The Florida Senate

395.0199  Private utilization review.--

(1)  The purpose of this section is to:

(a)  Promote the delivery of quality health care in a cost-effective manner.

(b)  Foster greater coordination between providers and health insurers performing utilization review.

(c)  Protect patients and insurance providers by ensuring that private review agents are qualified to perform utilization review activities and to make informed decisions on the appropriateness of medical care.

(d)  This section does not regulate the activities of private review agents, health insurers, health maintenance organizations, or hospitals, except as expressly provided herein, or authorize regulation or intervention as to the correctness of utilization review decisions of insurers or private review agents.

(2)  The requirements of part II of chapter 408 apply to the provision of services that require registration or licensure pursuant to this section and part II of chapter 408 and to persons registered by or applying for such registration from the Agency for Health Care Administration pursuant to this section. Registration or a license issued by the agency is required in order to perform as a private review agent conducting utilization review as to health care services in this state.

(3)  In accordance with s. 408.805, an applicant for registration or the registrant shall pay a fee for each registration application submitted under this section, part II of chapter 408, and applicable rules. The amount of the fee shall be established by rule and shall be sufficient to pay for the administrative costs of registering the agent, but may not exceed $500.

(4)  In addition to the requirements of part II of chapter 408, registration shall include the following:

(a)  A description of the review policies and procedures to be used in evaluating proposed or delivered hospital care.

(b)  The name, address, and telephone number of the utilization review agent performing utilization review, who shall be at least:

1.  A licensed practical nurse or licensed registered nurse, or other similarly qualified medical records or health care professionals, for performing initial review when information is necessary from the physician or hospital to determine the medical necessity or appropriateness of hospital services; or

2.  A licensed physician, or a licensed physician practicing in the field of psychiatry for review of mental health services, for an initial denial determination prior to a final denial determination by the health insurer and which shall include the written evaluation and findings of the reviewing physician.

(c)  A description of an appeal procedure for patients or health care providers whose services are under review, who may appeal an initial denial determination prior to a final determination by the health insurer with whom the private review agent has contracted. The appeal procedure shall provide for review by a licensed physician, or by a licensed physician practicing in the field of psychiatry for review of mental health services, and shall include the written evaluation and findings of the reviewing physician.

(d)  A designation of the times when the staff of the utilization review agent will be available by toll-free telephone, which shall include at least 40 hours per week during the normal business hours of the agent.

(e)  An acknowledgment and agreement that any private review agent which, as a general business practice, fails to adhere to the policies, procedures, and representations made in its application for registration shall have its registration revoked.

(f)  Disclosure of any incentive payment provision or quota provision which is contained in the agent's contract with a health insurer and is based on reduction or denial of services, reduction of length of stay, or selection of treatment setting.

(g)  Updates of any material changes to review policies or procedures.

(5)  No insurer shall knowingly contract with or utilize a private review agent which has failed to register as required by this section or which has had a registration revoked by the agency.

(6)  A private review agent which operates under contract with the federal or state government for utilization review of patients eligible for hospital or other services under Title XVIII or Title XIX of the Social Security Act is exempt from the provisions of this section for services provided under such contract. A private review agent which provides utilization review services to the federal or state government and a private insurer shall not be exempt for services provided to nonfederally funded patients. This section shall not apply to persons who perform utilization review services for medically necessary hospital services provided to injured workers pursuant to chapter 440 and shall not apply to self-insurance funds or service companies authorized pursuant to chapter 440 or part VII of chapter 626.

(7)  Facilities licensed under this chapter shall promptly comply with the requests of utilization review agents or insurers which are reasonably necessary to facilitate prompt accomplishment of utilization review activities.

(8)  The agency shall adopt rules to implement the provisions of this section.

History.--s. 1, ch. 90-187; s. 184, ch. 91-108; s. 6, ch. 91-201; ss. 17, 98, ch. 92-289; ss. 39, 71, ch. 98-171; s. 67, ch. 2000-349; s. 25, ch. 2001-53; s. 2, ch. 2001-67; s. 148, ch. 2001-277; s. 44, ch. 2004-267; s. 45, ch. 2007-230.

Note.--Former s. 395.0172.