable as a nonmoving
51 violation as provided in chapter 318, unless the officer
52 determines that due to injuries or other special circumstances
53 such insurance information cannot be provided immediately. If
54 the person provides the law enforcement agency, within 24 hours
55 after the crash, proof of insurance that was valid at the time
56 of the crash, the law enforcement agency may void the citation.
57 (e)(d) The driver of a vehicle that was in any manner
58 involved in a crash resulting in damage to any vehicle or other
59 property in an amount of $500 or more, which crash was not
60 investigated by a law enforcement agency, shall, within 10 days
61 after the crash, submit a written report of the crash to the
62 department or traffic records center. The entity receiving the
63 report may require witnesses of the crash crashes to render
64 reports and may require any driver of a vehicle involved in a
65 crash of which a written report must be made as provided in this
66 section to file supplemental written reports if whenever the
67 original report is deemed insufficient by the receiving entity.
68 (f) The investigating law enforcement officer may testify
69 at trial or provide a signed affidavit to confirm or supplement
70 the information included on the long-form or short-form report.
71 (e) Short-form crash reports prepared by law enforcement
72 shall be maintained by the law enforcement officer’s agency.
73 Section 2. Subsection (6) is added to section 400.991,
74 Florida Statutes, to read:
75 400.991 License requirements; background screenings;
76 prohibitions.—
77 (6) All forms that constitute part of the application for
78 licensure or exemption from licensure under this part must
79 contain the following statement:
80
81 INSURANCE FRAUD NOTICE.—Submitting a false, misleading, or
82 fraudulent application or other document when applying for
83 licensure as a health care clinic, when seeking an exemption
84 from licensure as a health care clinic, or when demonstrating
85 compliance with part X of chapter 400, Florida Statutes, is a
86 fraudulent insurance act, as defined in s. 626.989 or s.
87 817.234, Florida Statutes, subject to investigation by the
88 Division of Insurance Fraud, and is grounds for discipline by
89 the appropriate licensing board of the Department of Health.
90 Section 3. Section 626.9894, Florida Statutes, is created
91 to read:
92 626.9894 Motor vehicle insurance fraud direct-support
93 organization.—
94 (1) DEFINITIONS.—As used in this section, the term:
95 (a) “Division” means the Division of Insurance Fraud of the
96 Department of Financial Services.
97 (b) “Motor vehicle insurance fraud” means any act defined
98 as a “fraudulent insurance act” under s. 626.989, which relates
99 to the coverage of motor vehicle insurance as described in part
100 XI of chapter 627.
101 (c) “Organization” means the direct-support organization
102 established under this section.
103 (2) ORGANIZATION ESTABLISHED.—The division may establish a
104 direct-support organization, to be known as the “Automobile
105 Insurance Fraud Strike Force,” whose sole purpose is to support
106 the prosecution, investigation, and prevention of motor vehicle
107 insurance fraud. The organization shall:
108 (a) Be a not-for-profit corporation incorporated under
109 chapter 617 and approved by the Department of State.
110 (b) Be organized and operated to conduct programs and
111 activities; to raise funds; to request and receive grants,
112 gifts, and bequests of money; to acquire, receive, hold, invest,
113 and administer, in its own name, securities, funds, objects of
114 value, or other property, real or personal; and to make grants
115 and expenditures to or for the direct or indirect benefit of the
116 division, state attorneys’ offices, the statewide prosecutor,
117 the Agency for Health Care Administration, and the Department of
118 Health to the extent that such grants and expenditures are to be
119 used exclusively to advance the purpose of prosecuting,
120 investigating, or preventing motor vehicle insurance fraud.
121 Grants and expenditures may include the cost of salaries or
122 benefits of dedicated motor vehicle insurance fraud
123 investigators, prosecutors, or support personnel if such grants
124 and expenditures do not interfere with prosecutorial
125 independence or otherwise create conflicts of interest which
126 threaten the success of prosecutions.
127 (c) Be determined by the division to operate in a manner
128 that promotes the goals of laws relating to motor vehicle
129 insurance fraud, that is in the best interest of the state, and
130 that is in accordance with the adopted goals and mission of the
131 division.
132 (d) Use all of its grants and expenditures solely for the
133 purpose of preventing and decreasing motor vehicle insurance
134 fraud, and not for the purpose of lobbying as defined in s.
135 11.045.
136 (e) Be subject to an annual financial audit in accordance
137 with s. 215.981.
138 (3) CONTRACT.—The organization shall operate under written
139 contract with the division. The contract must provide for:
140 (a) Approval of the articles of incorporation and bylaws of
141 the organization by the division.
142 (b) Submission of an annual budget for the approval of the
143 division. The budget must require the organization to minimize
144 costs to the division and its members at all times by using
145 existing personnel and property and allowing for telephonic
146 meetings when appropriate.
147 (c) Certification by the division that the direct-support
148 organization is complying with the terms of the contract and in
149 a manner consistent with the goals and purposes of the
150 department and in the best interest of the state. Such
151 certification must be made annually and reported in the official
152 minutes of a meeting of the organization.
153 (d) Allocation of funds to address motor vehicle insurance
154 fraud.
155 (e) Reversion of moneys and property held in trust by the
156 organization for motor vehicle insurance fraud prosecution,
157 investigation, and prevention to the division if the
158 organization is no longer approved to operate for the department
159 or if the organization ceases to exist, or to the state if the
160 division ceases to exist.
161 (f) Specific criteria to be used by the organization’s
162 board of directors to evaluate the effectiveness of funding used
163 to combat motor vehicle insurance fraud.
164 (g) The fiscal year of the organization, which begins July
165 1 of each year and ends June 30 of the following year.
166 (h) Disclosure of the material provisions of the contract,
167 and distinguishing between the department and the organization
168 to donors of gifts, contributions, or bequests, including
169 providing such disclosure on all promotional and fundraising
170 publications.
171 (4) BOARD OF DIRECTORS.—The board of directors of the
172 organization shall consist of the following seven members:
173 (a) The Chief Financial Officer, or designee, who shall
174 serve as chair.
175 (b) Two state attorneys, one of whom shall be appointed by
176 the Chief Financial Officer and one of whom shall be appointed
177 by the Attorney General.
178 (c) Two representatives of motor vehicle insurers appointed
179 by the Chief Financial Officer.
180 (d) Two representatives of local law enforcement agencies,
181 both of whom shall be appointed by the Chief Financial Officer.
182
183 The officer who appointed a member of the board may remove
184 that member for cause. The term of office of an appointed member
185 expires at the same time as the term of the officer who
186 appointed him or her or at such earlier time as the person
187 ceases to be qualified.
188 (5) USE OF PROPERTY.—The department may authorize, without
189 charge, appropriate use of fixed property and facilities of the
190 division by the organization, subject to this subsection.
191 (a) The department may prescribe any condition with which
192 the organization must comply in order to use the division’s
193 property or facilities.
194 (b) The department may not authorize the use of the
195 division’s property or facilities if the organization does not
196 provide equal membership and employment opportunities to all
197 persons regardless of race, religion, sex, age, or national
198 origin.
199 (c) The department shall adopt rules prescribing the
200 procedures by which the organization is governed and any
201 conditions with which the organization must comply to use the
202 division’s property or facilities.
203 (6) CONTRIBUTIONS.—Any contributions made by an insurer to
204 the organization shall be allowed as appropriate business
205 expenses for all regulatory purposes.
206 (7) DEPOSITORY.—Any moneys received by the organization may
207 be held in a separate depository account in the name of the
208 organization and subject to the provisions of the contract with
209 the division.
210 (8) DIVISION’S RECEIPT OF PROCEEDS.—If the division
211 receives proceeds from the organization, those proceeds shall be
212 deposited into the Insurance Regulatory Trust Fund.
213 Section 4. Subsection (3) is added to section 627.4137,
214 Florida Statutes, to read:
215 627.4137 Disclosure of certain information required.—
216 (3) Any request made to a self-insured corporation pursuant
217 to this section must be sent by certified mail to the registered
218 agent of the disclosing entity.
219 Section 5. Section 627.730, Florida Statutes, is amended to
220 read:
221 627.730 Florida Motor Vehicle No-Fault Law.—Sections
222 627.730-627.7407 627.730-627.7405 may be cited and known as the
223 “Florida Motor Vehicle No-Fault Law.”
224 Section 6. Section 627.731, Florida Statutes, is amended to
225 read:
226 627.731 Purpose; legislative intent.—The purpose of the no
227 fault law ss. 627.730-627.7405 is to provide for medical,
228 surgical, funeral, and disability insurance benefits without
229 regard to fault, and to require motor vehicle insurance securing
230 such benefits, for motor vehicles required to be registered in
231 this state and, with respect to motor vehicle accidents, a
232 limitation on the right to claim damages for pain, suffering,
233 mental anguish, and inconvenience.
234 (1) The Legislature finds that automobile insurance fraud
235 remains a major problem for state consumers and insurers.
236 According to the National Insurance Crime Bureau, in recent
237 years this state has been among those states that have the
238 highest number of fraudulent and questionable claims.
239 (2) The Legislature intends to balance the insured’s
240 interest in prompt payment of valid claims for insurance
241 benefits under the no-fault law with the public’s interest in
242 reducing fraud, abuse, and overuse of the no-fault system. To
243 that end, the Legislature intends that the investigation and
244 prevention of fraudulent insurance acts in this state be
245 enhanced, that additional sanctions for such acts be imposed,
246 and that the no-fault law be revised to remove incentives for
247 fraudulent insurance acts. The Legislature intends that the no
248 fault law be construed according to the plain language of the
249 statutory provisions, which are designed to meet these goals.
250 (3) The Legislature intends that:
251 (a) Insurers properly investigate claims, and as such, be
252 allowed to obtain examinations under oath and sworn statements
253 from any claimant seeking no-fault insurance benefits, and to
254 request mental and physical examinations of persons seeking
255 personal injury protection coverage or benefits.
256 (b) Any false, misleading, or otherwise fraudulent activity
257 associated with a claim renders any claim brought by a claimant
258 engaging in such activity invalid. An insurer must be able to
259 raise fraud as a defense to a claim for no-fault insurance
260 benefits irrespective of any prior adjudication of guilt or
261 determination of fraud by the Department of Financial Services.
262 (c) Insurers toll the payment or denial of a claim, with
263 respect to any portion of a claim for which the insurer has a
264 reasonable belief that a fraudulent insurance act, as defined in
265 s. 626.989, has been committed.
266 (d) Insurers discover the names of all passengers involved
267 in an automobile accident before paying claims or benefits
268 pursuant to an insurance policy governed by the no-fault law. A
269 rebuttable presumption must be established that a person was not
270 involved in the event giving rise to the claim if that person’s
271 name does not appear on the police report.
272 (e) The insured’s interest in obtaining competent counsel
273 must be balanced with the public’s interest in preventing a no
274 fault system that encourages litigation by allowing for
275 exorbitant attorney’s fees. Courts should limit attorney fee
276 awards so as to eliminate the incentive for attorneys to
277 manufacture unnecessary litigation.
278 Section 7. Section 627.732, Florida Statutes, is reordered
279 and amended to read:
280 627.732 Definitions.—As used in the no-fault law ss.
281 627.730-627.7405, the term:
282 (1) “Broker” means any person not possessing a license
283 under chapter 395, chapter 400, chapter 429, chapter 458,
284 chapter 459, chapter 460, chapter 461, or chapter 641 who
285 charges or receives compensation for any use of medical
286 equipment and is not the 100-percent owner or the 100-percent
287 lessee of such equipment. For purposes of this section, such
288 owner or lessee may be an individual, a corporation, a
289 partnership, or any other entity and any of its 100-percent
290 owned affiliates and subsidiaries. For purposes of this
291 subsection, the term “lessee” means a long-term lessee under a
292 capital or operating lease, but does not include a part-time
293 lessee. The term “broker” does not include a hospital or
294 physician management company whose medical equipment is
295 ancillary to the practices managed, a debt collection agency, or
296 an entity that has contracted with the insurer to obtain a
297 discounted rate for such services; or nor does the term include
298 a management company that has contracted to provide general
299 management services for a licensed physician or health care
300 facility and whose compensation is not materially affected by
301 the usage or frequency of usage of medical equipment or an
302 entity that is 100-percent owned by one or more hospitals or
303 physicians. The term “broker” does not include a person or
304 entity that certifies, upon request of an insurer, that:
305 (a) It is a clinic licensed under ss. 400.990-400.995;
306 (b) It is a 100-percent owner of medical equipment; and
307 (c) The owner’s only part-time lease of medical equipment
308 for personal injury protection patients is on a temporary basis,
309 not to exceed 30 days in a 12-month period, and such lease is
310 solely for the purposes of necessary repair or maintenance of
311 the 100-percent-owned medical equipment or pending the arrival
312 and installation of the newly purchased or a replacement for the
313 100-percent-owned medical equipment, or for patients for whom,
314 because of physical size or claustrophobia, it is determined by
315 the medical director or clinical director to be medically
316 necessary that the test be performed in medical equipment that
317 is open-style. The leased medical equipment may not cannot be
318 used by patients who are not patients of the registered clinic
319 for medical treatment of services. Any person or entity making a
320 false certification under this subsection commits insurance
321 fraud as defined in s. 817.234. However, the 30-day period
322 provided in this paragraph may be extended for an additional 60
323 days as applicable to magnetic resonance imaging equipment if
324 the owner certifies that the extension otherwise complies with
325 this paragraph.
326 (10)(2) “Medically necessary” refers to a medical service
327 or supply that a prudent physician would provide for the purpose
328 of preventing, diagnosing, or treating an illness, injury,
329 disease, or symptom in a manner that is:
330 (a) In accordance with generally accepted standards of
331 medical practice;
332 (b) Clinically appropriate in terms of type, frequency,
333 extent, site, and duration; and
334 (c) Not primarily for the convenience of the patient,
335 physician, or other health care provider.
336 (11)(3) “Motor vehicle” means a any self-propelled vehicle
337 with four or more wheels which is of a type both designed and
338 required to be licensed for use on the highways of this state,
339 and any trailer or semitrailer designed for use with such
340 vehicle, and includes:
341 (a) A “private passenger motor vehicle,” which is any motor
342 vehicle that which is a sedan, station wagon, or jeep-type
343 vehicle and, if not used primarily for occupational,
344 professional, or business purposes, a motor vehicle of the
345 pickup, panel, van, camper, or motor home type.
346 (b) A “commercial motor vehicle,” which is any motor
347 vehicle that which is not a private passenger motor vehicle.
348
349 The term “motor vehicle” does not include a mobile home or
350 any motor vehicle that which is used in mass transit, other than
351 public school transportation, and designed to transport more
352 than five passengers exclusive of the operator of the motor
353 vehicle and that which is owned by a municipality, a transit
354 authority, or a political subdivision of the state.
355 (12)(4) “Named insured” means a person, usually the owner
356 of a vehicle, identified in a policy by name as the insured
357 under the policy.
358 (13) “No-fault law” means the Florida Motor Vehicle No
359 Fault Law codifed at ss. 627.730-627.7407.
360 (14)(5) “Owner” means a person who holds the legal title to
361 a motor vehicle; or, if in the event a motor vehicle is the
362 subject of a security agreement or lease with an option to
363 purchase with the debtor or lessee having the right to
364 possession, then the debtor or lessee is shall be deemed the
365 owner for the purposes of the no-fault law ss. 627.730-627.7405.
366 (16)(6) “Relative residing in the same household” means a
367 relative of any degree by blood or by marriage who usually makes
368 her or his home in the same family unit, whether or not
369 temporarily living elsewhere.
370 (2)(7) “Certify” means to swear or attest to being true or
371 represented in writing.
372 (3) “Claimant” means the person, organization, or entity
373 seeking benefits, including all assignees.
374 (4) “Entity wholly owned” means a proprietorship, group
375 practice, partnership, or corporation that provides health care
376 services rendered by licensed health care practitioners. In
377 order to be wholly owned, licensed health care practitioners
378 must be the business owners of all aspects of the business
379 entity, including, but not limited to, being reflected as the
380 business owners on the title or lease of the physical facility,
381 filing taxes as the business owners, being account holders on
382 the entity’s bank account, being listed as the principals on all
383 incorporation documents required by this state, and having
384 ultimate authority over all personnel and compensation decisions
385 relating to the entity.
386 (6)(8) “Immediate personal supervision,” as it relates to
387 the performance of medical services by nonphysicians not in a
388 hospital, means that an individual licensed to perform the
389 medical service or provide the medical supplies must be present
390 within the confines of the physical structure where the medical
391 services are performed or where the medical supplies are
392 provided such that the licensed individual can respond
393 immediately to any emergencies if needed.
394 (7)(9) “Incident,” with respect to services considered as
395 incident to a physician’s professional service, for a physician
396 licensed under chapter 458, chapter 459, chapter 460, or chapter
397 461, if not furnished in a hospital, means such services that
398 are must be an integral, even if incidental, part of a covered
399 physician’s service.
400 (8)(10) “Knowingly” means that a person, with respect to
401 information, has actual knowledge of the information,; acts in
402 deliberate ignorance of the truth or falsity of the
403 information,; or acts in reckless disregard of the information.,
404 and Proof of specific intent to defraud is not required.
405 (9)(11) “Lawful” or “lawfully” means in substantial
406 compliance with all relevant applicable criminal, civil, and
407 administrative requirements of state and federal law related to
408 the provision of medical services or treatment.
409 (5)(12) “Hospital” means a facility that, at the time
410 services or treatment were rendered, was licensed under chapter
411 395.
412 (15)(13) “Properly completed” means providing truthful,
413 substantially complete, and substantially accurate responses as
414 to all material elements of to each applicable request for
415 information or statement by a means that may lawfully be
416 provided and that complies with this section, or as agreed by
417 the parties.
418 (18)(14) “Upcoding” means submitting an action that submits
419 a billing code that would result in payment greater in amount
420 than would be paid using a billing code that accurately
421 describes the services performed. The term does not include an
422 otherwise lawful bill by a magnetic resonance imaging facility,
423 which globally combines both technical and professional
424 components, if the amount of the global bill is not more than
425 the components if billed separately; however, payment of such a
426 bill constitutes payment in full for all components of such
427 service.
428 (17)(15) “Unbundling” means submitting an action that
429 submits a billing code that is properly billed under one billing
430 code, but that has been separated into two or more billing
431 codes, and would result in payment greater than the in amount
432 that than would be paid using one billing code.
433 Section 8. Subsections (1) and (4) of section 627.736,
434 Florida Statutes, are amended, subsections (5) through (16) of
435 that section are redesignated as subsections (6) through (17),
436 respectively, a new subsection (5) is added to that section,
437 present subsection (5), paragraph (b) of present subsection (6),
438 paragraph (b) of present subsection (7), and present subsections
439 (8), (9), and (10) of that section are amended, to read:
440 627.736 Required personal injury protection benefits;
441 exclusions; priority; claims.—
442 (1) REQUIRED BENEFITS.—Every insurance policy complying
443 with the security requirements of s. 627.733 must shall provide
444 personal injury protection to the named insured, relatives
445 residing in the same household, persons operating the insured
446 motor vehicle, passengers in such motor vehicle, and other
447 persons struck by such motor vehicle and suffering bodily injury
448 while not an occupant of a self-propelled vehicle, subject to
449 the provisions of subsection (2) and paragraph (4)(h) (4)(e), to
450 a limit of $10,000 for loss sustained by any such person as a
451 result of bodily injury, sickness, disease, or death arising out
452 of the ownership, maintenance, or use of a motor vehicle as
453 follows:
454 (a) Medical benefits.—Eighty percent of all reasonable
455 expenses, charged pursuant to subsection (6), for medically
456 necessary medical, surgical, X-ray, dental, and rehabilitative
457 services, including prosthetic devices, and for medically
458 necessary ambulance, hospital, and nursing services. However,
459 the medical benefits shall provide reimbursement only for such
460 services and care that are lawfully provided, supervised,
461 ordered, or prescribed by a physician licensed under chapter 458
462 or chapter 459, a dentist licensed under chapter 466, or a
463 chiropractic physician licensed under chapter 460, or an
464 acupuncturist licensed under chapter 457 exclusively to provide
465 oriental medicine as defined in s. 457.102, or that are provided
466 by any of the following persons or entities:
467 1. A hospital or ambulatory surgical center licensed under
468 chapter 395.
469 2. A person or entity licensed under part III of chapter
470 401 which ss. 401.2101-401.45 that provides emergency
471 transportation and treatment.
472 3. An entity wholly owned by one or more physicians
473 licensed under chapter 458 or chapter 459, chiropractic
474 physicians licensed under chapter 460, or dentists licensed
475 under chapter 466 or by such practitioner or practitioners and
476 the spouse, parent, child, or sibling of such that practitioner
477 or those practitioners.
478 4. An entity wholly owned, directly or indirectly, by a
479 hospital or hospitals.
480 5. A health care clinic licensed under part X of chapter
481 400 which ss. 400.990-400.995 that is:
482 a. Accredited by the Joint Commission on Accreditation of
483 Healthcare Organizations, the American Osteopathic Association,
484 the Commission on Accreditation of Rehabilitation Facilities, or
485 the Accreditation Association for Ambulatory Health Care, Inc.;
486 or
487 b. A health care clinic that:
488 (I) Has a medical director licensed under chapter 458,
489 chapter 459, or chapter 460;
490 (II) Has been continuously licensed for more than 3 years
491 or is a publicly traded corporation that issues securities
492 traded on an exchange registered with the United States
493 Securities and Exchange Commission as a national securities
494 exchange; and
495 (III) Provides at least four of the following medical
496 specialties:
497 (A) General medicine.
498 (B) Radiography.
499 (C) Orthopedic medicine.
500 (D) Physical medicine.
501 (E) Physical therapy.
502 (F) Physical rehabilitation.
503 (G) Prescribing or dispensing outpatient prescription
504 medication.
505 (H) Laboratory services.
506
507 If any services are provided by an entity or clinic
508 described in subparagraph 3., subparagraph 4., or subparagraph
509 5., the entity or clinic must provide the insurer at the initial
510 submission of the claim with a form adopted by the Department of
511 Financial Services which documents that the entity or clinic
512 meets applicable criteria for such entity or clinic and includes
513 a sworn statement or affidavit to that effect. Any change in
514 ownership requires the filing of a new form within 10 days after
515 the date of the change in ownership. If an insurer denies a
516 claim based on failure to submit the proper form, the insurer
517 must notify the provider, and the provider shall have 30 days
518 after receipt of such notice to submit a properly completed
519 form. If the provider fails to timely submit a properly
520 completed claim, the insurer is not required to pay the claim.
521 The Financial Services Commission shall adopt by rule the form
522 that must be used by an insurer and a health care provider
523 specified in subparagraph 3., subparagraph 4., or subparagraph
524 5. to document that the health care provider meets the criteria
525 of this paragraph, which rule must include a requirement for a
526 sworn statement or affidavit.
527 (b) Disability benefits.—Sixty percent of any loss of gross
528 income and loss of earning capacity per individual from
529 inability to work proximately caused by the injury sustained by
530 the injured person, plus all expenses reasonably incurred in
531 obtaining from others ordinary and necessary services in lieu of
532 those that, but for the injury, the injured person would have
533 performed without income for the benefit of his or her
534 household. All disability benefits payable under this provision
535 must shall be paid at least not less than every 2 weeks.
536 (c) Death benefits.—Death benefits equal to the lesser of
537 $5,000 or the remainder of unused personal injury protection
538 benefits per individual. The insurer may pay such benefits to
539 the executor or administrator of the deceased, to any of the
540 deceased’s relatives by blood, or legal adoption, or connection
541 by marriage, or to any person appearing to the insurer to be
542 equitably entitled thereto.
543
544 Only insurers writing motor vehicle liability insurance in
545 this state may provide the required benefits of this section,
546 and no such insurers may not insurer shall require the purchase
547 of any other motor vehicle coverage other than the purchase of
548 property damage liability coverage as required by s. 627.7275 as
549 a condition for providing such required benefits. Insurers may
550 not require that property damage liability insurance in an
551 amount greater than $10,000 be purchased in conjunction with
552 personal injury protection. Such insurers shall make benefits
553 and required property damage liability insurance coverage
554 available through normal marketing channels. An Any insurer
555 writing motor vehicle liability insurance in this state who
556 fails to comply with such availability requirement as a general
557 business practice violates shall be deemed to have violated part
558 IX of chapter 626, and such violation constitutes shall
559 constitute an unfair method of competition or an unfair or
560 deceptive act or practice involving the business of insurance.
561 An; and any such insurer committing such violation is shall be
562 subject to the penalties afforded in such part, as well as those
563 that are which may be afforded elsewhere in the insurance code.
564 (4) BENEFITS; WHEN DUE.—Benefits due from an insurer under
565 the no-fault law are ss. 627.730-627.7405 shall be primary,
566 except that benefits received under any workers’ compensation
567 law shall be credited against the benefits provided by
568 subsection (1) and are shall be due and payable as loss accrues,
569 upon the receipt of reasonable proof of such loss and the amount
570 of expenses and loss incurred which are covered by the policy
571 issued under the no-fault law ss. 627.730-627.7405. If When the
572 Agency for Health Care Administration provides, pays, or becomes
573 liable for medical assistance under the Medicaid program related
574 to injury, sickness, disease, or death arising out of the
575 ownership, maintenance, or use of a motor vehicle, the benefits
576 are under ss. 627.730-627.7405 shall be subject to the
577 provisions of the Medicaid program.
578 (a) An insurer may require written notice to be given as
579 soon as practicable after an accident involving a motor vehicle
580 with respect to which the policy affords the security required
581 by the no-fault law ss. 627.730-627.7405.
582 (b) Personal injury protection insurance benefits paid
583 pursuant to this section are shall be overdue if not paid within
584 30 days after the insurer is furnished written notice of the
585 fact of a covered loss and of the amount of same. If such
586 written notice is not furnished to the insurer as to the entire
587 claim, any partial amount supported by written notice is overdue
588 if not paid within 30 days after the such written notice is
589 furnished to the insurer. Any part or all of the remainder of
590 the claim that is subsequently supported by written notice is
591 overdue if not paid within 30 days after such written notice is
592 furnished to the insurer. For the purpose of calculating the
593 extent to which benefits are overdue, payment shall be
594 considered made on the date a draft or other valid instrument
595 that is equivalent to payment is placed in the United States
596 mail in a properly addressed, postpaid envelope, or, if not so
597 posted, on the date of delivery.
598 (c) If When an insurer pays only a portion of a claim or
599 rejects a claim, the insurer shall provide at the time of the
600 partial payment or rejection an itemized specification of each
601 item that the insurer had reduced, omitted, or declined to pay
602 and any information that the insurer desires the claimant to
603 consider related to the medical necessity of the denied
604 treatment or to explain the reasonableness of the reduced
605 charge, provided that this does shall not limit the introduction
606 of evidence at trial.; and The insurer must shall include the
607 name and address of the person to whom the claimant should
608 respond, and a claim number to be referenced in future
609 correspondence, and a detailed description of the amount paid
610 for each date of service. The insurer’s failure to send an
611 itemized specification or explanation of benefits does not waive
612 other grounds for rejecting an invalid claim.
613 (d) A However, notwithstanding the fact that written notice
614 has been furnished to the insurer, Any payment is shall not be
615 deemed overdue if when the insurer has reasonable proof to
616 establish that the insurer is not responsible for the payment.
617 An insurer may obtain evidence and assert any ground for
618 adjustment or rejection of a For the purpose of calculating the
619 extent to which any benefits are overdue, payment shall be
620 treated as being made on the date a draft or other valid
621 instrument which is equivalent to payment was placed in the
622 United States mail in a properly addressed, postpaid envelope
623 or, if not so posted, on the date of delivery. This paragraph
624 does not preclude or limit the ability of the insurer to assert
625 that the claim that is was unrelated, was not medically
626 necessary, or was unreasonable, or submitted that the amount of
627 the charge was in excess of that permitted under, or in
628 violation of, subsection (6) (5). Such assertion by the insurer
629 may be made at any time, including after payment of the claim,
630 or after the 30-day time period for payment set forth in this
631 paragraph (b), or after the filing of a lawsuit.
632 (e) The 30-day period for payment is tolled while the
633 insurer investigates a fraudulent insurance act, as defined in
634 s. 626.989, with respect to any portion of a claim for which the
635 insurer has a reasonable belief that a fraudulent insurance act
636 has been committed. The insurer must notify the claimant in
637 writing that it is investigating a fraudulent insurance act
638 within 30 days after the date it has a reasonable belief that
639 such act has been committed. The insurer must pay or deny the
640 claim, in full or in part, within 15 days after completion of
641 its investigation. However, no payment is due to a claimant who
642 has violated paragraph (k).
643 (f)(c) Except as otherwise provided under a local lien law
644 applicable to a trauma center hospital that compensates
645 physicians who provide emergency services and care or hospital
646 inpatient services, upon receiving notice of an accident that is
647 potentially covered by personal injury protection benefits, the
648 insurer must reserve $5,000 of personal injury protection
649 benefits for payment to physicians licensed under chapter 458 or
650 chapter 459 or dentists licensed under chapter 466 who provide
651 emergency services and care, as defined in s. 395.002(9), or who
652 provide hospital inpatient care. The amount required to be held
653 in reserve may be used only to pay claims from such physicians
654 or dentists until 30 days after the date the insurer receives
655 notice of the accident. After the 30-day period, any amount of
656 the reserve for which the insurer has not received notice of
657 such a claim from a physician or dentist who provided emergency
658 services and care or who provided hospital inpatient care may
659 then be used by the insurer to pay other claims. The time
660 periods specified in paragraph (b) for required payment of
661 personal injury protection benefits are shall be tolled for the
662 period of time that an insurer is required by this paragraph to
663 hold payment of a claim that is not from a physician or dentist
664 who provided emergency services and care or who provided
665 hospital inpatient care to the extent that the personal injury
666 protection benefits not held in reserve are insufficient to pay
667 the claim. This paragraph does not require an insurer to
668 establish a claim reserve for insurance accounting purposes.
669 (g)(d) All overdue payments shall bear simple interest at
670 the rate established under s. 55.03 or the rate established in
671 the insurance contract, whichever is greater, for the year in
672 which the payment became overdue, calculated from the date the
673 insurer was furnished with written notice of the amount of
674 covered loss. Interest is shall be due at the time payment of
675 the overdue claim is made. However, interest on a payment that
676 is overdue pursuant to paragraph (e) shall be calculated from
677 the date the payment is due pursuant to paragraph (b).
678 (h)(e) The insurer of the owner of a motor vehicle shall
679 pay personal injury protection benefits for:
680 1. Accidental bodily injury sustained in this state by the
681 owner while occupying a motor vehicle, or while not an occupant
682 of a self-propelled vehicle if the injury is caused by physical
683 contact with a motor vehicle.
684 2. Accidental bodily injury sustained outside this state,
685 but within the United States of America or its territories or
686 possessions or Canada, by the owner while occupying the owner’s
687 motor vehicle.
688 3. Accidental bodily injury sustained by a relative of the
689 owner residing in the same household, under the circumstances
690 described in subparagraph 1. or subparagraph 2. if, provided the
691 relative at the time of the accident is domiciled in the owner’s
692 household and is not himself or herself the owner of a motor
693 vehicle with respect to which security is required under the no
694 fault law ss. 627.730-627.7405.
695 4. Accidental bodily injury sustained in this state by any
696 other person while occupying the owner’s motor vehicle or, if a
697 resident of this state, while not an occupant of a self
698 propelled vehicle, if the injury is caused by physical contact
699 with such motor vehicle if, provided the injured person is not
700 himself or herself:
701 a. The owner of a motor vehicle with respect to which
702 security is required under the no-fault law ss. 627.730
703 627.7405; or
704 b. Entitled to personal injury benefits from the insurer of
705 the owner or owners of such a motor vehicle.
706 (i)(f) If two or more insurers are liable to pay personal
707 injury protection benefits for the same injury to any one
708 person, the maximum payable is shall be as specified in
709 subsection (1), and any insurer paying the benefits is shall be
710 entitled to recover from each of the other insurers an equitable
711 pro rata share of the benefits paid and expenses incurred in
712 processing the claim.
713 (j)(g) It is a violation of the insurance code for an
714 insurer to fail to timely provide benefits as required by this
715 section with such frequency as to constitute a general business
716 practice.
717 (k)(h) Benefits are shall not be due or payable to a
718 claimant who knowingly: or on the behalf of an insured person if
719 that person has
720 1. Submits a false or misleading statement, document,
721 record, or bill;
722 2. Submits false or misleading information; or
723 3. Has otherwise committed or attempted to commit a
724 fraudulent insurance act as defined in s. 626.989.
725
726 A claimant that violates this paragraph is not entitled to any
727 personal injury protection benefits or reimbursement for any
728 benefits provided, regardless of whether a portion of the claim
729 may be legitimate. However, a medical provider that does not
730 violate this paragraph may not be denied reimbursement for
731 benefits provided solely due to violation by another medical
732 provider.
733 (l) Notwithstanding any remedies afforded by law, the
734 insurer may recover from a claimant who violates paragraph (k)
735 any sums previously paid to that claimant and may bring any
736 available common law and statutory causes of action. A claimant
737 has violated paragraph (k) committed, by a material act or
738 omission, any insurance fraud relating to personal injury
739 protection coverage under his or her policy, if the fraud is
740 admitted to in a sworn statement by the insured or if it is
741 established in a court of competent jurisdiction. Any insurance
742 fraud voids shall void all coverage arising from the claim
743 related to such fraud under the personal injury protection
744 coverage of the claimant insured person who committed the fraud,
745 irrespective of whether a portion of the insured person’s claim
746 may be legitimate, and any benefits paid before prior to the
747 discovery of the insured person’s insurance fraud is shall be
748 recoverable by the insurer from the claimant person who
749 committed insurance fraud in their entirety. The prevailing
750 party is entitled to its costs and attorney’s fees in any action
751 in which it prevails in an insurer’s action to enforce its right
752 of recovery under this paragraph. This paragraph does not
753 preclude or limit an insurer’s right to deny a claim based on
754 other evidence of fraud or affect an insurer’s right to plead
755 and prove a claim or defense of fraud under common law. If a
756 physician, hospital, clinic, or other medical institution
757 violates paragraph (k), the injured party is not liable for, and
758 the physician, hospital, clinic, or other medical institution
759 may not bill the insured for, charges that are unpaid because of
760 failure to comply with paragraph (k). Any agreement requiring
761 the injured person or insured to pay for such charges is
762 unenforceable.
763 (5) INSURER INVESTIGATIONS.—An insurer has the right and
764 duty to conduct a reasonable investigation of a claim. In the
765 course of the insurer’s investigation of a claim:
766 (a) The insurer may require the insured, claimant, or
767 medical provider to provide copies of the treatment and
768 examination records. The records review need not be based on a
769 physical examination and may be obtained at any time, including
770 after reduction or denial of the claim.
771 1. The 30-day period for payment under paragraph (4)(b) is
772 tolled from the date the insurer sends its request for treatment
773 records to the date that the insurer receives such records.
774 2. A medical provider may impose a reasonable, cost-based
775 fee that includes only the cost of copying and postage, but does
776 not include the cost of labor for copying. The cost of copying
777 may not exceed $1 per page for the first 25 pages and 25 cents
778 per page for each page in excess of 25 pages. However, a medical
779 provider may impose the reasonable costs of reproducing X rays
780 and other special kinds of records, including the actual cost of
781 the material and supplies used to duplicate the record, as well
782 as the labor costs and overhead costs associated with such
783 duplication.
784 (b) In all circumstances, an insured seeking benefits under
785 the no-fault law must comply with the terms of the policy, which
786 includes, but is not limited to, submitting to examinations
787 under oath. Compliance with this paragraph is a condition
788 precedent to receiving benefits.
789 (c) An insurer may deny benefits if the insured, claimant,
790 or medical provider fails to:
791 1. Cooperate in the insurer’s investigation;
792 2. Commits a fraud or material misrepresentation; or
793 3. Comply with this subsection.
794 (6)(5) CHARGES FOR TREATMENT OF INJURED PERSONS.—
795 (a)1. Any physician, hospital, clinic, or other person or
796 institution lawfully rendering treatment to an injured person
797 for a bodily injury covered by personal injury protection
798 insurance may charge the insurer and injured party only a
799 reasonable amount pursuant to this section for the services and
800 supplies rendered, and the insurer providing such coverage may
801 pay for such charges directly to the such person or institution
802 lawfully rendering such treatment, if the insured receiving such
803 treatment or his or her guardian has countersigned the properly
804 completed invoice, bill, or claim form approved by the office
805 upon which such charges are to be paid for as having actually
806 been rendered, to the best knowledge of the insured or his or
807 her guardian. In no event, However, may such charges may not
808 exceed a charge be in excess of the amount the person or
809 institution customarily charges for like services or supplies.
810 In determining With respect to a determination of whether a
811 charge for a particular service, treatment, or otherwise is
812 reasonable, consideration may be given to evidence of usual and
813 customary charges and payments accepted by the provider involved
814 in the dispute, and reimbursement levels in the community, and
815 various federal and state medical fee schedules applicable to
816 automobile and other insurance coverages, and other information
817 relevant to the reasonableness of the reimbursement for the
818 service, treatment, or supply.
819 1.2. The insurer may limit reimbursement to 80 percent of
820 the following schedule of maximum charges:
821 a. For emergency transport and treatment by providers
822 licensed under chapter 401, 200 percent of Medicare.
823 b. For emergency services and care provided by a hospital
824 licensed under chapter 395, 75 percent of the hospital’s usual
825 and customary charges.
826 c. For emergency services and care as defined by s.
827 395.002(9) provided in a facility licensed under chapter 395
828 rendered by a physician or dentist, and related hospital
829 inpatient services rendered by a physician or dentist, the usual
830 and customary charges in the community.
831 d. For hospital inpatient services, other than emergency
832 services and care, 200 percent of the Medicare Part A
833 prospective payment applicable to the specific hospital
834 providing the inpatient services.
835 e. For hospital outpatient services, other than emergency
836 services and care, 200 percent of the Medicare Part A Ambulatory
837 Payment Classification for the specific hospital providing the
838 outpatient services.
839 f. For all other medical services, supplies, and care, 200
840 percent of the allowable amount under the participating
841 physicians schedule of Medicare Part B; for other supplies and
842 care, including care and services rendered by ambulatory
843 surgical centers and clinical laboratories, 200 percent of the
844 allowable amount under Medicare Part B; and for durable medical
845 equipment, the allowable amount under the Durable Medical
846 Equipment, Prosthetics, Orthotics, and Supplies fee schedule
847 under Medicare Part B. However, if such services, supplies, or
848 care is not reimbursable under Medicare Part B, the insurer may
849 limit reimbursement to 80 percent of the maximum reimbursable
850 allowance under workers’ compensation, as determined under s.
851 440.13 and rules adopted thereunder which are in effect at the
852 time such services, supplies, or care is provided. Services,
853 supplies, or care that is not reimbursable under Medicare or
854 workers’ compensation is not required to be reimbursed by the
855 insurer.
856 2.3. For purposes of subparagraph 1. 2., the applicable fee
857 schedule or payment limitation under Medicare is the fee
858 schedule or payment limitation in effect on January 1 of the
859 year in which at the time the services, supplies, or care was
860 rendered and for the area in which such services were rendered,
861 which shall apply throughout the remainder of the year
862 notwithstanding any subsequent changes made to the fee schedule
863 or payment limitation, except that it may not be less than the
864 allowable amount under the participating physicians schedule of
865 Medicare Part B for 2007 for medical services, supplies, and
866 care subject to Medicare Part B.
867 3.4. Subparagraph 1. 2. does not allow the insurer to apply
868 any limitation on the number of treatments or other utilization
869 limits that apply under Medicare or workers’ compensation. An
870 insurer that applies the allowable payment limitations of
871 subparagraph 1. 2. must reimburse a provider who lawfully
872 provided care or treatment under the scope of his or her
873 license, regardless of whether such provider is would be
874 entitled to reimbursement under Medicare due to restrictions or
875 limitations on the types or discipline of health care providers
876 who may be reimbursed for particular procedures or procedure
877 codes.
878 4.5. If an insurer limits payment as authorized by
879 subparagraph 1. 2., the person providing such services,
880 supplies, or care may not bill or attempt to collect from the
881 insured any amount in excess of such limits, except for amounts
882 that are not covered by the insured’s personal injury protection
883 coverage due to the coinsurance amount or maximum policy limits.
884 5. If a provider submits a charge for an amount less than
885 the amount allowed under subparagraphs 1. and 2., the insurer
886 may pay the amount of the charge submitted.
887 6. Effective January 1, 2012, an insurer may limit
888 reimbursement to the amounts stated in this paragraph only if
889 the insurance policy provides notice that the insurer may limit
890 reimbursement pursuant to the schedule of charges specified in
891 this paragraph. Policy provisions approved by the office satisfy
892 this requirement.
893 (b)1. An insurer or insured is not required to pay a claim
894 or charges:
895 a. Made by a broker or by a person making a claim on behalf
896 of a broker;
897 b. For any service or treatment that was not lawful at the
898 time rendered;
899 c. To any person who knowingly submits a false or
900 misleading statement relating to the claim or charges;
901 d. With respect to a bill or statement that does not
902 substantially meet the applicable requirements of paragraphs
903 (c), paragraph (d), and (e);
904 e. Except for services provided by a hospital licensed
905 pursuant to chapter 395, for physician or other provider
906 services or treatment provided within that hospital, if the
907 insured failed to countersign a billing form or patient log
908 related to such claim or charges. Failure to submit a
909 countersigned billing form or patient log creates a rebuttable
910 presumption that the insured did not receive the alleged
911 treatment. The insurer is not considered to have been furnished
912 with notice of the loss and treatment until the insurer is able
913 to verify that the insured received the alleged treatment. If an
914 insurer denies a claim based on failure to submit a
915 countersigned billing form or patient log, the insurer must
916 notify the provider, and the provider shall have 30 days after
917 receipt of such notice to submit a properly countersigned
918 billing form or patient log. If the provider fails to comply
919 with this requirement, the insurer is not required to pay the
920 claim. As used in this sub-subparagraph, the term
921 “countersigned” means a second or verifying signature, as on a
922 previously signed document, and is not satisfied by the
923 statement “signature on file” or similar statement;
924 f.e. For any treatment or service that is upcoded, or that
925 is unbundled if when such treatment or services should be
926 bundled, in accordance with paragraph (d). To facilitate prompt
927 payment of lawful services, an insurer may change codes that it
928 determines to have been improperly or incorrectly upcoded or
929 unbundled, and may make payment based on the changed codes,
930 without affecting the right of the provider to dispute the
931 change by the insurer if, provided that before doing so, the
932 insurer contacts must contact the health care provider and
933 discusses discuss the reasons for the insurer’s change and the
934 health care provider’s reason for the coding, or makes make a
935 reasonable good faith effort to do so, as documented in the
936 insurer’s file; and
937 g.f. For medical services or treatment billed by a
938 physician and not provided in a hospital unless such services
939 are rendered by the physician or are incident to his or her
940 professional services and are included on the physician’s bill,
941 including documentation verifying that the physician is
942 responsible for the medical services that were rendered and
943 billed.
944 2. The Department of Health, in consultation with the
945 appropriate professional licensing boards, shall adopt, by rule,
946 a list of diagnostic tests deemed not to be medically necessary
947 for use in the treatment of persons sustaining bodily injury
948 covered by personal injury protection benefits under this
949 section. The initial list shall be adopted by January 1, 2004,
950 and shall be revised from time to time as determined by the
951 Department of Health, in consultation with the respective
952 professional licensing boards. Inclusion of a test on the list
953 must of invalid diagnostic tests shall be based on lack of
954 demonstrated medical value and a level of general acceptance by
955 the relevant provider community and may shall not be dependent
956 for results entirely upon subjective patient response.
957 Notwithstanding its inclusion on a fee schedule in this
958 subsection, an insurer or insured is not required to pay any
959 charges or reimburse claims for any invalid diagnostic test as
960 determined by the Department of Health.
961 (c)1. With respect to any treatment or service, other than
962 medical services billed by a hospital or other provider for
963 emergency services as defined in s. 395.002 or inpatient
964 services rendered at a hospital-owned facility, the statement of
965 charges must be furnished to the insurer by the provider and may
966 not include, and the insurer is not required to pay, charges for
967 treatment or services rendered more than 35 days before the
968 postmark date or electronic transmission date of the statement,
969 except for past due amounts previously billed on a timely basis
970 under this paragraph, and except that, if the provider submits
971 to the insurer a notice of initiation of treatment within 21
972 days after its first examination or treatment of the claimant,
973 the statement may include charges for treatment or services
974 rendered up to, but not more than, 75 days before the postmark
975 date of the statement. The injured party is not liable for, and
976 the provider may shall not bill the injured party for, charges
977 that are unpaid because of the provider’s failure to comply with
978 this paragraph. Any agreement requiring the injured person or
979 insured to pay for such charges is unenforceable.
980 1.2. If, however, the insured fails to furnish the provider
981 with the correct name and address of the insured’s personal
982 injury protection insurer, the provider has 35 days from the
983 date the provider obtains the correct information to furnish the
984 insurer with a statement of the charges. The insurer is not
985 required to pay for such charges unless the provider includes
986 with the statement documentary evidence that was provided by the
987 insured during the 35-day period demonstrating that the provider
988 reasonably relied on erroneous information from the insured and
989 either:
990 a. A denial letter from the incorrect insurer; or
991 b. Proof of mailing, which may include an affidavit under
992 penalty of perjury, reflecting timely mailing to the incorrect
993 address or insurer.
994 2.3. For emergency services and care as defined in s.
995 395.002 rendered in a hospital emergency department or for
996 transport and treatment rendered by an ambulance provider
997 licensed pursuant to part III of chapter 401, the provider is
998 not required to furnish the statement of charges within the time
999 periods established by this paragraph,; and the insurer is shall
1000 not be considered to have been furnished with notice of the
1001 amount of covered loss for purposes of paragraph (4)(b) until it
1002 receives a statement complying with paragraph (d), or copy
1003 thereof, which specifically identifies the place of service to
1004 be a hospital emergency department or an ambulance in accordance
1005 with billing standards recognized by the Centers for Medicare
1006 and Medicaid Services Health Care Finance Administration.
1007 3.4. Each notice of the insured’s rights under s. 627.7401
1008 must include the following statement in type no smaller than 12
1009 points:
1010
1011 BILLING REQUIREMENTS.—Florida Statutes provide that with
1012 respect to any treatment or services, other than certain
1013 hospital and emergency services, the statement of charges
1014 furnished to the insurer by the provider may not include, and
1015 the insurer and the injured party are not required to pay,
1016 charges for treatment or services rendered more than 35 days
1017 before the postmark date of the statement, except for past due
1018 amounts previously billed on a timely basis, and except that, if
1019 the provider submits to the insurer a notice of initiation of
1020 treatment within 21 days after its first examination or
1021 treatment of the claimant, the first billing cycle statement may
1022 include charges for treatment or services rendered up to, but
1023 not more than, 75 days before the postmark date of the
1024 statement.
1025
1026 (d) All statements and bills for medical services rendered
1027 by any physician, hospital, clinic, or other person or
1028 institution shall be submitted to the insurer on a properly
1029 completed Centers for Medicare and Medicaid Services (CMS) 1500
1030 form, UB 92 forms, or any other standard form approved by the
1031 office or adopted by the commission for purposes of this
1032 paragraph. All billings for such services rendered by providers
1033 must shall, to the extent applicable, follow the Physicians’
1034 Current Procedural Terminology (CPT) or Healthcare Correct
1035 Procedural Coding System (HCPCS), or ICD-9 in effect for the
1036 year in which services are rendered and comply with the Centers
1037 for Medicare and Medicaid Services (CMS) 1500 form instructions
1038 and the American Medical Association Current Procedural
1039 Terminology (CPT) Editorial Panel and Healthcare Correct
1040 Procedural Coding System (HCPCS). All providers other than
1041 hospitals shall include on the applicable claim form the
1042 professional license number of the provider in the line or space
1043 provided for “Signature of Physician or Supplier, Including
1044 Degrees or Credentials.” In determining compliance with
1045 applicable CPT and HCPCS coding, guidance shall be provided by
1046 the Physicians’ Current Procedural Terminology (CPT) or the
1047 Healthcare Correct Procedural Coding System (HCPCS) in effect
1048 for the year in which services were rendered, the Office of the
1049 Inspector General (OIG), Physicians Compliance Guidelines, and
1050 other authoritative treatises designated by rule by the Agency
1051 for Health Care Administration. A No statement of medical
1052 services may not include charges for medical services of a
1053 person or entity that performed such services without possessing
1054 the valid licenses required to perform such services. For
1055 purposes of paragraph (4)(b), an insurer is shall not be
1056 considered to have been furnished with notice of the amount of
1057 covered loss or medical bills due unless the statements or bills
1058 comply with this paragraph, and unless the statements or bills
1059 are comply with this paragraph, and unless the statements or
1060 bills are properly completed in their entirety as to all
1061 material provisions, with all relevant information being
1062 provided therein. If an insurer denies a claim due to a
1063 provider’s failure to submit a properly completed statement or
1064 bill, the insurer shall notify the provider as to the provisions
1065 that were improperly completed, and the provider shall have 30
1066 days after the receipt of such notice to submit a properly
1067 completed statement or bill. If the provider fails to comply
1068 with this requirement, the insurer is not required to pay for
1069 improperly billed services.
1070 (e)1. At the initial treatment or service provided, each
1071 physician, other licensed professional, clinic, or other medical
1072 institution providing medical services upon which a claim for
1073 personal injury protection benefits is based shall require an
1074 insured person, or his or her guardian, to execute a disclosure
1075 and acknowledgment form, which reflects at a minimum that:
1076 a. The insured, or his or her guardian, must countersign
1077 the form attesting to the fact that the services set forth
1078 therein were actually rendered. Listing CPT codes or other
1079 coding on the disclosure and acknowledgment form does not
1080 satisfy this requirement;
1081 b. The insured, or his or her guardian, has both the right
1082 and affirmative duty to confirm that the services were actually
1083 rendered;
1084 c. The insured, or his or her guardian, was not solicited
1085 by any person to seek any services from the medical provider;
1086 d. The physician, other licensed professional, clinic, or
1087 other medical institution rendering services for which payment
1088 is being claimed explained the services to the insured or his or
1089 her guardian; and
1090 e. If the insured notifies the insurer in writing of a
1091 billing error, the insured may be entitled to a certain
1092 percentage of a reduction in the amounts paid by the insured’s
1093 motor vehicle insurer.
1094 2. The physician, other licensed professional, clinic, or
1095 other medical institution rendering services for which payment
1096 is being claimed has the affirmative duty to explain the
1097 services rendered to the insured, or his or her guardian, so
1098 that the insured, or his or her guardian, countersigns the form
1099 with informed consent.
1100 3. Countersignature by the insured, or his or her guardian,
1101 is not required for the reading of diagnostic tests or other
1102 services that are of such a nature that they are not required to
1103 be performed in the presence of the insured.
1104 4. The licensed medical professional rendering treatment
1105 for which payment is being claimed must sign, by his or her own
1106 hand, the form complying with this paragraph.
1107 5. An insurer is not considered to have been furnished with
1108 notice of the amount of a covered loss or medical bills unless
1109 the original completed disclosure and acknowledgment form is
1110 shall be furnished to the insurer pursuant to paragraph (4)(b)
1111 and sub-subparagraph 1.a. The disclosure and acknowledgement
1112 form may not be electronically furnished. A disclosure and
1113 acknowledgement form that does not meet the minimum requirements
1114 of sub-subparagraph 1.a. does not provide an insurer with notice
1115 of the amount of a covered loss or medical bills due.
1116 6. This disclosure and acknowledgment form is not required
1117 for services billed by a provider for emergency services as
1118 defined in s. 395.002, for emergency services and care as
1119 defined in s. 395.002 rendered in a hospital emergency
1120 department, for inpatient hospital services, or for transport
1121 and treatment rendered by an ambulance provider licensed
1122 pursuant to part III of chapter 401.
1123 7. The Financial Services Commission shall adopt, by rule,
1124 a standard disclosure and acknowledgment form to that shall be
1125 used to fulfill the requirements of this paragraph, effective 90
1126 days after such form is adopted and becomes final. The
1127 commission shall adopt a proposed rule by October 1, 2003. Until
1128 the rule is final, the provider may use a form of its own which
1129 otherwise complies with the requirements of this paragraph.
1130 8. As used in this paragraph, the term “countersigned” or
1131 “countersignature” means a second or verifying signature, as on
1132 a previously signed document, and is not satisfied by the
1133 statement “signature on file” or any similar statement.
1134 9. The requirements of this paragraph apply only with
1135 respect to the initial treatment or service of the insured by a
1136 provider. For subsequent treatments or service, the provider
1137 must maintain a patient log signed by the patient, in
1138 chronological order by date of service, that is consistent with
1139 the services being rendered to the patient as claimed. Listing
1140 CPT codes or other coding on the patient log does not satisfy
1141 this requirement. The provider must provide copies of the
1142 patient log to the insurer within 30 days after receiving a
1143 written request from the insurer. Failure to maintain a patient
1144 log renders the treatment unlawful and noncompensable. The
1145 requirements of this subparagraph for maintaining a patient log
1146 signed by the patient may be met by a hospital that maintains
1147 medical records as required by s. 395.3025 and applicable rules
1148 and makes such records available to the insurer upon request.
1149 (f) Upon written notification by any person, an insurer
1150 shall investigate any claim of improper billing by a physician
1151 or other medical provider. The insurer shall determine if the
1152 insured was properly billed for only those services and
1153 treatments that the insured actually received. If the insurer
1154 determines that the insured has been improperly billed, the
1155 insurer shall notify the insured, the person making the written
1156 notification, and the provider of its findings and shall reduce
1157 the amount of payment to the provider by the amount determined
1158 to be improperly billed. If a reduction is made due to such
1159 written notification by any person, the insurer shall pay to the
1160 person 20 percent of the amount of the reduction, up to $500. If
1161 the provider is arrested due to the improper billing, then the
1162 insurer shall pay to the person 40 percent of the amount of the
1163 reduction, up to $500.
1164 (g) An insurer may not systematically downcode with the
1165 intent to deny reimbursement otherwise due. Such action
1166 constitutes a material misrepresentation under s.
1167 626.9541(1)(i)2.
1168 (7)(6) DISCOVERY OF FACTS ABOUT AN INJURED PERSON;
1169 DISPUTES.—
1170 (b) Every physician, hospital, clinic, or other medical
1171 institution providing, before or after bodily injury upon which
1172 a claim for personal injury protection insurance benefits is
1173 based, any products, services, or accommodations in relation to
1174 that or any other injury, or in relation to a condition claimed
1175 to be connected with that or any other injury, shall, if
1176 requested to do so by the insurer against whom the claim has
1177 been made, permit the insurer or the insurer’s representative to
1178 conduct an onsite physical review and examination of the
1179 treatment location, treatment apparatuses, diagnostic devices,
1180 and any other medical equipment used for the services rendered
1181 in any location, other than a hospital licensed pursuant to
1182 chapter 395, within 10 days after the insurer’s request, and
1183 furnish forthwith a written report of the history, condition,
1184 treatment, dates, and costs of such treatment of the injured
1185 person and why the items identified by the insurer were
1186 reasonable in amount and medically necessary, together with a
1187 sworn statement that the treatment or services rendered were
1188 reasonable and necessary with respect to the bodily injury
1189 sustained and identifying which portion of the expenses for such
1190 treatment or services was incurred as a result of such bodily
1191 injury, and produce forthwith, and permit the inspection and
1192 copying of, his or her or its records regarding such history,
1193 condition, treatment, dates, and costs of treatment if; provided
1194 that this does shall not limit the introduction of evidence at
1195 trial. Such sworn statement must shall read as follows: “Under
1196 penalty of perjury, I declare that I have read the foregoing,
1197 and the facts alleged are true, to the best of my knowledge and
1198 belief.” A No cause of action for violation of the physician
1199 patient privilege or invasion of the right of privacy may not be
1200 brought shall be permitted against any physician, hospital,
1201 clinic, or other medical institution complying with the
1202 provisions of this section. The person requesting such records
1203 and such sworn statement shall pay all reasonable costs
1204 connected therewith.
1205 1. If an insurer makes a written request for documentation
1206 or information under this paragraph within 30 days after having
1207 received notice of the amount of a covered loss under paragraph
1208 (4)(a), the amount or the partial amount that which is the
1209 subject of the insurer’s inquiry is shall become overdue if the
1210 insurer does not pay in accordance with paragraph (4)(b) or
1211 within 10 days after the insurer’s receipt of the requested
1212 documentation or information, whichever occurs later. For
1213 purposes of this subparagraph paragraph, the term “receipt”
1214 includes, but is not limited to, inspection and copying pursuant
1215 to this paragraph. An Any insurer that requests documentation or
1216 information pertaining to reasonableness of charges or medical
1217 necessity under this paragraph without a reasonable basis for
1218 such requests as a general business practice is engaging in an
1219 unfair trade practice under the insurance code.
1220 2. If an insured seeking to recover benefits pursuant to
1221 the no-fault law assigns the contractual right to those benefits
1222 or payment of those benefits to any person or entity, the
1223 assignee must comply with the terms of the policy. In all
1224 circumstances, the assignee is obligated to cooperate under the
1225 policy, which includes, but is not limited to, participating in
1226 an examination under oath. Examinations under oath may be
1227 recorded by audio, video, court reporter, or any combination
1228 thereof. Compliance with this paragraph is a condition precedent
1229 to recovery of benefits pursuant to the no-fault law.
1230 a. If an insurer requests an examination under oath of a
1231 medical provider, the provider must produce the persons having
1232 the most knowledge of the issues identified by the insurer in
1233 the request for the examination. Before the commencement of the
1234 examination under oath, the insurer must pay the medical
1235 provider reasonable compensation for attending the examination.
1236 Such compensation shall be based upon a good faith estimate of
1237 the time required to conduct the examination under oath. If
1238 additional time is necessary, the insurer must provide
1239 compensation to the medical provider for the time that exceeds
1240 the good faith estimate within 15 days after the examination if
1241 the provider completes the examination. The medical provider may
1242 have an attorney present at the examination under oath to
1243 provide advice and counsel at the provider’s own expense.
1244 b. Before requesting that an assignee participate in an
1245 examination under oath, the insurer must send a written request
1246 to the assignee requesting all information that the insurer
1247 believes is necessary to process the claim and relevant to the
1248 services rendered, including the information contemplated under
1249 this subparagraph. All claimants must produce and allow for the
1250 inspection of all documents requested by the insurer which are
1251 relevant to the services rendered and reasonably obtainable by
1252 the claimant.
1253 c. An insurer that, as a general practice, requests
1254 examinations under oath of an assignee without a reasonable
1255 basis is engaging in an unfair and deceptive trade practice.
1256 (8)(7) MENTAL AND PHYSICAL EXAMINATION OF INJURED PERSON;
1257 REPORTS.—
1258 (b) If requested by the person examined, a party causing an
1259 examination to be made shall deliver to him or her a copy of
1260 every written report concerning the examination rendered by an
1261 examining physician, at least one of which reports must set out
1262 the examining physician’s findings and conclusions in detail.
1263 After such request and delivery, the party causing the
1264 examination to be made is entitled, upon request, to receive
1265 from the person examined every written report available to him
1266 or her or his or her representative concerning any examination,
1267 previously or thereafter made, of the same mental or physical
1268 condition. By requesting and obtaining a report of the
1269 examination so ordered, or by taking the deposition of the
1270 examiner, the person examined waives any privilege he or she may
1271 have, in relation to the claim for benefits, regarding the
1272 testimony of every other person who has examined, or may
1273 thereafter examine, him or her in respect to the same mental or
1274 physical condition. If a person fails to appear for unreasonably
1275 refuses to submit to an examination, the personal injury
1276 protection carrier is not required to pay no longer liable for
1277 subsequent personal injury protection benefits incurred after
1278 the date of the first requested examination until the insured
1279 appears for the examination. Failure to appear for two scheduled
1280 examinations raises a rebuttable presumption that such failure
1281 was unreasonable. Submission to an examination is a condition
1282 precedent to the recovery of benefits.
1283 (9)(8) APPLICABILITY OF PROVISION REGULATING ATTORNEY’S
1284 FEES.—With respect to any dispute under the provisions of ss.
1285 627.730-627.7405 between the insured and the insurer under the
1286 no-fault law, or between an assignee of an insured’s rights and
1287 the insurer, the provisions of s. 627.428 shall apply, except as
1288 provided in subsections (11) and (16) (10) and (15).
1289 (10)(9) PREFERRED PROVIDERS.—An insurer may negotiate and
1290 enter into contracts with preferred licensed health care
1291 providers for the benefits described in this section, referred
1292 to in this section as “preferred providers,” which include shall
1293 include health care providers licensed under chapter 457,
1294 chapter chapters 458, chapter 459, chapter 460, chapter 461, or
1295 chapter and 463.
1296 (a) The insurer may provide an option to an insured to use
1297 a preferred provider at the time of purchase of the policy for
1298 personal injury protection benefits, if the requirements of this
1299 subsection are met. However, if the insurer offers a preferred
1300 provider option, it must also offer a nonpreferred provider
1301 policy. If the insured elects to use a provider who is not a
1302 preferred provider, whether the insured purchased a preferred
1303 provider policy or a nonpreferred provider policy, the medical
1304 benefits provided by the insurer must shall be as required by
1305 this section.
1306 (b) If the insured elects the to use a provider who is a
1307 preferred provider option, the insurer may pay medical benefits
1308 in excess of the benefits required by this section and may waive
1309 or lower the amount of any deductible that applies to such
1310 medical benefits. As an alternative, or in addition to such
1311 benefits, waiver, or reduction, the insurer may provide an
1312 actuarially appropriate premium discount as specified in an
1313 approved rate filing to an insured who selects the preferred
1314 provider option. If the preferred provider option provides a
1315 premium discount, the insured forfeits the premium discount
1316 effective on the date that the insured elects to use a provider
1317 who is not a preferred provider and who renders nonemergency
1318 services, unless there is no member of the preferred provider
1319 network located within 15 miles of the insured’s place of
1320 residence whose scope of practice includes the required
1321 services, or unless the nonemergency services are rendered in
1322 the emergency room of a hospital licensed under chapter 395. If
1323 the insurer offers a preferred provider policy to a policyholder
1324 or applicant, it must also offer a nonpreferred provider policy.
1325 (c) The insurer shall provide each insured policyholder
1326 with a current roster of preferred providers in the county in
1327 which the insured resides at the time of purchasing purchase of
1328 such policy, and shall make such list available for public
1329 inspection during regular business hours at the insurer’s
1330 principal office of the insurer within the state. The insurer
1331 may contract with a health insurer to use an existing preferred
1332 provider network to implement the preferred provider option. All
1333 providers and entities that are eligible to receive
1334 reimbursement pursuant to paragraph (1)(a) may provide services
1335 through a preferred provider network. Any other arrangement is
1336 subject to the approval of the Office of Insurance Regulation.
1337 (11)(10) DEMAND LETTER.—
1338 (a) As a condition precedent to filing any action for
1339 benefits under this section, the claimant filing suit must
1340 provide the insurer must be provided with written notice of an
1341 intent to initiate litigation. Such notice may not be sent until
1342 the claim is overdue, including any additional time the insurer
1343 has to pay the claim pursuant to paragraph (4)(b). A premature
1344 demand letter is defective and cannot be cured unless the court
1345 first abates the action or the claimant first voluntarily
1346 dismisses the action.
1347 (b) The notice required notice must shall state that it is
1348 a “demand letter under s. 627.736(10)” and shall state with
1349 specificity:
1350 1. The name of the insured upon which such benefits are
1351 being sought, including a copy of the assignment giving rights
1352 to the claimant if the claimant is not the insured.
1353 2. The claim number or policy number upon which such claim
1354 was originally submitted to the insurer.
1355 3. To the extent applicable, the name of any medical
1356 provider who rendered to an insured the treatment, services,
1357 accommodations, or supplies that form the basis of such claim;
1358 and an itemized statement specifying each exact amount, the date
1359 of treatment, service, or accommodation, and the type of benefit
1360 claimed to be due. A completed form satisfying the requirements
1361 of paragraph (6)(5)(d) or the lost-wage statement previously
1362 submitted may be used as the itemized statement. To the extent
1363 that the demand involves an insurer’s withdrawal of payment
1364 under paragraph (7)(a) for future treatment not yet rendered,
1365 the claimant shall attach a copy of the insurer’s notice
1366 withdrawing such payment and an itemized statement of the type,
1367 frequency, and duration of future treatment claimed to be
1368 reasonable and medically necessary.
1369 (c) Each notice required by this subsection must be
1370 delivered to the insurer by United States certified or
1371 registered mail, return receipt requested. Such postal costs
1372 shall be reimbursed by the insurer if so requested by the
1373 claimant in the notice, when the insurer pays the claim. Such
1374 notice must be sent to the person and address specified by the
1375 insurer for the purposes of receiving notices under this
1376 subsection. Each licensed insurer, whether domestic, foreign, or
1377 alien, shall file with the office designation of the name and
1378 address of the person to whom notices must pursuant to this
1379 subsection shall be sent which the office shall make available
1380 on its Internet website. The name and address on file with the
1381 office pursuant to s. 624.422 shall be deemed the authorized
1382 representative to accept notice pursuant to this subsection if
1383 in the event no other designation has been made.
1384 (d) If, within 30 days after receipt of notice by the
1385 insurer, the overdue claim specified in the notice is paid by
1386 the insurer together with applicable interest and a penalty of
1387 10 percent of the overdue amount paid by the insurer, subject to
1388 a maximum penalty of $250, no action may be brought against the
1389 insurer. If the demand involves an insurer’s withdrawal of
1390 payment under paragraph (7)(a) for future treatment not yet
1391 rendered, no action may be brought against the insurer if,
1392 within 30 days after its receipt of the notice, the insurer
1393 mails to the person filing the notice a written statement of the
1394 insurer’s agreement to pay for such treatment in accordance with
1395 the notice and to pay a penalty of 10 percent, subject to a
1396 maximum penalty of $250, when it pays for such future treatment
1397 in accordance with the requirements of this section. To the
1398 extent the insurer determines not to pay any amount demanded,
1399 the penalty is shall not be payable in any subsequent action.
1400 For purposes of this subsection, payment or the insurer’s
1401 agreement is shall be treated as being made on the date a draft
1402 or other valid instrument that is equivalent to payment, or the
1403 insurer’s written statement of agreement, is placed in the
1404 United States mail in a properly addressed, postpaid envelope,
1405 or if not so posted, on the date of delivery. The insurer is not
1406 obligated to pay any attorney’s fees if the insurer pays the
1407 claim or mails its agreement to pay for future treatment within
1408 the time prescribed by this subsection.
1409 (e) The applicable statute of limitation for an action
1410 under this section shall be tolled for a period of 30 business
1411 days by the mailing of the notice required by this subsection.
1412 (f) A demand letter that does not meet the minimum
1413 requirements set forth in this subsection or that is sent during
1414 the pendency of the lawsuit is defective. A defective demand
1415 letter cannot be cured unless the court first abates the action
1416 or the claimant first voluntarily dismisses the action.
1417 (g)(f) An Any insurer making a general business practice of
1418 not paying valid claims until receipt of the notice required by
1419 this subsection is engaging in an unfair trade practice under
1420 the insurance code.
1421 (h) If the insurer pays in response to a demand letter and
1422 the claimant disputes the amount paid, the claimant must send a
1423 second demand letter by certified or registered mail stating the
1424 exact amount that the claimant believes the insurer owes and why
1425 the claimant believes the amount paid is incorrect. The insurer
1426 has an additional 10 days after receipt of the second letter to
1427 issue any additional payment that is owed. The purpose of this
1428 provision is to avoid unnecessary litigation over miscalculated
1429 payments.
1430 (i) Demand letters may not be used to request the
1431 production of claim documents or other records from the insurer.
1432 Section 9. Subsection (10) of section 817.234, Florida
1433 Statutes, is amended, present subsection (12) of that section is
1434 renumbered as subsection (13) and amended, and a new subsection
1435 (12) is added to that section, to read:
1436 817.234 False and fraudulent insurance claims.—
1437 (10)(a) Any person who owns an business entity eligible for
1438 reimbursement under s. 627.736(1) and who is found guilty of
1439 insurance fraud under this section shall lose his or her
1440 occupational license for such entity for 5 years and may not
1441 receive reimbursement for personal injury protection benefits
1442 for 10 years.
1443 (b) Any licensed health care practitioner found guilty of
1444 insurance fraud under this section shall lose his or her license
1445 to practice for 5 years and may not receive reimbursement for
1446 personal injury protection benefits for 10 years. As used in
1447 this section, the term “insurer” means any insurer, health
1448 maintenance organization, self-insurer, self-insurance fund, or
1449 other similar entity or person regulated under chapter 440 or
1450 chapter 641 or by the Office of Insurance Regulation under the
1451 Florida Insurance Code.
1452 (12) In addition to any criminal liability, a person
1453 convicted of violating any provision of this section for the
1454 purpose of receiving insurance proceeds from a motor vehicle
1455 insurance contract is subject to a civil penalty.
1456 (a) Except for a violation of subsection (9), the civil
1457 penalty shall be:
1458 1. A fine up to $5,000 for a first offense.
1459 2. A fine greater than $5,000, but not to exceed $10,000,
1460 for a second offense.
1461 3. A fine greater than $10,000, but not to exceed $15,000,
1462 for a third or subsequent offense.
1463 (b) The civil penalty for a violation of subsection (9)
1464 must be at least $15,000, but may not exceed $50,000.
1465 (c) The civil penalty shall be paid to the Insurance
1466 Regulatory Trust Fund within the Department of Financial
1467 Services and used by the department for the investigation and
1468 prosecution of insurance fraud.
1469 (d) This subsection does not prohibit a state attorney from
1470 entering into a written agreement in which the person charged
1471 with the violation does not admit to or deny the charges but
1472 consents to payment of the civil penalty.
1473 (13)(12) As used in this section, the term:
1474 (a) “Insurer” means any insurer, health maintenance
1475 organization, self-insurer, self-insurance fund, or similar
1476 entity or person regulated under chapter 440 or chapter 641 or
1477 by the Office of Insurance Regulation under the Florida
1478 Insurance Code.
1479 (b)(a) “Property” means property as defined in s. 812.012.
1480 (c)(b) “Value” has the same meaning means value as provided
1481 defined in s. 812.012.
1482 Section 10. Subsection (1) of section 324.021, Florida
1483 Statutes, is amended to read:
1484 324.021 Definitions; minimum insurance required.—The
1485 following words and phrases when used in this chapter shall, for
1486 the purpose of this chapter, have the meanings respectively
1487 ascribed to them in this section, except in those instances
1488 where the context clearly indicates a different meaning:
1489 (1) MOTOR VEHICLE.—Every self-propelled vehicle that which
1490 is designed and required to be licensed for use upon a highway,
1491 including trailers and semitrailers designed for use with such
1492 vehicles, except traction engines, road rollers, farm tractors,
1493 power shovels, and well drillers, and every vehicle that which
1494 is propelled by electric power obtained from overhead wires but
1495 not operated upon rails, but not including any bicycle or moped.
1496 However, the term does “motor vehicle” shall not include a any
1497 motor vehicle as defined in s. 627.732(3) if when the owner of
1498 such vehicle has complied with the no-fault law requirements of
1499 ss. 627.730-627.7405, inclusive, unless the provisions of s.
1500 324.051 apply; and, in such case, the applicable proof of
1501 insurance provisions of s. 320.02 apply.
1502 Section 11. Paragraph (k) of subsection (2) of section
1503 456.057, Florida Statutes, is amended to read:
1504 456.057 Ownership and control of patient records; report or
1505 copies of records to be furnished.—
1506 (2) As used in this section, the terms “records owner,”
1507 “health care practitioner,” and “health care practitioner’s
1508 employer” do not include any of the following persons or
1509 entities; furthermore, the following persons or entities are not
1510 authorized to acquire or own medical records, but are authorized
1511 under the confidentiality and disclosure requirements of this
1512 section to maintain those documents required by the part or
1513 chapter under which they are licensed or regulated:
1514 (k) Persons or entities practicing under s. 627.736(8)
1515 627.736(7).
1516 Section 12. Paragraph (b) of subsection (1) of section
1517 627.7401, Florida Statutes, is amended to read:
1518 627.7401 Notification of insured’s rights.—
1519 (1) The commission, by rule, shall adopt a form for the
1520 notification of insureds of their right to receive personal
1521 injury protection benefits under the Florida Motor Vehicle no
1522 fault law. Such notice shall include:
1523 (b) An advisory informing insureds that:
1524 1. Pursuant to s. 626.9892, the Department of Financial
1525 Services may pay rewards of up to $25,000 to persons providing
1526 information leading to the arrest and conviction of persons
1527 committing crimes investigated by the Division of Insurance
1528 Fraud arising from violations of s. 440.105, s. 624.15, s.
1529 626.9541, s. 626.989, or s. 817.234.
1530 2. Pursuant to s. 627.736(6)(e)1. 627.736(5)(e)1., if the
1531 insured notifies the insurer of a billing error, the insured may
1532 be entitled to a certain percentage of a reduction in the amount
1533 paid by the insured’s motor vehicle insurer.
1534 Section 13. This act shall take effect July 1, 2011.
1535
1536
1537 ================= T I T L E A M E N D M E N T ================
1538 And the title is amended as follows:
1539 Delete everything before the enacting clause
1540 and insert:
1541 A bill to be entitled
1542 An act relating to motor vehicle personal injury
1543 protection insurance; amending s. 316.066, F.S.;
1544 revising provisions relating to the contents of
1545 written reports of motor vehicle crashes; requiring
1546 short-form crash reports by a law enforcement officer
1547 to be maintained by the officer’s agency; authorizing
1548 the investigating officer to testify at trial or
1549 provide an affidavit concerning the content of the
1550 reports; amending s. 400.991, F.S.; requiring that an
1551 application for licensure as a mobile clinic include a
1552 statement regarding insurance fraud; creating s.
1553 626.9894, F.S.; providing definitions; authorizing the
1554 Division of Insurance Fraud to establish a direct
1555 support organization for the purpose of prosecuting,
1556 investigating, and preventing motor vehicle insurance
1557 fraud; providing requirements for the organization and
1558 the organization’s contract with the division;
1559 providing for a board of directors; authorizing the
1560 organization to use the division’s property and
1561 facilities subject to certain requirements;
1562 authorizing contributions from insurers; providing
1563 that any moneys received by the organization may be
1564 held in a separate depository account in the name of
1565 the organization; requiring the division to deposit
1566 certain proceeds into the Insurance Regulatory Trust
1567 Fund; amending s. 627.4137, F.S.; requiring a
1568 claimant’s request about insurance coverage to be
1569 appropriately served upon the disclosing entity;
1570 amending s. 627.730, F.S.; conforming a cross
1571 reference; amending s. 627.731, F.S.; providing
1572 legislative intent with respect to the Florida Motor
1573 Vehicle No-Fault Law; amending s. 627.732, F.S.;
1574 defining the terms “claimant,” “entity wholly owned,”
1575 and “no-fault law”; amending s. 627.736, F.S.;
1576 conforming a cross-reference; adding licensed
1577 acupuncturists to the list of practitioners authorized
1578 to provide, supervise, order, or prescribe services;
1579 requiring certain entities providing medical services
1580 to document that they meet required criteria; revising
1581 requirements relating to the claim form that must be
1582 submitted by certain providers; requiring an entity or
1583 clinic to file a new form within a specified period
1584 after the date of a change of ownership; specifying
1585 the time period for submitting a properly completed
1586 claim; revising provisions relating to when payment
1587 for a benefit is due; providing that an insurer’s
1588 failure to send certain specification or explanation
1589 of benefits does not waive other grounds for rejecting
1590 an invalid claim; authorizing an insurer to obtain
1591 evidence and assert any ground for adjusting or
1592 rejecting a claim; providing that the time period for
1593 paying a claim is tolled during the investigation of a
1594 fraudulent insurance act; specifying when benefits are
1595 not payable; providing an exception for trauma centers
1596 covered by a local lien law from the requirement for
1597 an insurer to set aside a certain amount for the
1598 payment of benefits to medical providers; providing
1599 that a claimant that violates certain provisions is
1600 not entitled to any payment, regardless of whether a
1601 portion of the claim may be legitimate; authorizing an
1602 insurer to recover payments and bring a cause of
1603 action to recover payments; providing that an insurer
1604 may deny any claim based on other evidence of fraud;
1605 forbidding a physician, hospital, clinic, or other
1606 medical institution that fails to comply with certain
1607 provisions from billing the injured person or the
1608 insured; providing that an insurer has a right to
1609 conduct reasonable investigations of claims;
1610 authorizing an insurer to require a claimant to
1611 provide certain records; specifying when the period
1612 for payment is tolled; authorizing an insurer to deny
1613 benefits if an insured, claimant, or medical provider
1614 fails to comply with certain provisions; revising
1615 insurer reimbursement limitations; authorizing an
1616 insurer to pay the amount billed if less than the
1617 amount allowed; providing a limit on the amount of
1618 reimbursement if the insurance policy includes a
1619 schedule of charges; authorizing an insurer to not pay
1620 certain claims if the insured failed to countersign
1621 the billing form or patient log; creating a rebuttable
1622 presumption that the insured did not receive the
1623 alleged treatment if the insured does not countersign
1624 the billing form or patient log; providing a procedure
1625 for correcting such failure; authorizing the insurer
1626 to deny a claim if the provider does not submit a
1627 properly completed statement or bill within a certain
1628 time; specifying requirements for furnishing the
1629 insured with notice of the amount of covered loss;
1630 deleting an obsolete provision; requiring the provider
1631 to provide copies of the patient log within a certain
1632 time if requested by the insurer; providing that
1633 failure to maintain a patient log renders the
1634 treatment unlawful and noncompensable; revising
1635 requirements relating to discovery; authorizing the
1636 insurer to conduct a physical review of the treatment
1637 location; providing an exception for hospitals;
1638 requiring the insured and assignee to comply with
1639 certain provisions to recover benefits; requiring the
1640 provider to produce persons having the most knowledge
1641 in specified circumstances; requiring the insurer to
1642 pay reasonable compensation to the provider for
1643 attending the examination; requiring the insurer to
1644 request certain information before requesting an
1645 assignee to participate in an examination under oath;
1646 providing that an insurer that requests an examination
1647 under oath without a reasonable basis is engaging in
1648 an unfair and deceptive trade practice; providing that
1649 failure to appear for scheduled examinations
1650 establishes a rebuttable presumption that such failure
1651 was unreasonable; authorizing an insurer to contract
1652 with a preferred provider network; authorizing an
1653 insurer to provide a premium discount to an insured
1654 who selects a preferred provider; authorizing an
1655 insurance policy to not pay for nonemergency services
1656 performed by a nonpreferred provider in specified
1657 circumstances; authorizing an insurer to use a
1658 preferred provider network; revising requirements
1659 relating to demand letters in an action for benefits;
1660 specifying when a demand letter is defective;
1661 requiring a second demand letter under certain
1662 circumstances; deleting obsolete provisions; providing
1663 that a demand letter may not be used to request the
1664 production of claim documents or records from the
1665 insurer; amending s. 817.234, F.S.; providing that
1666 persons and business entities found guilty of
1667 insurance fraud lose their occupational and
1668 practitioner licenses for a certain period; providing
1669 civil penalties for fraudulent insurance claims;
1670 amending ss. 324.021, 456.057, and 627.7401, F.S.;
1671 conforming cross-references; providing an effective
1672 date.