Florida Senate - 2012 SENATOR AMENDMENT
Bill No. CS for CS for SB 1860
Barcode 435312
LEGISLATIVE ACTION
Senate . House
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Floor: 5/AD/2R .
03/06/2012 05:28 PM .
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Senator Negron moved the following:
1 Senate Amendment (with title amendment)
2
3 Delete lines 507 - 1390
4 and insert:
5 Section 7. Subsections (1), (4), (5), (6), (8), (9), (10),
6 and (11) of section 627.736, Florida Statutes, are amended to
7 read:
8 627.736 Required personal injury protection benefits;
9 exclusions; priority; claims.—
10 (1) REQUIRED BENEFITS.—An Every insurance policy complying
11 with the security requirements of s. 627.733 must shall provide
12 personal injury protection to the named insured, relatives
13 residing in the same household, persons operating the insured
14 motor vehicle, passengers in the such motor vehicle, and other
15 persons struck by the such motor vehicle and suffering bodily
16 injury while not an occupant of a self-propelled vehicle,
17 subject to the provisions of subsection (2) and paragraph
18 (4)(e), to a limit of $10,000 in medical and disability benefits
19 and $5,000 in death benefits resulting from for loss sustained
20 by any such person as a result of bodily injury, sickness,
21 disease, or death arising out of the ownership, maintenance, or
22 use of a motor vehicle as follows:
23 (a) Medical benefits.—Eighty percent of all reasonable
24 expenses for medically necessary medical, surgical, X-ray,
25 dental, and rehabilitative services, including prosthetic
26 devices, and medically necessary ambulance, hospital, and
27 nursing services if the individual receives initial services and
28 care pursuant to subparagraph 1. within 14 days after the motor
29 vehicle accident. However, The medical benefits shall provide
30 reimbursement only for: such
31 1. Initial services and care that are lawfully provided,
32 supervised, ordered, or prescribed by a physician licensed under
33 chapter 458 or chapter 459, by a dentist licensed under chapter
34 466, or a chiropractic physician licensed under chapter 460 or
35 that are provided in a hospital or in a facility that owns, or
36 is wholly owned by, a hospital. Initial services and care may
37 also be provided by a person or entity licensed under part III
38 of chapter 401 which provides emergency transportation and
39 treatment.
40 2. Followup services and care consistent with the
41 underlying medical diagnosis rendered pursuant to subparagraph
42 1. which may be provided, supervised, ordered, or prescribed
43 only by a physician licensed under chapter 458 or chapter 459, a
44 chiropractic physician licensed under chapter 460, a dentist
45 licensed under chapter 466, or, to the extent permitted by
46 applicable law and under the supervision of such physician,
47 osteopathic physician, chiropractic physician, or dentist, by a
48 physician assistant licensed under chapter 458 or chapter 459 or
49 an advanced registered nurse practitioner licensed under chapter
50 464. Followup services and care may also be provided by any of
51 the following persons or entities:
52 a.1. A hospital or ambulatory surgical center licensed
53 under chapter 395.
54 2. A person or entity licensed under ss. 401.2101-401.45
55 that provides emergency transportation and treatment.
56 b.3. An entity wholly owned by one or more physicians
57 licensed under chapter 458 or chapter 459, chiropractic
58 physicians licensed under chapter 460, or dentists licensed
59 under chapter 466 or by such practitioner or practitioners and
60 the spouse, parent, child, or sibling of such that practitioner
61 or those practitioners.
62 c.4. An entity that owns or is wholly owned, directly or
63 indirectly, by a hospital or hospitals.
64 d. A physical therapist licensed under chapter 486.
65 e.5. A health care clinic licensed under part X of chapter
66 400 which ss. 400.990-400.995 that is:
67 a. accredited by the Joint Commission on Accreditation of
68 Healthcare Organizations, the American Osteopathic Association,
69 the Commission on Accreditation of Rehabilitation Facilities, or
70 the Accreditation Association for Ambulatory Health Care, Inc.;
71 or
72 b. A health care clinic that:
73 (I) Has a medical director licensed under chapter 458,
74 chapter 459, or chapter 460;
75 (II) Has been continuously licensed for more than 3 years
76 or is a publicly traded corporation that issues securities
77 traded on an exchange registered with the United States
78 Securities and Exchange Commission as a national securities
79 exchange; and
80 (III) Provides at least four of the following medical
81 specialties:
82 (A) General medicine.
83 (B) Radiography.
84 (C) Orthopedic medicine.
85 (D) Physical medicine.
86 (E) Physical therapy.
87 (F) Physical rehabilitation.
88 (G) Prescribing or dispensing outpatient prescription
89 medication.
90 (H) Laboratory services.
91 3. Reimbursement for services and care provided by each
92 type of licensed medical provider authorized to render such
93 services and care is limited to the lesser of 24 treatments or
94 to services or care rendered within 12 weeks after the date of
95 the initial treatment, whichever comes first, unless the insurer
96 authorizes additional services or care.
97 4. Medical benefits do not include massage as defined in s.
98 480.033 or acupuncture as defined in s. 457.102, regardless of
99 the person, entity, or licensee providing massage or
100 acupuncture, and a licensed massage therapist or licensed
101 acupuncturist may not be reimbursed for medical benefits under
102 this section.
103 5. The Financial Services Commission shall adopt by rule
104 the form that must be used by an insurer and a health care
105 provider specified in sub-subparagraph 3.b., sub-subparagraph
106 3.c., or sub-subparagraph 3.e. subparagraph 3., subparagraph 4.,
107 or subparagraph 5. to document that the health care provider
108 meets the criteria of this paragraph, which rule must include a
109 requirement for a sworn statement or affidavit.
110 (b) Disability benefits.—Sixty percent of any loss of gross
111 income and loss of earning capacity per individual from
112 inability to work proximately caused by the injury sustained by
113 the injured person, plus all expenses reasonably incurred in
114 obtaining from others ordinary and necessary services in lieu of
115 those that, but for the injury, the injured person would have
116 performed without income for the benefit of his or her
117 household. All disability benefits payable under this provision
118 must shall be paid at least not less than every 2 weeks.
119 (c) Death benefits.—Death benefits equal to the lesser of
120 $5,000 or the remainder of unused personal injury protection
121 benefits per individual. Death benefits are in addition to the
122 medical and disability benefits provided under the insurance
123 policy. The insurer may pay death such benefits to the executor
124 or administrator of the deceased, to any of the deceased’s
125 relatives by blood, or legal adoption, or connection by
126 marriage, or to any person appearing to the insurer to be
127 equitably entitled to such benefits thereto.
128
129 Only insurers writing motor vehicle liability insurance in this
130 state may provide the required benefits of this section, and no
131 such insurer may not shall require the purchase of any other
132 motor vehicle coverage other than the purchase of property
133 damage liability coverage as required by s. 627.7275 as a
134 condition for providing such required benefits. Insurers may not
135 require that property damage liability insurance in an amount
136 greater than $10,000 be purchased in conjunction with personal
137 injury protection. Such insurers shall make benefits and
138 required property damage liability insurance coverage available
139 through normal marketing channels. An Any insurer writing motor
140 vehicle liability insurance in this state who fails to comply
141 with such availability requirement as a general business
142 practice violates shall be deemed to have violated part IX of
143 chapter 626, and such violation constitutes shall constitute an
144 unfair method of competition or an unfair or deceptive act or
145 practice involving the business of insurance. An; and any such
146 insurer committing such violation is shall be subject to the
147 penalties provided under that afforded in such part, as well as
148 those provided which may be afforded elsewhere in the insurance
149 code.
150 (4) PAYMENT OF BENEFITS; WHEN DUE.—Benefits due from an
151 insurer under ss. 627.730-627.7405 are shall be primary, except
152 that benefits received under any workers’ compensation law must
153 shall be credited against the benefits provided by subsection
154 (1) and are shall be due and payable as loss accrues, upon
155 receipt of reasonable proof of such loss and the amount of
156 expenses and loss incurred which are covered by the policy
157 issued under ss. 627.730-627.7405. If When the Agency for Health
158 Care Administration provides, pays, or becomes liable for
159 medical assistance under the Medicaid program related to injury,
160 sickness, disease, or death arising out of the ownership,
161 maintenance, or use of a motor vehicle, the benefits under ss.
162 627.730-627.7405 are shall be subject to the provisions of the
163 Medicaid program. However, within 30 days after receiving notice
164 that the Medicaid program paid such benefits, the insurer shall
165 repay the full amount of the benefits to the Medicaid program.
166 (a) An insurer may require written notice to be given as
167 soon as practicable after an accident involving a motor vehicle
168 with respect to which the policy affords the security required
169 by ss. 627.730-627.7405.
170 (b) Personal injury protection insurance benefits paid
171 pursuant to this section are shall be overdue if not paid within
172 30 days after the insurer is furnished written notice of the
173 fact of a covered loss and of the amount of same. However:
174 1. If such written notice of the entire claim is not
175 furnished to the insurer as to the entire claim, any partial
176 amount supported by written notice is overdue if not paid within
177 30 days after such written notice is furnished to the insurer.
178 Any part or all of the remainder of the claim that is
179 subsequently supported by written notice is overdue if not paid
180 within 30 days after such written notice is furnished to the
181 insurer.
182 2. If When an insurer pays only a portion of a claim or
183 rejects a claim, the insurer shall provide at the time of the
184 partial payment or rejection an itemized specification of each
185 item that the insurer had reduced, omitted, or declined to pay
186 and any information that the insurer desires the claimant to
187 consider related to the medical necessity of the denied
188 treatment or to explain the reasonableness of the reduced charge
189 if, provided that this does shall not limit the introduction of
190 evidence at trial.; and The insurer must also shall include the
191 name and address of the person to whom the claimant should
192 respond and a claim number to be referenced in future
193 correspondence.
194 3. If an insurer pays only a portion of a claim or rejects
195 a claim due to an alleged error in the claim, the insurer, at
196 the time of the partial payment or rejection, shall provide an
197 itemized specification or explanation of benefits due to the
198 specified error. Upon receiving the specification or
199 explanation, the person making the claim, at the person’s option
200 and without waiving any other legal remedy for payment, has 15
201 days to submit a revised claim, which shall be considered a
202 timely submission of written notice of a claim.
203 4. However, Notwithstanding the fact that written notice
204 has been furnished to the insurer, any payment is shall not be
205 deemed overdue if when the insurer has reasonable proof to
206 establish that the insurer is not responsible for the payment.
207 5. For the purpose of calculating the extent to which any
208 benefits are overdue, payment shall be treated as being made on
209 the date a draft or other valid instrument that which is
210 equivalent to payment was placed in the United States mail in a
211 properly addressed, postpaid envelope or, if not so posted, on
212 the date of delivery.
213 6. This paragraph does not preclude or limit the ability of
214 the insurer to assert that the claim was unrelated, was not
215 medically necessary, or was unreasonable or that the amount of
216 the charge was in excess of that permitted under, or in
217 violation of, subsection (5). Such assertion by the insurer may
218 be made at any time, including after payment of the claim or
219 after the 30-day time period for payment set forth in this
220 paragraph.
221 (c) Upon receiving notice of an accident that is
222 potentially covered by personal injury protection benefits, the
223 insurer must reserve $5,000 of personal injury protection
224 benefits for payment to physicians licensed under chapter 458 or
225 chapter 459 or dentists licensed under chapter 466 who provide
226 emergency services and care, as defined in s. 395.002(9), or who
227 provide hospital inpatient care. The amount required to be held
228 in reserve may be used only to pay claims from such physicians
229 or dentists until 30 days after the date the insurer receives
230 notice of the accident. After the 30-day period, any amount of
231 the reserve for which the insurer has not received notice of
232 such claims a claim from a physician or dentist who provided
233 emergency services and care or who provided hospital inpatient
234 care may then be used by the insurer to pay other claims. The
235 time periods specified in paragraph (b) for required payment of
236 personal injury protection benefits are shall be tolled for the
237 period of time that an insurer is required by this paragraph to
238 hold payment of a claim that is not from such a physician or
239 dentist who provided emergency services and care or who provided
240 hospital inpatient care to the extent that the personal injury
241 protection benefits not held in reserve are insufficient to pay
242 the claim. This paragraph does not require an insurer to
243 establish a claim reserve for insurance accounting purposes.
244 (d) All overdue payments shall bear simple interest at the
245 rate established under s. 55.03 or the rate established in the
246 insurance contract, whichever is greater, for the year in which
247 the payment became overdue, calculated from the date the insurer
248 was furnished with written notice of the amount of covered loss.
249 Interest is shall be due at the time payment of the overdue
250 claim is made.
251 (e) The insurer of the owner of a motor vehicle shall pay
252 personal injury protection benefits for:
253 1. Accidental bodily injury sustained in this state by the
254 owner while occupying a motor vehicle, or while not an occupant
255 of a self-propelled vehicle if the injury is caused by physical
256 contact with a motor vehicle.
257 2. Accidental bodily injury sustained outside this state,
258 but within the United States of America or its territories or
259 possessions or Canada, by the owner while occupying the owner’s
260 motor vehicle.
261 3. Accidental bodily injury sustained by a relative of the
262 owner residing in the same household, under the circumstances
263 described in subparagraph 1. or subparagraph 2., if provided the
264 relative at the time of the accident is domiciled in the owner’s
265 household and is not himself or herself the owner of a motor
266 vehicle with respect to which security is required under ss.
267 627.730-627.7405.
268 4. Accidental bodily injury sustained in this state by any
269 other person while occupying the owner’s motor vehicle or, if a
270 resident of this state, while not an occupant of a self
271 propelled vehicle, if the injury is caused by physical contact
272 with such motor vehicle, if provided the injured person is not
273 himself or herself:
274 a. The owner of a motor vehicle with respect to which
275 security is required under ss. 627.730-627.7405; or
276 b. Entitled to personal injury benefits from the insurer of
277 the owner or owners of such a motor vehicle.
278 (f) If two or more insurers are liable for paying to pay
279 personal injury protection benefits for the same injury to any
280 one person, the maximum payable is shall be as specified in
281 subsection (1), and the any insurer paying the benefits is shall
282 be entitled to recover from each of the other insurers an
283 equitable pro rata share of the benefits paid and expenses
284 incurred in processing the claim.
285 (g) It is a violation of the insurance code for an insurer
286 to fail to timely provide benefits as required by this section
287 with such frequency as to constitute a general business
288 practice.
289 (h) Benefits are shall not be due or payable to or on the
290 behalf of an insured person if that person has committed, by a
291 material act or omission, any insurance fraud relating to
292 personal injury protection coverage under his or her policy, if
293 the fraud is admitted to in a sworn statement by the insured or
294 if it is established in a court of competent jurisdiction. Any
295 insurance fraud voids shall void all coverage arising from the
296 claim related to such fraud under the personal injury protection
297 coverage of the insured person who committed the fraud,
298 irrespective of whether a portion of the insured person’s claim
299 may be legitimate, and any benefits paid before prior to the
300 discovery of the insured person’s insurance fraud is shall be
301 recoverable by the insurer in its entirety from the person who
302 committed insurance fraud in their entirety. The prevailing
303 party is entitled to its costs and attorney attorney’s fees in
304 any action in which it prevails in an insurer’s action to
305 enforce its right of recovery under this paragraph.
306 (i) If an insurer has a reasonable belief that a fraudulent
307 insurance act, as defined in s. 626.989 or s. 817.234, has been
308 committed, the insurer shall notify the claimant in writing
309 within 30 days after submission of the claim that the claim is
310 being investigated for suspected fraud and execute and provide
311 to the insured and the office an affidavit under oath stating
312 that there is a factual basis that there is a probability of
313 fraud. The insurer has an additional 60 days, beginning at the
314 end of the initial 30-day period, to conduct its fraud
315 investigation. Notwithstanding subsection (10), no later than
316 the 90th day after the submission of the claim, the insurer must
317 deny the claim or pay the claim along with simple interest as
318 provided in paragraph (d). All claims denied for suspected
319 fraudulent insurance acts shall be reported to the Division of
320 Insurance Fraud.
321 (j) An insurer shall create and maintain for each insured a
322 log of personal injury protection benefits paid by the insurer
323 on behalf of the insured. If litigation is commenced, the
324 insurer shall provide to the insured, or an assignee of the
325 insured, a copy of the log within 30 days after receiving a
326 request for the log from the insured or the assignee.
327 (5) CHARGES FOR TREATMENT OF INJURED PERSONS.—
328 (a)1. A Any physician, hospital, clinic, or other person or
329 institution lawfully rendering treatment to an injured person
330 for a bodily injury covered by personal injury protection
331 insurance may charge the insurer and injured party only a
332 reasonable amount pursuant to this section for the services and
333 supplies rendered, and the insurer providing such coverage may
334 pay for such charges directly to such person or institution
335 lawfully rendering such treatment, if the insured receiving such
336 treatment or his or her guardian has countersigned the properly
337 completed invoice, bill, or claim form approved by the office
338 upon which such charges are to be paid for as having actually
339 been rendered, to the best knowledge of the insured or his or
340 her guardian. In no event, However, may such a charge may not
341 exceed be in excess of the amount the person or institution
342 customarily charges for like services or supplies. In
343 determining With respect to a determination of whether a charge
344 for a particular service, treatment, or otherwise is reasonable,
345 consideration may be given to evidence of usual and customary
346 charges and payments accepted by the provider involved in the
347 dispute, and reimbursement levels in the community and various
348 federal and state medical fee schedules applicable to motor
349 vehicle automobile and other insurance coverages, and other
350 information relevant to the reasonableness of the reimbursement
351 for the service, treatment, or supply.
352 1.2. The insurer may limit reimbursement to 80 percent of
353 the following schedule of maximum charges:
354 a. For emergency transport and treatment by providers
355 licensed under chapter 401, 200 percent of Medicare.
356 b. For emergency services and care provided by a hospital
357 licensed under chapter 395, 75 percent of the hospital’s usual
358 and customary charges.
359 c. For emergency services and care as defined by s.
360 395.002(9) provided in a facility licensed under chapter 395
361 rendered by a physician or dentist, and related hospital
362 inpatient services rendered by a physician or dentist, the usual
363 and customary charges in the community.
364 d. For hospital inpatient services, other than emergency
365 services and care, 200 percent of the Medicare Part A
366 prospective payment applicable to the specific hospital
367 providing the inpatient services.
368 e. For hospital outpatient services, other than emergency
369 services and care, 200 percent of the Medicare Part A Ambulatory
370 Payment Classification for the specific hospital providing the
371 outpatient services.
372 f. For all other medical services, supplies, and care, 200
373 percent of the allowable amount under:
374 (I) The participating physicians fee schedule of Medicare
375 Part B, except as provided in sub-sub-subparagraphs (II) and
376 (III).
377 (II) Medicare Part B, in the case of services, supplies,
378 and care provided by ambulatory surgical centers and clinical
379 laboratories.
380 (III) The Durable Medical Equipment Prosthetics/Orthotics
381 and Supplies fee schedule of Medicare Part B, in the case of
382 durable medical equipment.
383
384 However, if such services, supplies, or care is not reimbursable
385 under Medicare Part B, as provided in this sub-subparagraph, the
386 insurer may limit reimbursement to 80 percent of the maximum
387 reimbursable allowance under workers’ compensation, as
388 determined under s. 440.13 and rules adopted thereunder which
389 are in effect at the time such services, supplies, or care is
390 provided. Services, supplies, or care that is not reimbursable
391 under Medicare or workers’ compensation is not required to be
392 reimbursed by the insurer.
393 2.3. For purposes of subparagraph 1. 2., the applicable fee
394 schedule or payment limitation under Medicare is the fee
395 schedule or payment limitation in effect on January 1 of the
396 year in which at the time the services, supplies, or care is was
397 rendered and for the area in which such services, supplies, or
398 care is were rendered, and the applicable fee schedule or
399 payment limitation applies throughout the remainder of that
400 year, notwithstanding any subsequent change made to the fee
401 schedule or payment limitation, except that it may not be less
402 than the allowable amount under the applicable participating
403 physicians schedule of Medicare Part B for 2007 for medical
404 services, supplies, and care subject to Medicare Part B.
405 3.4. Subparagraph 1. 2. does not allow the insurer to apply
406 any limitation on the number of treatments or other utilization
407 limits that apply under Medicare or workers’ compensation. An
408 insurer that applies the allowable payment limitations of
409 subparagraph 1. 2. must reimburse a provider who lawfully
410 provided care or treatment under the scope of his or her
411 license, regardless of whether such provider is would be
412 entitled to reimbursement under Medicare due to restrictions or
413 limitations on the types or discipline of health care providers
414 who may be reimbursed for particular procedures or procedure
415 codes. However, subparagraph 1. does not prohibit an insurer
416 from using the Medicare coding policies and payment
417 methodologies of the federal Centers for Medicare and Medicaid
418 Services, including applicable modifiers, to determine the
419 appropriate amount of reimbursement for medical services,
420 supplies, or care if the coding policy or payment methodology
421 does not constitute a utilization limit.
422 4.5. If an insurer limits payment as authorized by
423 subparagraph 1. 2., the person providing such services,
424 supplies, or care may not bill or attempt to collect from the
425 insured any amount in excess of such limits, except for amounts
426 that are not covered by the insured’s personal injury protection
427 coverage due to the coinsurance amount or maximum policy limits.
428 5. Effective July 1, 2012, an insurer may limit payment as
429 authorized by this paragraph only if the insurance policy
430 includes a notice at the time of issuance or renewal that the
431 insurer may limit payment pursuant to the schedule of charges
432 specified in this paragraph. A policy form approved by the
433 office satisfies this requirement. If a provider submits a
434 charge for an amount less than the amount allowed under
435 subparagraph 1., the insurer may pay the amount of the charge
436 submitted.
437 (b)1. An insurer or insured is not required to pay a claim
438 or charges:
439 a. Made by a broker or by a person making a claim on behalf
440 of a broker;
441 b. For any service or treatment that was not lawful at the
442 time rendered;
443 c. To any person who knowingly submits a false or
444 misleading statement relating to the claim or charges;
445 d. With respect to a bill or statement that does not
446 substantially meet the applicable requirements of paragraph (d);
447 e. For any treatment or service that is upcoded, or that is
448 unbundled when such treatment or services should be bundled, in
449 accordance with paragraph (d). To facilitate prompt payment of
450 lawful services, an insurer may change codes that it determines
451 to have been improperly or incorrectly upcoded or unbundled, and
452 may make payment based on the changed codes, without affecting
453 the right of the provider to dispute the change by the insurer,
454 if, provided that before doing so, the insurer contacts must
455 contact the health care provider and discusses discuss the
456 reasons for the insurer’s change and the health care provider’s
457 reason for the coding, or makes make a reasonable good faith
458 effort to do so, as documented in the insurer’s file; and
459 f. For medical services or treatment billed by a physician
460 and not provided in a hospital unless such services are rendered
461 by the physician or are incident to his or her professional
462 services and are included on the physician’s bill, including
463 documentation verifying that the physician is responsible for
464 the medical services that were rendered and billed.
465 2. The Department of Health, in consultation with the
466 appropriate professional licensing boards, shall adopt, by rule,
467 a list of diagnostic tests deemed not to be medically necessary
468 for use in the treatment of persons sustaining bodily injury
469 covered by personal injury protection benefits under this
470 section. The initial list shall be adopted by January 1, 2004,
471 and shall be revised from time to time as determined by the
472 Department of Health, in consultation with the respective
473 professional licensing boards. Inclusion of a test on the list
474 of invalid diagnostic tests shall be based on lack of
475 demonstrated medical value and a level of general acceptance by
476 the relevant provider community and may shall not be dependent
477 for results entirely upon subjective patient response.
478 Notwithstanding its inclusion on a fee schedule in this
479 subsection, an insurer or insured is not required to pay any
480 charges or reimburse claims for an any invalid diagnostic test
481 as determined by the Department of Health.
482 (c)1. With respect to any treatment or service, other than
483 medical services billed by a hospital or other provider for
484 emergency services and care as defined in s. 395.002 or
485 inpatient services rendered at a hospital-owned facility, the
486 statement of charges must be furnished to the insurer by the
487 provider and may not include, and the insurer is not required to
488 pay, charges for treatment or services rendered more than 35
489 days before the postmark date or electronic transmission date of
490 the statement, except for past due amounts previously billed on
491 a timely basis under this paragraph, and except that, if the
492 provider submits to the insurer a notice of initiation of
493 treatment within 21 days after its first examination or
494 treatment of the claimant, the statement may include charges for
495 treatment or services rendered up to, but not more than, 75 days
496 before the postmark date of the statement. The injured party is
497 not liable for, and the provider may shall not bill the injured
498 party for, charges that are unpaid because of the provider’s
499 failure to comply with this paragraph. Any agreement requiring
500 the injured person or insured to pay for such charges is
501 unenforceable.
502 1.2. If, however, the insured fails to furnish the provider
503 with the correct name and address of the insured’s personal
504 injury protection insurer, the provider has 35 days from the
505 date the provider obtains the correct information to furnish the
506 insurer with a statement of the charges. The insurer is not
507 required to pay for such charges unless the provider includes
508 with the statement documentary evidence that was provided by the
509 insured during the 35-day period demonstrating that the provider
510 reasonably relied on erroneous information from the insured and
511 either:
512 a. A denial letter from the incorrect insurer; or
513 b. Proof of mailing, which may include an affidavit under
514 penalty of perjury, reflecting timely mailing to the incorrect
515 address or insurer.
516 2.3. For emergency services and care as defined in s.
517 395.002 rendered in a hospital emergency department or for
518 transport and treatment rendered by an ambulance provider
519 licensed pursuant to part III of chapter 401, the provider is
520 not required to furnish the statement of charges within the time
521 periods established by this paragraph,; and the insurer is shall
522 not be considered to have been furnished with notice of the
523 amount of covered loss for purposes of paragraph (4)(b) until it
524 receives a statement complying with paragraph (d), or copy
525 thereof, which specifically identifies the place of service to
526 be a hospital emergency department or an ambulance in accordance
527 with billing standards recognized by the federal Centers for
528 Medicare and Medicaid Services Health Care Finance
529 Administration.
530 3.4. Each notice of the insured’s rights under s. 627.7401
531 must include the following statement in at least 12-point type
532 in type no smaller than 12 points:
533
534 BILLING REQUIREMENTS.—Florida law provides
535 Statutes provide that with respect to any treatment or
536 services, other than certain hospital and emergency
537 services, the statement of charges furnished to the
538 insurer by the provider may not include, and the
539 insurer and the injured party are not required to pay,
540 charges for treatment or services rendered more than
541 35 days before the postmark date of the statement,
542 except for past due amounts previously billed on a
543 timely basis, and except that, if the provider submits
544 to the insurer a notice of initiation of treatment
545 within 21 days after its first examination or
546 treatment of the claimant, the statement may include
547 charges for treatment or services rendered up to, but
548 not more than, 75 days before the postmark date of the
549 statement.
550
551 (d) All statements and bills for medical services rendered
552 by a any physician, hospital, clinic, or other person or
553 institution shall be submitted to the insurer on a properly
554 completed Centers for Medicare and Medicaid Services (CMS) 1500
555 form, UB 92 forms, or any other standard form approved by the
556 office or adopted by the commission for purposes of this
557 paragraph. All billings for such services rendered by providers
558 must shall, to the extent applicable, follow the Physicians’
559 Current Procedural Terminology (CPT) or Healthcare Correct
560 Procedural Coding System (HCPCS), or ICD-9 in effect for the
561 year in which services are rendered and comply with the Centers
562 for Medicare and Medicaid Services (CMS) 1500 form instructions,
563 and the American Medical Association Current Procedural
564 Terminology (CPT) Editorial Panel, and the Healthcare Correct
565 Procedural Coding System (HCPCS). All providers, other than
566 hospitals, must shall include on the applicable claim form the
567 professional license number of the provider in the line or space
568 provided for “Signature of Physician or Supplier, Including
569 Degrees or Credentials.” In determining compliance with
570 applicable CPT and HCPCS coding, guidance shall be provided by
571 the Physicians’ Current Procedural Terminology (CPT) or the
572 Healthcare Correct Procedural Coding System (HCPCS) in effect
573 for the year in which services were rendered, the Office of the
574 Inspector General (OIG), Physicians Compliance Guidelines, and
575 other authoritative treatises designated by rule by the Agency
576 for Health Care Administration. A No statement of medical
577 services may not include charges for medical services of a
578 person or entity that performed such services without possessing
579 the valid licenses required to perform such services. For
580 purposes of paragraph (4)(b), an insurer is shall not be
581 considered to have been furnished with notice of the amount of
582 covered loss or medical bills due unless the statements or bills
583 comply with this paragraph, and unless the statements or bills
584 are properly completed in their entirety as to all material
585 provisions, with all relevant information being provided
586 therein.
587 (e)1. At the initial treatment or service provided, each
588 physician, other licensed professional, clinic, or other medical
589 institution providing medical services upon which a claim for
590 personal injury protection benefits is based shall require an
591 insured person, or his or her guardian, to execute a disclosure
592 and acknowledgment form, which reflects at a minimum that:
593 a. The insured, or his or her guardian, must countersign
594 the form attesting to the fact that the services set forth
595 therein were actually rendered;
596 b. The insured, or his or her guardian, has both the right
597 and affirmative duty to confirm that the services were actually
598 rendered;
599 c. The insured, or his or her guardian, was not solicited
600 by any person to seek any services from the medical provider;
601 d. The physician, other licensed professional, clinic, or
602 other medical institution rendering services for which payment
603 is being claimed explained the services to the insured or his or
604 her guardian; and
605 e. If the insured notifies the insurer in writing of a
606 billing error, the insured may be entitled to a certain
607 percentage of a reduction in the amounts paid by the insured’s
608 motor vehicle insurer.
609 2. The physician, other licensed professional, clinic, or
610 other medical institution rendering services for which payment
611 is being claimed has the affirmative duty to explain the
612 services rendered to the insured, or his or her guardian, so
613 that the insured, or his or her guardian, countersigns the form
614 with informed consent.
615 3. Countersignature by the insured, or his or her guardian,
616 is not required for the reading of diagnostic tests or other
617 services that are of such a nature that they are not required to
618 be performed in the presence of the insured.
619 4. The licensed medical professional rendering treatment
620 for which payment is being claimed must sign, by his or her own
621 hand, the form complying with this paragraph.
622 5. The original completed disclosure and acknowledgment
623 form shall be furnished to the insurer pursuant to paragraph
624 (4)(b) and may not be electronically furnished.
625 6. The This disclosure and acknowledgment form is not
626 required for services billed by a provider for emergency
627 services as defined in s. 395.002, for emergency services and
628 care as defined in s. 395.002 rendered in a hospital emergency
629 department, or for transport and treatment rendered by an
630 ambulance provider licensed pursuant to part III of chapter 401.
631 7. The Financial Services Commission shall adopt, by rule,
632 a standard disclosure and acknowledgment form to that shall be
633 used to fulfill the requirements of this paragraph, effective 90
634 days after such form is adopted and becomes final. The
635 commission shall adopt a proposed rule by October 1, 2003. Until
636 the rule is final, the provider may use a form of its own which
637 otherwise complies with the requirements of this paragraph.
638 8. As used in this paragraph, the term “countersign” or
639 “countersignature” “countersigned” means a second or verifying
640 signature, as on a previously signed document, and is not
641 satisfied by the statement “signature on file” or any similar
642 statement.
643 9. The requirements of this paragraph apply only with
644 respect to the initial treatment or service of the insured by a
645 provider. For subsequent treatments or service, the provider
646 must maintain a patient log signed by the patient, in
647 chronological order by date of service, which that is consistent
648 with the services being rendered to the patient as claimed. The
649 requirement to maintain requirements of this subparagraph for
650 maintaining a patient log signed by the patient may be met by a
651 hospital that maintains medical records as required by s.
652 395.3025 and applicable rules and makes such records available
653 to the insurer upon request.
654 (f) Upon written notification by any person, an insurer
655 shall investigate any claim of improper billing by a physician
656 or other medical provider. The insurer shall determine if the
657 insured was properly billed for only those services and
658 treatments that the insured actually received. If the insurer
659 determines that the insured has been improperly billed, the
660 insurer shall notify the insured, the person making the written
661 notification, and the provider of its findings and shall reduce
662 the amount of payment to the provider by the amount determined
663 to be improperly billed. If a reduction is made due to a such
664 written notification by any person, the insurer shall pay to the
665 person 20 percent of the amount of the reduction, up to $500. If
666 the provider is arrested due to the improper billing, then the
667 insurer shall pay to the person 40 percent of the amount of the
668 reduction, up to $500.
669 (g) An insurer may not systematically downcode with the
670 intent to deny reimbursement otherwise due. Such action
671 constitutes a material misrepresentation under s.
672 626.9541(1)(i)2.
673 (h) As provided in s. 400.9905, an entity excluded from the
674 definition of a clinic shall be deemed a clinic and must be
675 licensed under part X of chapter 400 in order to receive
676 reimbursement under ss. 627.730-627.7405. However, this
677 licensing requirement does not apply to:
678 1. An entity wholly owned by a physician licensed under
679 chapter 458 or chapter 459, or by the physician and the spouse,
680 parent, child, or sibling of the physician;
681 2. An entity wholly owned by a dentist licensed under
682 chapter 466, or by the dentist and the spouse, parent, child, or
683 sibling of the dentist;
684 3. An entity wholly owned by a chiropractic physician
685 licensed under chapter 460, or by the chiropractic physician and
686 the spouse, parent, child, or sibling of the chiropractic
687 physician;
688 4. A hospital or ambulatory surgical center licensed under
689 chapter 395;
690 5. An entity that wholly owns or is wholly owned, directly
691 or indirectly, by a hospital or hospitals licensed under chapter
692 395; or
693 6. An entity that is a clinical facility affiliated with an
694 accredited medical school at which training is provided for
695 medical students, residents, or fellows.
696 (6) DISCOVERY OF FACTS ABOUT AN INJURED PERSON; DISPUTES.—
697 (a) Every employer shall, If a request is made by an
698 insurer providing personal injury protection benefits under ss.
699 627.730-627.7405 against whom a claim has been made, an employer
700 must furnish forthwith, in a form approved by the office, a
701 sworn statement of the earnings, since the time of the bodily
702 injury and for a reasonable period before the injury, of the
703 person upon whose injury the claim is based.
704 (b) Every physician, hospital, clinic, or other medical
705 institution providing, before or after bodily injury upon which
706 a claim for personal injury protection insurance benefits is
707 based, any products, services, or accommodations in relation to
708 that or any other injury, or in relation to a condition claimed
709 to be connected with that or any other injury, shall, if
710 requested to do so by the insurer against whom the claim has
711 been made, furnish forthwith a written report of the history,
712 condition, treatment, dates, and costs of such treatment of the
713 injured person and why the items identified by the insurer were
714 reasonable in amount and medically necessary, together with a
715 sworn statement that the treatment or services rendered were
716 reasonable and necessary with respect to the bodily injury
717 sustained and identifying which portion of the expenses for such
718 treatment or services was incurred as a result of such bodily
719 injury, and produce forthwith, and allow permit the inspection
720 and copying of, his or her or its records regarding such
721 history, condition, treatment, dates, and costs of treatment if;
722 provided that this does shall not limit the introduction of
723 evidence at trial. Such sworn statement must shall read as
724 follows: “Under penalty of perjury, I declare that I have read
725 the foregoing, and the facts alleged are true, to the best of my
726 knowledge and belief.” A No cause of action for violation of the
727 physician-patient privilege or invasion of the right of privacy
728 may not be brought shall be permitted against any physician,
729 hospital, clinic, or other medical institution complying with
730 the provisions of this section. The person requesting such
731 records and such sworn statement shall pay all reasonable costs
732 connected therewith. If an insurer makes a written request for
733 documentation or information under this paragraph within 30 days
734 after having received notice of the amount of a covered loss
735 under paragraph (4)(a), the amount or the partial amount that
736 which is the subject of the insurer’s inquiry is shall become
737 overdue if the insurer does not pay in accordance with paragraph
738 (4)(b) or within 10 days after the insurer’s receipt of the
739 requested documentation or information, whichever occurs later.
740 As used in For purposes of this paragraph, the term “receipt”
741 includes, but is not limited to, inspection and copying pursuant
742 to this paragraph. An Any insurer that requests documentation or
743 information pertaining to reasonableness of charges or medical
744 necessity under this paragraph without a reasonable basis for
745 such requests as a general business practice is engaging in an
746 unfair trade practice under the insurance code.
747 (c) In the event of a any dispute regarding an insurer’s
748 right to discovery of facts under this section, the insurer may
749 petition a court of competent jurisdiction to enter an order
750 permitting such discovery. The order may be made only on motion
751 for good cause shown and upon notice to all persons having an
752 interest, and must it shall specify the time, place, manner,
753 conditions, and scope of the discovery. Such court may, In order
754 to protect against annoyance, embarrassment, or oppression, as
755 justice requires, the court may enter an order refusing
756 discovery or specifying conditions of discovery and may order
757 payments of costs and expenses of the proceeding, including
758 reasonable fees for the appearance of attorneys at the
759 proceedings, as justice requires.
760 (d) The injured person shall be furnished, upon request, a
761 copy of all information obtained by the insurer under the
762 provisions of this section, and shall pay a reasonable charge,
763 if required by the insurer.
764 (e) Notice to an insurer of the existence of a claim may
765 shall not be unreasonably withheld by an insured.
766 (f) In a dispute between the insured and the insurer, or
767 between an assignee of the insured’s rights and the insurer, the
768 insurer must notify the insured or the assignee that the policy
769 limits under this section have been reached within 15 days after
770 the limits have been reached.
771 (8) APPLICABILITY OF PROVISION REGULATING ATTORNEY
772 ATTORNEY’S FEES.—With respect to any dispute under the
773 provisions of ss. 627.730-627.7405 between the insured and the
774 insurer, or between an assignee of an insured’s rights and the
775 insurer, the provisions of ss. s. 627.428 and 768.79 shall
776 apply, except as provided in subsections (10) and (15).
777 (9) PREFERRED PROVIDERS.—An insurer may negotiate and
778 contract enter into contracts with preferred licensed health
779 care providers for the benefits described in this section,
780 referred to in this section as “preferred providers,” which
781 shall include health care providers licensed under chapter
782 chapters 458, chapter 459, chapter 460, chapter 461, or chapter
783 and 463. The insurer may provide an option to an insured to use
784 a preferred provider at the time of purchasing purchase of the
785 policy for personal injury protection benefits, if the
786 requirements of this subsection are met. If the insured elects
787 to use a provider who is not a preferred provider, whether the
788 insured purchased a preferred provider policy or a nonpreferred
789 provider policy, the medical benefits provided by the insurer
790 shall be as required by this section. If the insured elects to
791 use a provider who is a preferred provider, the insurer may pay
792 medical benefits in excess of the benefits required by this
793 section and may waive or lower the amount of any deductible that
794 applies to such medical benefits. If the insurer offers a
795 preferred provider policy to a policyholder or applicant, it
796 must also offer a nonpreferred provider policy. The insurer
797 shall provide each insured policyholder with a current roster of
798 preferred providers in the county in which the insured resides
799 at the time of purchase of such policy, and shall make such list
800 available for public inspection during regular business hours at
801 the insurer’s principal office of the insurer within the state.
802 (10) DEMAND LETTER.—
803 (a) As a condition precedent to filing any action for
804 benefits under this section, the insurer must be provided with
805 written notice of an intent to initiate litigation must be
806 provided to the insurer. Such notice may not be sent until the
807 claim is overdue, including any additional time the insurer has
808 to pay the claim pursuant to paragraph (4)(b).
809 (b) The notice must required shall state that it is a
810 “demand letter under s. 627.736(10)” and shall state with
811 specificity:
812 1. The name of the insured upon which such benefits are
813 being sought, including a copy of the assignment giving rights
814 to the claimant if the claimant is not the insured.
815 2. The claim number or policy number upon which such claim
816 was originally submitted to the insurer.
817 3. To the extent applicable, the name of any medical
818 provider who rendered to an insured the treatment, services,
819 accommodations, or supplies that form the basis of such claim;
820 and an itemized statement specifying each exact amount, the date
821 of treatment, service, or accommodation, and the type of benefit
822 claimed to be due. A completed form satisfying the requirements
823 of paragraph (5)(d) or the lost-wage statement previously
824 submitted may be used as the itemized statement. To the extent
825 that the demand involves an insurer’s withdrawal of payment
826 under paragraph (7)(a) for future treatment not yet rendered,
827 the claimant shall attach a copy of the insurer’s notice
828 withdrawing such payment and an itemized statement of the type,
829 frequency, and duration of future treatment claimed to be
830 reasonable and medically necessary.
831 (c) Each notice required by this subsection must be
832 delivered to the insurer by United States certified or
833 registered mail, return receipt requested. Such postal costs
834 shall be reimbursed by the insurer if so requested by the
835 claimant in the notice, when the insurer pays the claim. Such
836 notice must be sent to the person and address specified by the
837 insurer for the purposes of receiving notices under this
838 subsection. Each licensed insurer, whether domestic, foreign, or
839 alien, shall file with the office designation of the name and
840 address of the person to whom notices must pursuant to this
841 subsection shall be sent which the office shall make available
842 on its Internet website. The name and address on file with the
843 office pursuant to s. 624.422 are shall be deemed the authorized
844 representative to accept notice pursuant to this subsection if
845 in the event no other designation has been made.
846 (d) If, within 30 days after receipt of notice by the
847 insurer, the overdue claim specified in the notice is paid by
848 the insurer together with applicable interest and a penalty of
849 10 percent of the overdue amount paid by the insurer, subject to
850 a maximum penalty of $250, no action may be brought against the
851 insurer. If the demand involves an insurer’s withdrawal of
852 payment under paragraph (7)(a) for future treatment not yet
853 rendered, no action may be brought against the insurer if,
854 within 30 days after its receipt of the notice, the insurer
855 mails to the person filing the notice a written statement of the
856 insurer’s agreement to pay for such treatment in accordance with
857 the notice and to pay a penalty of 10 percent, subject to a
858 maximum penalty of $250, when it pays for such future treatment
859 in accordance with the requirements of this section. To the
860 extent the insurer determines not to pay any amount demanded,
861 the penalty is shall not be payable in any subsequent action.
862 For purposes of this subsection, payment or the insurer’s
863 agreement shall be treated as being made on the date a draft or
864 other valid instrument that is equivalent to payment, or the
865 insurer’s written statement of agreement, is placed in the
866 United States mail in a properly addressed, postpaid envelope,
867 or if not so posted, on the date of delivery. The insurer is not
868 obligated to pay any attorney attorney’s fees if the insurer
869 pays the claim or mails its agreement to pay for future
870 treatment within the time prescribed by this subsection.
871 (e) The applicable statute of limitation for an action
872 under this section shall be tolled for a period of 30 business
873 days by the mailing of the notice required by this subsection.
874 (f) Any insurer making a general business practice of not
875 paying valid claims until receipt of the notice required by this
876 subsection is engaging in an unfair trade practice under the
877 insurance code.
878 (11) FAILURE TO PAY VALID CLAIMS; UNFAIR OR DECEPTIVE
879 PRACTICE.—
880 (a) If An insurer fails to pay valid claims for personal
881 injury protection with such frequency so as to indicate a
882 general business practice, the insurer is engaging in a
883 prohibited unfair or deceptive practice that is subject to the
884 penalties provided in s. 626.9521 and the office has the powers
885 and duties specified in ss. 626.9561-626.9601 if the insurer,
886 with such frequency so as to indicate a general business
887 practice: with respect thereto
888 1. Fails to pay valid claims for personal injury
889 protection; or
890 2. Fails to pay valid claims until receipt of the notice
891 required by subsection (10).
892 (b) Notwithstanding s. 501.212, the Department of Legal
893 Affairs may investigate and initiate actions for a violation of
894 this subsection, including, but not limited to, the powers and
895 duties specified in part II of chapter 501.
896 Section 8. Effective December 1, 2012, subsection (16) of
897 section 627.736, Florida Statutes, is amended to read:
898 627.736 Required personal injury protection benefits;
899 exclusions; priority; claims.—
900 (16) SECURE ELECTRONIC DATA TRANSFER.—If all parties
901 mutually and expressly agree, A notice, documentation,
902 transmission, or communication of any kind required or
903 authorized under ss. 627.730-627.7405 may be transmitted
904 electronically if it is transmitted by secure electronic data
905 transfer that is consistent with state and federal privacy and
906 security laws.
907
908 ================= T I T L E A M E N D M E N T ================
909 And the title is amended as follows:
910 Delete lines 45 - 81
911 and insert:
912 627.736, F.S.; revising the cap on benefits to provide
913 that death benefits are in addition to medical and
914 disability benefits; revising medical benefits;
915 distinguishing between initial and followup services;
916 excluding massage and acupuncture from medical
917 benefits that may be reimbursed under the Florida
918 Motor Vehicle No-Fault Law; adding physical therapists
919 to the list of providers that may provide services;
920 requiring that an insurer repay any benefits covered
921 by the Medicaid program; requiring that an insurer
922 provide a claimant an opportunity to revise claims
923 that contain errors; authorizing an insurer to provide
924 notice to the claimant and conduct an investigation if
925 fraud is suspected; requiring that an insurer create
926 and maintain a log of personal injury protection
927 benefits paid and that the insurer provide to the
928 insured or an assignee of the insured, upon request, a
929 copy of the log if litigation is commenced; revising
930 the Medicare fee schedules that an insurer may use as
931 a basis for limiting reimbursement of personal injury
932 protection benefits; providing that the Medicare fee
933 schedule in effect on a specific date applies for
934 purposes of limiting such reimbursement; authorizing
935 insurers to apply certain Medicare coding policies and
936 payment methodologies; requiring that an insurer that
937 limits payments based on the statutory fee schedule
938 include a notice in insurance policies at the time of
939 issuance or renewal; deleting obsolete provisions;
940 providing that certain entities exempt from licensure
941 as a clinic must nonetheless be licensed to receive
942 reimbursement for the provision of personal injury
943 protection benefits; providing exceptions; requiring
944 that an insurer notify parties in disputes over
945 personal injury protection claims when policy limits
946 are reached; consolidating provisions relating to
947 unfair or deceptive practices under certain
948 conditions; eliminating a requirement that all parties
949 mutually and expressly agree to the use of electronic
950 transmission of data; amending s. 817.234, F.S.;