Florida Senate - 2013 SB 1692
By Senator Gibson
9-01049A-13 20131692__
1 A bill to be entitled
2 An act relating to health care coverage; amending ss.
3 627.6471 and 627.6472, F.S.; providing reimbursement
4 rates applicable to payments by insurers for covered
5 health care services provided in a hospital by
6 physicians who are not members of a preferred provider
7 network or exclusive provider network; providing
8 requirements and limitations with respect to the
9 collection of fees or payments for such services;
10 defining the term “hospital-based physician” or
11 “physician”; requiring an insurer to report certain
12 violations to the Department of Health; amending s.
13 641.31, F.S.; providing applicability; amending s.
14 641.513, F.S.; providing reimbursement rates
15 applicable to payments by health maintenance
16 organizations for covered health care services
17 provided in a hospital setting by physicians who do
18 not have a contract with the health maintenance
19 organization; providing requirements and limitations
20 with respect to the collection of fees or payments for
21 such services; defining the term “hospital-based
22 physician” or “physician”; requiring a health
23 maintenance organization to report certain violations
24 to the Department of Health; providing an effective
25 date.
26
27 Be It Enacted by the Legislature of the State of Florida:
28
29 Section 1. Subsection (7) is added to section 627.6471,
30 Florida Statutes, to read:
31 627.6471 Contracts for reduced rates of payment;
32 limitations; coinsurance and deductibles.—
33 (7) When a hospital is a member of an insurer’s preferred
34 provider network, and the hospital-based physicians that provide
35 covered services at that hospital are not members of the
36 insurer’s preferred provider network, the following apply:
37 (a) Reimbursement by the insurer for covered services
38 rendered to covered persons by the physician shall be the same
39 as the percentage rate that is paid to preferred providers, and
40 that reimbursement rate must be applied to the lesser of the
41 following amounts:
42 1. The physician’s charges;
43 2. The usual and customary amount accepted by physicians
44 for similar services in the community where the services were
45 provided; or
46 3. The amount mutually agreed to by the physician and the
47 insurer.
48 (b) If the insurer is liable for services rendered by the
49 hospital-based physician, the insurer is liable for payment of
50 the fees to the physician, and the covered persons are not
51 liable for payment of fees to the physician, except for co
52 insurance or other cost sharing applicable pursuant to the
53 covered persons insurance contract. A physician or any
54 representative of the physician may not collect or attempt to
55 collect money from, maintain any action at law against, or
56 report to a credit agency a covered person for payment of
57 services for which the insurer is liable, if the physician in
58 good faith knows or should know that the insurer is liable. This
59 prohibition applies during the pendency of any claim for payment
60 made by the physician to the insurer for payment of the services
61 and any legal proceedings or dispute resolution process to
62 determine whether the insurer is liable for the services if the
63 physician is informed that such proceedings are taking place. It
64 is presumed that a physician does not know and should not know
65 that the insurer is liable unless:
66 1. The physician is informed by the insurer that it accepts
67 liability;
68 2. A court of competent jurisdiction determines that the
69 insurer is liable; or
70 3. The office makes a final determination that the insurer
71 is required to pay for such services.
72 (c) For purposes of this subsection, the term “hospital
73 based physician” or “physician” means any physician, including,
74 but not limited to, radiologists, anesthesiologists,
75 pathologists, emergency room physicians, or group of physicians,
76 that have entered into a contract with a hospital that:
77 1. Allows a physician to provide medical services for
78 inpatient and outpatient treatment through the hospital without
79 being specifically chosen by the patient;
80 2. Precludes similar-specialty physicians from providing
81 medical treatment for inpatient and outpatient treatment through
82 the hospital; or
83 3. Fosters the opportunity for a physician to provide
84 medical services for inpatient and outpatient treatment through
85 the hospital.
86 (d) The insurer shall report any suspected violation of
87 this subsection to the Department of Health, which shall take
88 appropriate action as authorized by law.
89 Section 2. Subsection (19) is added to section 627.6472,
90 Florida Statutes, to read:
91 627.6472 Exclusive provider organizations.—
92 (19) When a hospital is a member of an insurer’s exclusive
93 provider network, and the hospital-based physicians that provide
94 covered services at that hospital are not members of the
95 insurer’s exclusive provider network, the following apply:
96 (a) Reimbursement by the insurer for covered services
97 rendered to covered persons by the physician shall be the same
98 as the percentage rate that is paid to exclusive providers, and
99 that reimbursement rate must be applied to the lesser of the
100 following amounts:
101 1. The physician’s charges;
102 2. The usual and customary amount accepted by physicians
103 for similar services in the community where the services were
104 provided; or
105 3. The amount mutually agreed to by the physician and the
106 insurer.
107 (b) If the insurer is liable for services rendered by the
108 hospital-based physician, the insurer is liable for payment of
109 the fees to the physician, and the covered persons are not
110 liable for payment of fees to the physician, except for co
111 insurance or other cost sharing applicable pursuant to the
112 covered persons insurance contract. A physician or any
113 representative of the physician may not collect or attempt to
114 collect money from, maintain any action at law against, or
115 report to a credit agency a covered person for payment of
116 services for which the insurer is liable, if the physician in
117 good faith knows or should know that the insurer is liable. This
118 prohibition applies during the pendency of any claim for payment
119 made by the physician to the insurer for payment of the services
120 and any legal proceedings or dispute resolution process to
121 determine whether the insurer is liable for the services if the
122 physician is informed that such proceedings are taking place. It
123 is presumed that a physician does not know and should not know
124 that the insurer is liable unless:
125 1. The physician is informed by the insurer that it accepts
126 liability;
127 2. A court of competent jurisdiction determines that the
128 insurer is liable; or
129 3. The office makes a final determination that the insurer
130 is required to pay for such services.
131 (c) For purposes of this subsection, the term “hospital
132 based physician” or “physician” means any physician, including,
133 but not limited to, radiologists, anesthesiologists,
134 pathologists, emergency room physicians, or group of physicians,
135 that have entered into a contract with a hospital that:
136 1. Allows a physician to provide medical services for
137 inpatient and outpatient treatment through the hospital without
138 being specifically chosen by the patient;
139 2. Precludes similar-specialty physicians from providing
140 medical treatment for inpatient and outpatient treatment through
141 the hospital; or
142 3. Fosters the opportunity for a physician to provide
143 medical services for inpatient and outpatient treatment through
144 the hospital.
145 (d) The insurer shall report any suspected violation of
146 this subsection to the Department of Health, which shall take
147 appropriate action as authorized by law.
148 Section 3. Paragraph (d) of subsection (38) of section
149 641.31, Florida Statutes, is amended to read:
150 641.31 Health maintenance contracts.—
151 (38)
152 (d) Notwithstanding the limitations of deductibles and
153 copayment provisions in this part, a point-of-service rider may
154 require the subscriber to pay a reasonable copayment for each
155 visit for services provided by a noncontracted provider chosen
156 at the time of the service. The copayment by the subscriber may
157 either be a specific dollar amount or a percentage of the
158 reimbursable provider charges covered by the contract and must
159 be paid by the subscriber to the noncontracted provider upon
160 receipt of covered services. The point-of-service rider may
161 require that a reasonable annual deductible for the expenses
162 associated with the point-of-service rider be met and may
163 include a lifetime maximum benefit amount. The rider must
164 include the language required by s. 627.6044 and must comply
165 with copayment limits described in s. 627.6471. Section 641.3154
166 does not apply to a point-of-service rider authorized under this
167 subsection, unless the health care services are rendered in an
168 emergency setting or in a hospital or by hospital-based
169 physicians as described in s. 641.513.
170 Section 4. Subsection (5) of section 641.513, Florida
171 Statutes, is amended to read:
172 641.513 Requirements for providing emergency services and
173 care.—
174 (5)(a) Reimbursement for services pursuant to this section
175 by a provider, including those services rendered in an emergency
176 setting in a hospital or by a hospital-based physician, who does
177 not have a contract with the health maintenance organization
178 shall be the lesser of:
179 1.(a) The provider’s charges;
180 2.(b) The usual and customary provider charges for similar
181 services in the community where the services were provided; or
182 3.(c) The charge mutually agreed to by the health
183 maintenance organization and the provider within 60 days of the
184 submittal of the claim.
185 (b) If the health maintenance organization is liable for
186 services rendered by the hospital-based physician, the health
187 maintenance organization is liable for payment of the fees to
188 the physician, and the subscriber is not liable for payment of
189 fees to the physician, except for copayment or other cost
190 sharing applicable pursuant to the subscriber’s health
191 maintenance organization contract. A physician or any
192 representative of the physician may not collect or attempt to
193 collect money from, maintain any action at law against, or
194 report to a credit agency a subscriber for payment of services
195 for which the health maintenance organization is liable, if the
196 physician in good faith knows or should know that the health
197 maintenance organization is liable. This prohibition applies
198 during the pendency of any claim for payment made by the
199 physician to the health maintenance organization for payment of
200 the services and any legal proceedings or dispute resolution
201 process to determine whether the health maintenance organization
202 is liable for the services if the physician is informed that
203 such proceedings are taking place. It is presumed that a
204 physician does not know and should not know that the health
205 maintenance organization is liable unless:
206 1. The physician is informed by the health maintenance
207 organization that it accepts liability;
208 2. A court of competent jurisdiction determines that the
209 health maintenance organization is liable; or
210 3. The office makes a final determination that the health
211 maintenance organization is required to pay for such services.
212 (c) For purposes of this subsection, the term “hospital
213 based physician” or “physician” means any physician, including,
214 but not limited to, radiologists, anesthesiologists,
215 pathologists, emergency room physicians, or group of physicians,
216 that have entered into a contract with a hospital that:
217 1. Allows a physician to provide medical services for
218 inpatient and outpatient treatment through the hospital without
219 being specifically chosen by the patient;
220 2. Precludes similar-specialty physicians from providing
221 medical treatment for inpatient and outpatient treatment through
222 the hospital; or
223 3. Fosters the opportunity for a physician to provide
224 medical services for inpatient and outpatient treatment through
225 the hospital.
226 (d) The health maintenance organization shall report any
227 suspected violation of this subsection to the Department of
228 Health, which shall take appropriate action as authorized by
229 law.
230
231 Such reimbursement shall be net of any applicable copayment
232 authorized pursuant to subsection (4).
233 Section 5. This act shall take effect July 1, 2013.