CODING: Words stricken are deletions; words underlined are additions.House Bill 1005
Florida House of Representatives - 1997 HB 1005
By Representative Saunders
1 A bill to be entitled
2 An act relating to the Statewide Provider and
3 Subscriber Assistance Program; amending s.
4 408.7056, F.S.; providing definitions; revising
5 criteria and procedures for review of
6 grievances against a managed care entity by the
7 statewide provider and subscriber assistance
8 panel; providing for initial review by the
9 Agency for Health Care Administration;
10 providing time requirements for panel hearings
11 and recommendations, and final orders of the
12 agency or the Department of Insurance;
13 providing for notice; providing requirements
14 for expedited or emergency hearings; providing
15 an exemption from the Administrative Procedures
16 Act; providing for requests for patient
17 records; authorizing an administrative fine for
18 failure to timely provide records; providing
19 for furnishing of evidence in opposition to
20 panel recommendations; providing for adoption
21 of panel recommendations in final orders of the
22 agency or department; authorizing imposition of
23 fines and sanctions; specifying conditions for
24 rejection of panel recommendations; providing
25 for appeals; requiring certain notice to
26 subscribers and providers of their right to
27 file grievances; amending s. 641.511, F.S.;
28 correcting a cross reference; providing an
29 effective date.
30
31 Be It Enacted by the Legislature of the State of Florida:
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1 Section 1. Section 408.7056, Florida Statutes, 1996
2 Supplement, is amended to read:
3 408.7056 Statewide Provider and Subscriber Assistance
4 Program.--
5 (1) As used in this section, the term:
6 (a) "Managed care entity" means an accountable health
7 partnership certified under s. 408.706, a health maintenance
8 organization certified under chapter 641, a prepaid health
9 clinic, a prepaid health plan authorized pursuant to s.
10 409.912, or an exclusive provider organization certified under
11 s. 627.6472.
12 (b) "Panel" means a statewide provider and subscriber
13 assistance panel selected as provided in subsection (12).
14 (2)(1) The agency for Health Care Administration shall
15 adopt and implement a program to provide assistance to
16 subscribers and providers, including those whose grievances
17 are not resolved by the managed care entity accountable health
18 partnership, health maintenance organization, prepaid health
19 clinic, prepaid health plan authorized pursuant to s. 409.912,
20 or exclusive provider organization to the satisfaction of the
21 subscriber or provider. The program shall consist of a panel
22 which shall meet as often as necessary to timely review,
23 consider, and hear grievances and recommend to the agency or
24 the department any actions that should be taken concerning
25 individual cases heard by the panel. The panel shall hear
26 every grievance filed by subscribers and providers, unless the
27 grievance not consider grievances which:
28 (a) Relates to a managed care entity's Relate to an
29 accountable health partnership's, health maintenance
30 organization's, prepaid health clinic's, prepaid health
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1 plan's, or exclusive provider organization's refusal to accept
2 a provider into its network of providers;
3 (b) Is Are a part of a reconsideration appeal through
4 the Medicare appeals process that does not involve a quality
5 of care issue;
6 (c) Is Are related to a health plan not regulated by
7 the state such as an administrative services organization,
8 third-party administrator, or federal employee health benefit
9 program;
10 (d) Is Are related to appeals by in-plan suppliers and
11 providers, unless related to quality of care provided by the
12 plan; or
13 (e) Is Are part of a Medicaid fair hearing pursued
14 pursuant to 42 C.F.R. ss. 431.220 et seq.
15 (f) Is the basis for an action pending in state or
16 federal court;
17 (g) Is related to an appeal by nonparticipating
18 providers, unless related to the quality of care provided to a
19 subscriber by the managed care entity;
20 (h) Has been filed before the subscriber or provider
21 has completed the entire internal grievance procedure of the
22 managed care entity; provided the managed care entity has
23 complied with its timeframes for completing the internal
24 grievance procedure and the circumstances described in
25 subsection (6) do not apply;
26 (i) Has been resolved to the satisfaction of the
27 subscriber or provider who filed the grievance, unless the
28 managed care entity's initial action is egregious or may be
29 indicative of a pattern of inappropriate behavior;
30 (j) Is limited to seeking damages for pain and
31 suffering, lost wages, or other incidental expenses;
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1 (k) Is limited to issues involving conduct of a health
2 care provider or facility, staff member, or employee of a
3 managed care entity which constitutes grounds for disciplinary
4 action by the appropriate professional licensing board and is
5 not indicative of a pattern of inappropriate behavior, and the
6 agency or department has reported these grievances to the
7 appropriate professional licensing board or to the health
8 facility regulation section of the agency for possible
9 investigation; or
10 (l) Is withdrawn by the subscriber or provider.
11 Failure of the subscriber or the provider to attend the
12 hearing shall be considered a withdrawal of the grievance.
13 (3) The agency shall review all grievances within 60
14 days after receipt and make a determination whether the
15 grievance shall be heard. Once the agency notifies the panel,
16 the subscriber or provider, and the managed care entity that a
17 grievance will be heard by the panel, the panel shall hear the
18 grievance either in the network area or by teleconference no
19 later than 120 days after the date the grievance was filed.
20 The panel shall issue a recommendation to the provider or
21 subscriber, to the managed care entity, and to the agency or
22 the department no later than 15 working days after hearing the
23 grievance. If at the hearing the panel requests additional
24 documentation or additional records, the time for issuing a
25 recommendation shall be tolled until the information or
26 documentation requested has been provided to the panel. The
27 proceedings of the panel and the final order of the agency or
28 department shall not be subject to the provisions of chapter
29 120.
30 (4) If, upon receiving a proper patient authorization
31 along with a properly filed grievance, the agency requests
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1 medical records from a health care provider or managed care
2 entity, the health care provider or managed care entity in
3 custody of such records shall have 10 days to provide the
4 records to the agency. Failure to provide requested medical
5 records may result in the imposition of a fine of up to
6 $2,500. Each day that records are not produced shall be
7 considered a separate violation.
8 (5) Grievances that the agency determines pose an
9 immediate and serious threat to a subscriber's health shall be
10 given priority over other grievances. The panel may meet at
11 the call of the chair to hear such grievances as quickly as
12 possible but no later than 45 days after the date the
13 grievance is filed, unless the panel receives a waiver of the
14 time requirement from the subscriber. The panel shall issue a
15 recommendation to the department or the agency within 10 days
16 after hearing the expedited grievance.
17 (6) Where the agency determines that the life of a
18 subscriber is in imminent and emergent jeopardy, the chair of
19 the panel may convene an emergency hearing, within 24 hours
20 after notification to the managed care entity and to the
21 subscriber, to hear the grievance. The grievance shall be
22 heard notwithstanding that the subscriber has not completed
23 the internal grievance procedure of the managed care entity.
24 The panel shall, upon hearing the grievance, issue an
25 emergency recommendation to the managed care entity, to the
26 subscriber, and to the agency or the department for the
27 purpose of deferring the imminent and emergent jeopardy to the
28 subscriber's life. Within 24 hours after receipt of the
29 panel's emergency recommendation, the agency or department may
30 issue an emergency order to the managed care entity. The
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1 emergency order shall remain in force and effect until such
2 time as:
3 (a) The grievance has been resolved by the managed
4 care entity;
5 (b) Medical intervention is no longer necessary; or
6 (c) The panel has conducted a full hearing under
7 subsection (3) and issued a recommendation to the agency or
8 the department, and the agency or department has issued a
9 final order.
10 (7) After hearing a grievance, the panel shall make a
11 recommendation to the agency or the department which may
12 include specific actions the managed care entity must take to
13 comply with state laws or rules regulating managed care
14 entities.
15 (8) A managed care entity, subscriber, or provider
16 that is affected by a panel recommendation may within 10 days
17 after receipt of the panel's recommendation, or 72 hours after
18 receipt of a recommendation in an expedited grievance, furnish
19 to the agency or department written evidence in opposition to
20 the recommendation of the panel.
21 (9) No later than 30 days after the issuance of the
22 panel's recommendation and, for an expedited grievance, no
23 later than 10 days after the issuance of the panel's
24 recommendation, the agency or the department may adopt the
25 panel's recommendation in an order which it shall issue to the
26 managed care entity. The agency's or department's order may
27 impose fines or sanctions, including those contained in ss.
28 641.25 and 641.52. The agency or the department may reject
29 all or part of the panel's recommendation if the
30 recommendation:
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1 (a) Violates state or federal law, rules, or
2 regulations;
3 (b) Is inconsistent with previous agency or department
4 interpretations of state laws or rules regulating managed care
5 entities; or
6 (c) Is determined by the agency or department to be
7 unsupported by the facts.
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9 All fines collected pursuant to this subsection shall be
10 deposited into the Health Maintenance Organization Quality
11 Care Trust Fund.
12 (10) In determining any fine or sanction to be
13 imposed, the agency and the department may consider the
14 following factors:
15 (a) The severity of the noncompliance, including the
16 probability that death or serious harm to the health or safety
17 of the subscriber will result or has resulted, the severity of
18 the actual or potential harm, and the extent to which
19 provisions of chapter 641 were violated.
20 (b) Actions taken by the managed care entity to
21 resolve or remedy any quality of care grievance.
22 (c) Any previous incidents of noncompliance by the
23 managed care entity.
24 (d) Any other relevant factors the agency or
25 department deems appropriate in a particular grievance.
26 (11) Final orders issued by the agency or the
27 department under this section shall be appealable to the First
28 District Court of Appeal.
29 (2) The program shall include the following:
30 (a) A review panel which may periodically review,
31 consider, and recommend to the agency any actions the agency
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1 or the Department of Insurance should take concerning
2 individual cases heard by the panel, as well as the types of
3 grievances which have not been satisfactorily resolved after
4 subscribers or providers have followed the full grievance
5 procedures of the accountable health partnership, health
6 maintenance organization, prepaid health clinic, prepaid
7 health plan, or exclusive provider organization. The
8 proceedings of the grievance panel shall not be subject to the
9 provisions of chapter 120.
10 (12) The review panel shall consist of members
11 employed by the agency and members employed by the department
12 of Insurance, chosen by their respective agencies. The agency
13 may contract with a medical director and a primary care
14 physician who shall provide additional technical expertise to
15 the review panel. The medical director shall be selected from
16 a health maintenance organization with a current certificate
17 of authority to operate in Florida.
18 (b) A plan to disseminate information concerning the
19 program to the general public as widely as possible.
20 (13)(3) Every managed care entity accountable health
21 partnership, health maintenance organization, prepaid health
22 clinic, prepaid health plan authorized pursuant to s. 409.912,
23 or exclusive provider organization shall submit a quarterly
24 report to the agency and the department of Insurance listing
25 the number and the nature of all subscribers' and providers'
26 grievances which have not been resolved to the satisfaction of
27 the subscriber or provider after the subscriber or provider
28 follows the entire internal full grievance procedure of the
29 managed care entity organization. The agency shall notify all
30 subscribers and providers included in the quarterly reports of
31 their right to file an unresolved grievance with the panel.
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1 (4)(a) The Agency for Health Care Administration may
2 impose an administrative fine, after a formal investigation
3 has been conducted on the accountable health partnership's,
4 health maintenance organization's, prepaid health clinic's,
5 prepaid health plan's, or exclusive provider organization's
6 failure to comply with quality of health services standards
7 set forth in statute or rule. The Agency for Health Care
8 Administration may initiate such an investigation based on the
9 recommendations related to the quality of health services
10 received from the Statewide Provider and Subscriber Assistance
11 Panel pursuant to paragraph (2)(a). The fine shall not exceed
12 $2,500 per violation and in no event shall such fine exceed an
13 aggregate amount of $10,000 for noncompliance arising out of
14 the same action.
15 (b) In determining the amount to be levied for
16 noncompliance under paragraph (a), the following factors shall
17 be considered:
18 1. The severity of the noncompliance, including the
19 probability that death or serious harm to the health or safety
20 of the subscriber will result or has resulted, the severity of
21 actual or potential harm and the extent to which provisions of
22 this part were violated.
23 2. Actions taken by the accountable health
24 partnership, health maintenance organization, prepaid health
25 clinic, prepaid health plan, or exclusive provider
26 organization to resolve or remedy any quality of care
27 grievance.
28 3. Any previous incidences of noncompliance by the
29 accountable health partnership, health maintenance
30 organization, prepaid health clinic, prepaid health plan, or
31 exclusive provider organization.
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1 (c) All amounts collected pursuant to this subsection
2 shall be deposited into the Health Care Trust Fund.
3 (14)(5) Any information which would identify a
4 subscriber or the spouse, relative, or guardian of a
5 subscriber and which is contained in a report obtained by the
6 Department of Insurance pursuant to this section is
7 confidential and exempt from the provisions of s. 119.07(1)
8 and s. 24(a), Art. I of the State Constitution.
9 Section 2. Subsection (2) of section 641.511, Florida
10 Statutes, is amended to read:
11 641.511 Subscriber grievance reporting and resolution
12 requirements.--
13 (2) Each health maintenance organization shall send to
14 the department a copy of its annual and quarterly grievance
15 reports submitted to the Department of Insurance pursuant to
16 s. 408.7056(13)(2).
17 Section 3. This act shall take effect July 1, 1997.
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2 HOUSE SUMMARY
3
Revises criteria and procedures for review of grievances
4 against managed care entities under the Statewide
Provider and Subscriber Assistance Program. Provides for
5 review of grievances by the Agency for Health Care
Administration prior to referral to the statewide
6 subscriber and provider assistance panel. Expands the
list of circumstances under which a grievance will not be
7 heard. Specifies time requirements for panel hearings and
recommendations, and for final orders by the agency or
8 the Department of Insurance, including requirements for
expedited or emergency procedures. Provides certain
9 notification requirements. Exempts grievance proceedings
and final orders from the provisions of ch. 120, F.S.,
10 the Administrative Procedures Act. Authorizes the agency
to obtain patient medical records for grievance review,
11 and to impose a fine of up to $2,500 per day of violation
against an entity that fails to timely provide such
12 records. Provides for furnishing of evidence in
opposition to panel recommendations. Provides for
13 adoption of panel recommendations in final orders of the
agency or department. Authorizes impositions of fines and
14 sanctions. Provides conditions for rejection of panel
recommendations. Provides for appeal of final orders to
15 the First District Court of Appeal. Requires the agency
and department to notify certain subscribers and
16 providers of their right to file a grievance.
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