Senate Bill 1508c1
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Florida Senate - 2000 CS for SB 1508
By the Committee on Banking and Insurance; and Senator
Brown-Waite
311-1933-00
1 A bill to be entitled
2 An act relating to health maintenance
3 organizations; amending s. 641.315, F.S.;
4 revising provisions relating to provider
5 billing; amending s. 641.3155, F.S.; defining
6 the term "clean claim"; providing timeframes
7 for interest payment on late and overdue claim
8 payments; providing a schedule for electronic
9 billing; mandating acknowledgment of receipts
10 for electronically submitted claims; specifying
11 timeframes for duplicate billing; creating s.
12 641.3156, F.S.; providing for treatment
13 authorization and payment of claims; amending
14 s. 641.495, F.S.; revising provisions relating
15 to treatment authorization capabilities;
16 creating s. 408.7057, F.S.; providing for the
17 establishment of a statewide provider and
18 managed-care-organization claim-dispute
19 mediation panel; granting rulemaking authority
20 to the Agency for Health Care Administration;
21 providing an effective date.
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23 Be It Enacted by the Legislature of the State of Florida:
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25 Section 1. Section 641.315, Florida Statutes, is
26 amended to read:
27 641.315 Provider billing contracts.--
28 (1) If Whenever a contract exists between a health
29 maintenance organization and a provider and the organization
30 fails to meet its obligations to pay fees for services already
31 rendered to a subscriber, the health maintenance organization
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1 is shall be liable for such fee or fees rather than the
2 subscriber; and the contract must shall so state.
3 (2) A No subscriber of an HMO is not shall be liable
4 to any provider of health care services for any services
5 covered by the HMO.
6 (3) A No provider of services, whether contracted or
7 noncontracted, or any representative of such provider may not
8 shall collect or attempt to collect from an HMO subscriber any
9 money for services covered by an HMO, and a no provider or
10 representative of the such provider may not maintain any
11 action at law against a subscriber of an HMO to collect money
12 owed to the such provider by an HMO. The provider may not bill
13 the subscriber during any ongoing dispute-resolution process.
14 The responsibility for claims payment to providers rests with
15 the HMO/MCO and not with any party to which the HMO/MCO has
16 delegated the functions of claims or management claims
17 processing, or both. A provider of services or a
18 representative of the provider may not report a subscriber to
19 a credit agency for unpaid claims due from an HMO/MCO for
20 covered HMO services. A violation of this subsection by an
21 individual physician or a physician practice must be referred
22 to the agency for investigation and to the Board of Medicine
23 for final disciplinary action as part of the current Medical
24 Quality Assurance Program. A violation by a facility must be
25 referred to the agency. A violation of this subsection by an
26 institutional provider must be referred to the agency for
27 investigation as part of the agency's current Consumer
28 Assistance Program.
29 (4) Each Every contract between an HMO and a provider
30 of health care services must shall be in writing and shall
31 contain a provision that the subscriber is shall not be liable
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1 to the provider for any services covered by the subscriber's
2 contract with the HMO.
3 (5) The provisions of This section does shall not be
4 construed to apply to the amount of any deductible or
5 copayment which is not covered by the contract of the HMO.
6 (6)(a) For all provider contracts executed after
7 October 1, 1991, and within 180 days after October 1, 1991,
8 for contracts in existence as of October 1, 1991:
9 1. The contracts must require provide that the
10 provider to give shall provide 60 days' advance written notice
11 to the health maintenance organization and the department
12 before canceling the contract with the health maintenance
13 organization for any reason; and
14 2. The contract must also provide that nonpayment for
15 goods or services rendered by the provider to the health
16 maintenance organization is shall not be a valid reason for
17 avoiding the 60-day advance notice of cancellation.
18 (b) For all provider contracts executed after October
19 1, 1996, and within 180 days after October 1, 1996, for
20 contracts in existence as of October 1, 1996, the contracts
21 must provide that the health maintenance organization will
22 provide 60 days' advance written notice to the provider and
23 the department before canceling, without cause, the contract
24 with the provider, except in a case in which a patient's
25 health is subject to imminent danger or a physician's ability
26 to practice medicine is effectively impaired by an action by
27 the Board of Medicine or other governmental agency.
28 (7) Upon receipt by the health maintenance
29 organization of a 60-day cancellation notice, the health
30 maintenance organization may, if requested by the provider,
31 terminate the contract in less than 60 days if the health
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1 maintenance organization is not financially impaired or
2 insolvent.
3 (8) A contract between a health maintenance
4 organization and a provider of health care services may shall
5 not restrict contain any provision restricting the provider's
6 ability to communicate information to the provider's patient
7 regarding medical care or treatment options for the patient
8 when the provider deems knowledge of such information by the
9 patient to be in the best interest of the health of the
10 patient.
11 (9) A contract between a health maintenance
12 organization and a provider of health care services may not
13 contain any provision that in any way prohibits or restricts:
14 (a) The health care provider from entering into a
15 commercial contract with any other health maintenance
16 organization; or
17 (b) The health maintenance organization from entering
18 into a commercial contract with any other health care
19 provider.
20 (10) A health maintenance organization or health care
21 provider may not terminate a contract with a health care
22 provider or health maintenance organization unless the party
23 terminating the contract provides the terminated party with a
24 written reason for the contract termination, which may include
25 termination for business reasons of the terminating party. The
26 reason provided in the notice required by in this section or
27 any other information relating to the reason for termination
28 does not create any new administrative or civil action and may
29 not be used as substantive evidence in any such action, but
30 may be used for impeachment purposes. As used in this
31 subsection, the term "health care provider" means a physician
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1 licensed under chapter 458, chapter 459, chapter 460, or
2 chapter 461, or a dentist licensed under chapter 466.
3 Section 2. Section 641.3155, Florida Statutes, is
4 amended to read:
5 641.3155 Provider contracts; payment of claims.--
6 (1) As used in this section, the term "clean claim"
7 means a completed claim submitted by institutional providers
8 on a UB-92 claim form or other providers on a HCFA 1500 claim
9 form for medical care or health care services under a health
10 care plan. The department may adopt rules revising and
11 updating the definition of clean claim, to be consistent with
12 federal claim filing standards for health care plans as
13 required by the Health Care Financing Administration.
14 (2)(1)(a) A health maintenance organization shall pay
15 any clean claim or any portion of a clean claim made by a
16 contract provider for services or goods provided under a
17 contract with the health maintenance organization which the
18 organization does not contest or deny within 35 days after
19 receipt of the claim by the health maintenance organization
20 which is mailed or electronically transferred by the provider.
21 (b) A health maintenance organization that denies or
22 contests a provider's claim or any portion of a claim shall
23 notify the contract provider, in writing, within 35 days after
24 receipt of the claim by the health maintenance organization
25 receives the claim that the claim is contested or denied. The
26 notice that the claim is denied or contested must identify the
27 contested portion of the claim and the specific reason for
28 contesting or denying the claim, and must may include a
29 request for additional information. If the provider submits
30 health maintenance organization requests additional
31 information, the provider must shall, within 35 days after
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1 receipt of the such request, mail or electronically transfer
2 the information to the health maintenance organization. The
3 health maintenance organization shall pay or deny the claim or
4 portion of the claim within 45 days after receipt of the
5 information.
6 (3)(2) Payment of a claim is considered made on the
7 date the payment was received or electronically transferred or
8 otherwise delivered. An overdue payment of a claim bears
9 simple interest at the rate of 10 percent per year. Interest
10 on an overdue payment for a clean claim or for any uncontested
11 portion of a clean claim begins to accrue on the 36th day
12 after the claim has been received. The interest is payable
13 with the payment of the claim. Interest on overpayments made
14 to providers begins to accrue on the 36th day after the
15 provider receives notice of overpayment. Upon the 36th day,
16 plans must be allowed to offset any interest payment due
17 against future claims.
18 (4)(3) A health maintenance organization shall pay or
19 deny any claim no later than 120 days after receiving the
20 claim.
21 (5)(4) Any retroactive reductions of payments or
22 demands for refund of previous overpayments which are due to
23 retroactive review-of-coverage decisions or payment levels
24 must be reconciled to specific claims unless the parties agree
25 to other reconciliation methods and terms. Any retroactive
26 demands by providers for payment due to underpayments or
27 nonpayments for covered services must be reconciled to
28 specific claims unless the parties agree to other
29 reconciliation methods and terms. The look-back period may be
30 specified by the terms of the contract.
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1 (6) Providers must implement electronic billing in
2 accordance with the implementation schedule established by the
3 federal Health Insurance Portability and Accountability Act.
4 The department may grant special consideration and variance to
5 the implementation schedule to rural hospitals and physician's
6 practices.
7 (7) Providers who bill electronically are entitled to
8 electronic acknowledgement of receipts of claims within 48
9 hours. Providers must wait 45 days before submitting duplicate
10 bills if confirmation of receipt was received from the plan.
11 (8) The time limit for recouping or collecting
12 outstanding claims may not exceed 1 year for either a
13 contracted or a noncontracted provider.
14 Section 3. Section 641.3156, Florida Statutes, is
15 created to read:
16 641.3156 Treatment authorization; payment of claims.--
17 (1) A health maintenance organization must pay any
18 hospital-service or referral-service claim for treatment that
19 was authorized by a physician empowered by the HMO/MCO to
20 authorize or direct the patient's utilization of health care
21 services and that was also authorized in accordance with the
22 HMO/MCO's current and communicated procedures.
23 (2) A claim for treatment that was authorized in
24 accordance with this section may not be denied retroactively
25 by the HMO/MCO unless:
26 (a) The service is not covered;
27 (b) The subscriber was ineligible at the time the
28 services were rendered; or
29 (c) The physician provided information to the health
30 maintenance organization with the willful intention to
31 misinform the health maintenance organization.
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1 Section 4. Subsection (4) of section 641.495, Florida
2 Statutes, is amended to read:
3 641.495 Requirements for issuance and maintenance of
4 certificate.--
5 (4) The organization shall ensure that the health care
6 services it provides to subscribers, including physician
7 services as required by s. 641.19(13)(d) and (e), are
8 accessible to the subscribers, with reasonable promptness,
9 with respect to geographic location, hours of operation,
10 provision of after-hours service, and staffing patterns within
11 generally accepted industry norms for meeting the projected
12 subscriber needs. The health maintenance organization must
13 have the capability to provide treatment authorization 24
14 hours a day, 7 days a week. Requests for treatment
15 authorization may not be held pending unless the requesting
16 provider contractually agrees to take a pending or tracking
17 number.
18 Section 5. Section 408.7057, Florida Statutes, is
19 created to read:
20 408.7057 Statewide provider and managed care
21 organization claim dispute mediation panel.--
22 (1) As used in this section, the term:
23 (a) "Managed care entity" means a health maintenance
24 organization or a prepaid health clinic certified under
25 chapter 641, a prepaid health plan authorized under s.
26 409.912, or an exclusive provider organization certified under
27 s. 627.6472.
28 (b) "Resolution organization" means a qualified
29 independent third-party claims dispute resolution entity
30 selected by and contracted with the Agency for Health Care
31 Administration.
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1 (2)(a) The Agency for Health Care Administration shall
2 establish a program to provide assistance to contracting and
3 noncontracting providers and managed care organizations for
4 those claim disputes that are in violation of s. 641.3155 and
5 are not resolved by the provider and the managed care entity.
6 The program must include the agency contracting with a
7 resolution organization to timely review and consider claims
8 disputes submitted by providers and managed care organizations
9 and to recommend to the agency an appropriate resolution of
10 those disputes.
11 (b) The resolution organization shall review claim
12 disputes filed by participating and nonparticipating providers
13 and managed care organizations unless the disputed claim:
14 1. Is related to interest payment;
15 2. Is for an amount of $5,000 or less for a claim
16 against an institution or $1,000 or less for a claim against
17 an individual physician;
18 3. Is part of an internal grievance in a Medicare
19 managed care entity or a reconsideration appeal through the
20 Medicare appeals process;
21 4. Is related to a health plan that is not regulated
22 by the state, such as an administrative services organization,
23 a third-party administrator, or a federal employee health
24 benefit program;
25 5. Is part of a Medicaid fair hearing pursued under 42
26 C.F.R. ss. 431.220 et seq.;
27 6. Is the basis for an action pending in state or
28 federal court; or
29 7. Is subject to a binding claims dispute resolution
30 process provided by contract between the provider and the
31 managed care organization.
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1 (3) The agency shall adopt rules to establish a
2 process for the consideration by the resolution organization
3 of claims disputes submitted by either a provider or managed
4 care entity which shall include the issuance by the resolution
5 organization of a written recommendation, supported by
6 findings of fact, to the agency within 60 days after receipt
7 of the claims dispute submission.
8 (4) Within 30 days after receipt of the recommendation
9 of the resolution organization the agency shall issue a final
10 order subject to the provisions of chapter 120.
11 (5) The entity that does not prevail in the agency's
12 order must pay a review cost to the review organization as
13 determined by agency rule which shall include an apportionment
14 of the review fee in those cases where both parties may
15 prevail in part. The failure of the nonprevailing party to pay
16 the ordered review cost within 35 days of the agency's order
17 will subject the nonpaying party to a penalty of no more than
18 $500 per day until the penalty is paid.
19 Section 6. The Agency for Health Care Administration
20 may adopt rules necessary to administer this act.
21 Section 7. This act shall take effect October 1, 2000,
22 and shall apply to all requests for claim-dispute resolution
23 which are submitted by a provider or managed care entity 60
24 days after the effective date of the contract between the
25 resolution organization and the agency.
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1 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
2 Senate Bill 1508
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4 Specifies that the balanced billing prohibitions of s.
641.315, F.S., apply to either a contracted or non-contracted
5 provider who provides covered services to an HMO subscriber.
6 Deletes the state agency panel that the bill requires the
Agency for Health Care Administration to establish to help
7 resolve claims disputes between providers and managed care
entities and, instead, requires the agency to contract with
8 independent resolution organizations to recommend to the
agency an appropriate resolution of those disputes, subject to
9 a final order by the agency pursuant to chapter 120. This
process would not apply to a claim that is subject to a
10 binding claims dispute resolution process provided by the
managed care entity's provider contract.
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Revises the definition of "clean claim" to refer to specific
12 forms and authorizes the Department of Insurance to adopt
rules revising and updating the definition of clean claim to
13 be consistent with federal clean claim standards approved by
the Health Care Financing Administration.
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Changes the cross-reference from the "National Uniform Billing
15 Committee" to the "federal Health Insurance Portability and
Accountability Act" that establishes the schedule for
16 providers to implement electronic billing.
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