House Bill 1475
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Florida House of Representatives - 2000 HB 1475
By Representative Gay
1 A bill to be entitled
2 An act relating to payment of health insurance
3 claims; amending s. 408.7056, F.S.; requiring
4 the Agency for Health Care Administration to
5 review certain grievances; providing procedural
6 requirements; requiring notice; providing for a
7 panel to hear certain grievances; specifying
8 membership; providing for payment of interest
9 on unpaid portions of certain claims; amending
10 s. 641.3155, F.S.; providing a definition;
11 providing procedures and requirements for
12 health maintenance organizations to contest
13 certain claims; providing for payment of triple
14 the amount of certain claims under certain
15 circumstances; providing entitlement to certain
16 grievance review procedures under certain
17 circumstances; amending s. 641.511, F.S.;
18 correcting a cross reference, to conform;
19 providing an effective date.
20
21 Be It Enacted by the Legislature of the State of Florida:
22
23 Section 1. Section 408.7056, Florida Statutes, is
24 amended to read:
25 408.7056 Statewide Provider and Subscriber Assistance
26 Program.--
27 (1) As used in this section, the term:
28 (a) "Managed care entity" means a health maintenance
29 organization or a prepaid health clinic certified under
30 chapter 641, a prepaid health plan authorized under s.
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1 409.912, or an exclusive provider organization certified under
2 s. 627.6472.
3 (b) "Panel" means a statewide provider and subscriber
4 assistance panel selected as provided in subsections (12) and
5 (13) subsection (11).
6 (2) The agency shall adopt and implement a program to
7 provide assistance to subscribers and providers, including
8 those whose grievances are not resolved by the managed care
9 entity to the satisfaction of the subscriber or provider. The
10 program shall consist of one or more panels that meet as often
11 as necessary to timely review, consider, and hear grievances
12 and recommend to the agency or the department any actions that
13 should be taken concerning individual cases heard by the
14 panel. The panel shall hear every grievance filed by
15 subscribers and providers on behalf of subscribers, unless the
16 grievance:
17 (a) Relates to a managed care entity's refusal to
18 accept a provider into its network of providers;
19 (b) Is part of an internal grievance in a Medicare
20 managed care entity or a reconsideration appeal through the
21 Medicare appeals process which does not involve a quality of
22 care issue;
23 (c) Is related to a health plan not regulated by the
24 state such as an administrative services organization,
25 third-party administrator, or federal employee health benefit
26 program;
27 (d) Is related to appeals by in-plan suppliers and
28 providers, unless related to quality of care provided by the
29 plan or to the payment of claims submitted to the organization
30 by the providers;
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1 (e) Is part of a Medicaid fair hearing pursued under
2 42 C.F.R. ss. 431.220 et seq.;
3 (f) Is the basis for an action pending in state or
4 federal court;
5 (g) Is related to an appeal by nonparticipating
6 providers, unless related to the quality of care provided to a
7 subscriber by the managed care entity and the provider is
8 involved in the care provided to the subscriber or to the
9 payment of claims submitted to the organization by the
10 provider;
11 (h) Was filed before the subscriber or provider
12 completed the entire internal grievance procedure of the
13 managed care entity, the managed care entity has complied with
14 its timeframes for completing the internal grievance
15 procedure, and the circumstances described in subsection (7)
16 (6) do not apply;
17 (i) Has been resolved to the satisfaction of the
18 subscriber or provider who filed the grievance, unless the
19 managed care entity's initial action is egregious or may be
20 indicative of a pattern of inappropriate behavior;
21 (j) Is limited to seeking damages for pain and
22 suffering, lost wages, or other incidental expenses, including
23 accrued interest on unpaid balances, court costs, and
24 transportation costs associated with a grievance procedure;
25 (k) Is limited to issues involving conduct of a health
26 care provider or facility, staff member, or employee of a
27 managed care entity which constitute grounds for disciplinary
28 action by the appropriate professional licensing board and is
29 not indicative of a pattern of inappropriate behavior, and the
30 agency or department has reported these grievances to the
31 appropriate professional licensing board or to the health
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1 facility regulation section of the agency for possible
2 investigation; or
3 (l) Is withdrawn by the subscriber or provider.
4 Failure of the subscriber or the provider to attend the
5 hearing shall be considered a withdrawal of the grievance.
6 (3) Except for grievances that are filed by providers
7 relating to the payment of claims by a health maintenance
8 organization, the agency shall review all grievances within 30
9 60 days after receipt and make a determination whether the
10 grievance shall be heard. Once the agency notifies the panel,
11 the subscriber or provider, and the managed care entity that a
12 grievance will be heard by the panel, the panel shall hear the
13 grievance either in the network area or by teleconference no
14 later than 90 120 days after the date the grievance was filed
15 unless waived by all the parties. The agency shall notify the
16 parties, in writing, by facsimile transmission, or by phone,
17 of the time and place of the hearing. The panel may take
18 testimony under oath, request certified copies of documents,
19 and take similar actions to collect information and
20 documentation that will assist the panel in making findings of
21 fact and a recommendation. The panel shall issue a written
22 recommendation, supported by findings of fact, to the provider
23 or subscriber, to the managed care entity, and to the agency
24 or the department no later than 15 working days after hearing
25 the grievance. If, at the hearing, the panel requests
26 additional documentation or additional records, the time for
27 issuing a recommendation is tolled until the information or
28 documentation requested has been provided to the panel. The
29 proceedings of the panel are not subject to chapter 120.
30 (4) The agency shall review all grievances filed by
31 providers against an organization that allege the organization
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1 violated s. 641.3155 within 30 days after receiving such
2 grievances and make a determination as to whether the
3 grievance shall be heard. After the agency notifies the panel
4 created under subsection (13), the provider, and the managed
5 care entity that the panel will hear the grievance, the panel
6 shall hear the grievance in the network area or by
7 teleconference no later than 90 days after the date the
8 grievance was filed, unless waived by both the provider and
9 the managed care entity. The agency shall notify the parties
10 in writing, by facsimile transmission, or by telephone, of the
11 time and place of the hearing. The panel may take testimony
12 under oath, request certified copies of documents, and take
13 similar actions to collect information and documentation that
14 will assist the panel in making findings of fact and a
15 recommendation. The panel shall issue a written
16 recommendation, supported by findings of fact, to the
17 provider, to the managed care entity, and to the agency or the
18 department no later than 15 working days after hearing the
19 grievance. If, at the hearing, the panel requests additional
20 documentation or additional records, the time for issuing a
21 recommendation is tolled until the requested information or
22 documentation has been provided to the panel. The proceedings
23 of the panel are not subject to chapter 120.
24 (5)(4) If, upon receiving a proper patient
25 authorization along with a properly filed grievance, the
26 agency requests medical records from a health care provider or
27 managed care entity, the health care provider or managed care
28 entity that has custody of the records has 10 days to provide
29 the records to the agency. Failure to provide requested
30 medical records may result in the imposition of a fine of up
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1 to $500. Each day that records are not produced is considered
2 a separate violation.
3 (6)(5) Grievances considered under subsection (3)
4 which that the agency determines pose an immediate and serious
5 threat to a subscriber's health must be given priority over
6 other grievances. The panel may meet at the call of the chair
7 to hear the grievances as quickly as possible but no later
8 than 45 days after the date the grievance is filed, unless the
9 panel receives a waiver of the time requirement from the
10 subscriber. The panel shall issue a written recommendation,
11 supported by findings of fact, to the department or the agency
12 within 10 days after hearing the expedited grievance.
13 (7)(6) When the agency determines that the life of a
14 subscriber is in imminent and emergent jeopardy, the chair of
15 the panel may convene an emergency hearing, within 24 hours
16 after notification to the managed care entity and to the
17 subscriber, to hear the grievance. The grievance must be
18 heard notwithstanding that the subscriber has not completed
19 the internal grievance procedure of the managed care entity.
20 The panel shall, upon hearing the grievance, issue a written
21 emergency recommendation, supported by findings of fact, to
22 the managed care entity, to the subscriber, and to the agency
23 or the department for the purpose of deferring the imminent
24 and emergent jeopardy to the subscriber's life. Within 24
25 hours after receipt of the panel's emergency recommendation,
26 the agency or department may issue an emergency order to the
27 managed care entity. An emergency order remains in force
28 until:
29 (a) The grievance has been resolved by the managed
30 care entity;
31 (b) Medical intervention is no longer necessary; or
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1 (c) The panel has conducted a full hearing under
2 subsection (3) and issued a recommendation to the agency or
3 the department, and the agency or department has issued a
4 final order.
5 (8)(7) After hearing a grievance, the panel shall make
6 a recommendation to the agency or the department which may
7 include specific actions the managed care entity must take to
8 comply with state laws or rules regulating managed care
9 entities.
10 (9)(8) A managed care entity, subscriber, or provider
11 that is affected by a panel recommendation may within 10 days
12 after receipt of the panel's recommendation, or 72 hours after
13 receipt of a recommendation in an expedited grievance, furnish
14 to the agency or department written evidence in opposition to
15 the recommendation or findings of fact of the panel.
16 (10)(9) No later than 30 days after the issuance of
17 the panel's recommendation and, for an expedited grievance or
18 a grievance conducted pursuant to subsection (4), no later
19 than 10 days after the issuance of the panel's recommendation,
20 the agency or the department may adopt the panel's
21 recommendation or findings of fact in a proposed order or an
22 emergency order, as provided in chapter 120, which it shall
23 issue to the managed care entity. The agency or department
24 may issue a proposed order or an emergency order, as provided
25 in chapter 120, imposing fines or sanctions, including those
26 contained in ss. 641.25 and 641.52, and, for hearings
27 conducted pursuant to subsection (4), requiring payment of the
28 unpaid portion of any claim not paid by the organization,
29 which shall bear a simple interest rate of 10 percent from the
30 date the provider filed the grievance under this section. The
31 agency or the department may modify reject all or part of the
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1 panel's recommendation as provided in s. 120.57. All fines
2 collected under this subsection must be deposited into the
3 Health Care Trust Fund.
4 (11)(10) In determining any fine or sanction to be
5 imposed, the agency and the department may consider the
6 following factors:
7 (a) The severity of the noncompliance, including the
8 probability that death or serious harm to the health or safety
9 of the subscriber will result or has resulted, the severity of
10 the actual or potential harm, and the extent to which
11 provisions of chapter 641 were violated.
12 (b) Actions taken by the managed care entity to
13 resolve or remedy any quality-of-care grievance.
14 (c) Any previous incidents of noncompliance by the
15 managed care entity.
16 (d) Any other relevant factors the agency or
17 department considers appropriate in a particular grievance.
18 (12)(11) Except for the panel created pursuant to
19 subsection (13), the panel shall consist of members employed
20 by the agency and members employed by the department, chosen
21 by their respective agencies; a consumer appointed by the
22 Governor; a physician appointed by the Governor, as a standing
23 member; and physicians who have expertise relevant to the case
24 to be heard, on a rotating basis. The agency may contract with
25 a medical director and a primary care physician who shall
26 provide additional technical expertise to the panel. The
27 medical director shall be selected from a health maintenance
28 organization with a current certificate of authority to
29 operate in Florida.
30 (13) The panel created to hear grievances filed by
31 providers pursuant to subsection (4) shall be composed of five
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1 members, consisting of a medical director of an organization
2 that holds a current certificate of authority to operate in
3 this state, a physician licensed under chapter 458 or chapter
4 459, a member who represents a hospital, a member employed by
5 the agency, and a member employed by the department. The
6 Governor shall appoint the three members of the panel who are
7 not employed by the agency or the department. The remaining
8 two members of the panel shall be chosen by mutual agreement
9 of the agency and the department. Each member of the panel
10 shall be proficient in coding methodology.
11 (14)(12) Every managed care entity shall submit a
12 quarterly report to the agency and the department listing the
13 number and the nature of all subscribers' and providers'
14 grievances which have not been resolved to the satisfaction of
15 the subscriber or provider after the subscriber or provider
16 follows the entire internal grievance procedure of the managed
17 care entity. The agency shall notify all subscribers and
18 providers included in the quarterly reports of their right to
19 file an unresolved grievance with the panel.
20 (15)(13) Any information which would identify a
21 subscriber or the spouse, relative, or guardian of a
22 subscriber and which is contained in a report obtained by the
23 Department of Insurance pursuant to this section is
24 confidential and exempt from the provisions of s. 119.07(1)
25 and s. 24(a), Art. I of the State Constitution.
26 (16)(14) A proposed order issued by the agency or
27 department which only requires the managed care entity to take
28 a specific action under subsection (8) (7) is subject to a
29 summary hearing in accordance with s. 120.574, unless all of
30 the parties agree otherwise. If the managed care entity does
31 not prevail at the hearing, the managed care entity must pay
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1 reasonable costs and attorney's fees of the agency or the
2 department incurred in that proceeding.
3 (17)(15)(a) Any information which would identify a
4 subscriber or the spouse, relative, or guardian of a
5 subscriber which is contained in a document, report, or record
6 prepared or reviewed by the panel or obtained by the agency
7 pursuant to this section is confidential and exempt from the
8 provisions of s. 119.07(1) and s. 24(a), Art. I of the State
9 Constitution.
10 (b) Meetings of the panel shall be open to the public
11 unless the provider or subscriber whose grievance will be
12 heard requests a closed meeting or the agency or the
13 Department of Insurance determines that information of a
14 sensitive personal nature which discloses the subscriber's
15 medical treatment or history; or information which constitutes
16 a trade secret as defined by s. 812.081; or information
17 relating to internal risk management programs as defined in s.
18 641.55(5)(c), (6), and (8) may be revealed at the panel
19 meeting, in which case that portion of the meeting during
20 which such sensitive personal information, trade secret
21 information, or internal risk management program information
22 is discussed shall be exempt from the provisions of s. 286.011
23 and s. 24(b), Art. I of the State Constitution. All closed
24 meetings shall be recorded by a certified court reporter.
25
26 This subsection is subject to the Open Government Sunset
27 Review Act of 1995 in accordance with s. 119.15, and shall
28 stand repealed on October 2, 2003, unless reviewed and saved
29 from repeal through reenactment by the Legislature.
30 Section 2. Section 641.3155, Florida Statutes, is
31 amended to read:
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1 641.3155 Provider contracts; payment of claims.--
2 (1) For purposes of this section, the term "clean
3 claim" means a completed claim, as determined under department
4 rules adopted under chapter 120, submitted by a physician on
5 an HCFA 1500 claim form or by other providers on a UB-92 claim
6 form, for medical care or health care services under a health
7 care plan.
8 (2)(1)(a) A health maintenance organization shall pay
9 any clean claim or any portion of a clean claim made by a
10 contract provider for services or goods provided under a
11 contract with the health maintenance organization, or a
12 provider of emergency services and care pursuant to s.
13 641.513, which the organization does not contest or deny
14 within 35 days after receipt of the clean claim by the health
15 maintenance organization which is mailed or electronically
16 transferred by the provider.
17 (b) A health maintenance organization that denies or
18 contests a provider's clean claim or any portion of a clean
19 claim shall notify the contract provider, in writing, within
20 35 days after receipt of the claim by the health maintenance
21 organization that the claim is contested or denied. The notice
22 that the claim is denied or contested must identify the
23 contested portion of the claim and the specific reason for
24 contesting or denying the claim, and shall may include a
25 request for additional information. If the provider submits
26 health maintenance organization requests additional
27 information, the provider shall, within 35 days after receipt
28 of such notice request, mail or electronically transfer the
29 information to the health maintenance organization. The
30 provider may charge the organization the reasonable costs of
31 copying and providing the additional information, including
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1 the cost of reasonable staff time, as provided in ss. 395.3025
2 and 455.667. The health maintenance organization shall pay or
3 deny the claim or portion of the claim within 30 45 days after
4 receipt of the information.
5 (3) In order for a health maintenance organization to
6 contest a portion of a clean claim, the health maintenance
7 organization must pay to the provider the uncontested portion
8 of the claim. The failure to pay the uncontested portion of a
9 claim constitutes a complete waiver of the health maintenance
10 organization's right to deny any part of the claim. If the
11 health maintenance organization unreasonably denies the entire
12 claim for the purpose of delaying payment of the uncontested
13 portion of the claim, the organization must pay to the
14 provider three times the amount of the claim which was
15 unreasonably contested.
16 (4)(2) Payment of a claim is considered made on the
17 date the payment was received or electronically transferred or
18 otherwise delivered. An overdue payment of a claim bears
19 simple interest at the rate of 10 percent per year.
20 (5) Failure to pay the amount of the undisputed clean
21 claim to a provider within 35 days after receipt of the claim
22 entitles the provider to the procedures set forth in s.
23 408.7056(4).
24 (6)(3) A health maintenance organization shall pay or
25 deny any clean claim no later than 90 120 days after receiving
26 the original claim. The failure of a health maintenance
27 organization to pay any disputed clean claim or portion of a
28 clean claim within such period entitles the provider to the
29 procedures specified in s. 408.7056(4).
30 (7)(4) Any retroactive reductions of payments or
31 demands for refund of previous overpayments which are due to
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1 retroactive review-of-coverage decisions or payment levels
2 must be reconciled to specific claims unless the parties agree
3 to other reconciliation methods and terms. Any retroactive
4 demands by providers for payment due to underpayments or
5 nonpayments for covered services must be reconciled to
6 specific claims unless the parties agree to other
7 reconciliation methods and terms. The look-back period may be
8 specified by the terms of the contract.
9 Section 3. Subsection (7) of section 641.511, Florida
10 Statutes, is amended to read:
11 641.511 Subscriber grievance reporting and resolution
12 requirements.--
13 (7) Each organization shall send to the agency a copy
14 of its quarterly grievance reports submitted to the Department
15 of Insurance pursuant to s. 408.7056(14)(12).
16 Section 4. This act shall take effect July 1, 2000,
17 and shall apply to all claims submitted by a provider to a
18 health maintenance organization on or after such date.
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21 HOUSE SUMMARY
22
Provides procedures that a health maintenance
23 organization must follow in contesting certain claims
made by providers. Provides penalties for failure to pay
24 part or all of a "clean claim," as that term is defined
in the bill. Provides for the Agency for Health Care
25 Administration to review all provider grievances alleging
that a health maintenance organization has violated s.
26 641.3155, F.S. Provides for the appointment of a review
panel and specifies panel membership. Provides
27 applicability.
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