Senate Bill 2234
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Florida Senate - 2000 SB 2234
By Senator Saunders
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1 A bill to be entitled
2 An act relating to health care services;
3 amending s. 641.19, F.S.; providing
4 definitions; amending s. 641.315, F.S.;
5 providing that authorization for a covered
6 service provided by an HMO's physician,
7 employee, or contractee is binding on the HMO
8 and payment may not be denied; prohibiting
9 denial of payments by an HMO for covered
10 services provided by a hospital provider;
11 amending s. 641.3155, F.S.; requiring HMOs to
12 notify contract providers that a claim has been
13 received within a specified time; providing
14 conditions under which an HMO may contest a
15 contract provider's claim; providing for
16 reversion of overdue payments for claims;
17 creating s. 641.3156, F.S.; providing for
18 adoption of clean claims standards; amending s.
19 641.3903, F.S.; prohibiting specified false
20 statements and unfair claim settlement
21 practices; amending s. 641.3909, F.S.;
22 authorizing the Department of Insurance to
23 impose a monetary penalty for unfair methods of
24 competition or unfair and deceptive acts or
25 practices; amending s. 641.495, F.S.; providing
26 an additional requirement for the issuance and
27 maintenance of a health-care-provider
28 certificate; amending s. 641.51, F.S.;
29 requiring an HMO to ensure that only licensed
30 physicians may render an adverse determination
31 relating to a service provided by a licensed
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1 physician; requiring the physician to submit to
2 the provider and the subscriber facts and
3 documentation relating to the HMO's adverse
4 determination; providing an effective date.
5
6 Be It Enacted by the Legislature of the State of Florida:
7
8 Section 1. Section 641.19, Florida Statutes, is
9 amended to read:
10 641.19 Definitions.--As used in this part, the term:
11 (1) "Affiliate" means any entity which exercises
12 control over or is controlled by the health maintenance
13 organization, directly or indirectly, through:
14 (a) Equity ownership of voting securities;
15 (b) Common managerial control; or
16 (c) Collusive participation by the management of the
17 health maintenance organization and affiliate in the
18 management of the health maintenance organization or the
19 affiliate.
20 (2) "Agency" means the Agency for Health Care
21 Administration.
22 (3) "Capitation" means the fixed amount paid by an HMO
23 to a health care provider under contract with the health
24 maintenance organization in exchange for the rendering of
25 covered medical services.
26 (4) "Comprehensive health care services" means
27 services, medical equipment, and supplies furnished by a
28 provider, which may include, but which are not limited to,
29 medical, surgical, and dental care; psychological, optometric,
30 optic, chiropractic, podiatric, nursing, physical therapy, and
31 pharmaceutical services; health education, preventive medical,
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1 rehabilitative, and home health services; inpatient and
2 outpatient hospital services; extended care; nursing home
3 care; convalescent institutional care; technical and
4 professional clinical pathology laboratory services;
5 laboratory and ambulance services; appliances, drugs,
6 medicines, and supplies; and any other care, service, or
7 treatment of disease, or correction of defects for human
8 beings.
9 (5) "Copayment" means a specific dollar amount, except
10 as otherwise provided for by statute, that the subscriber must
11 pay upon receipt of covered health care services. Copayments
12 may not be established in an amount that will prevent a person
13 from receiving a covered service or benefit as specified in
14 the subscriber contract approved by the department.
15 (6) "Covered services" means health care services and
16 supplies delivered by providers which are reimbursable under a
17 subscriber's health maintenance contract.
18 (7)(6) "Department" means the Department of Insurance.
19 (8)(7) "Emergency medical condition" means:
20 (a) A medical condition manifesting itself by acute
21 symptoms of sufficient severity, which may include severe pain
22 or other acute symptoms, such that the absence of immediate
23 medical attention could reasonably be expected to result in
24 any of the following:
25 1. Serious jeopardy to the health of a patient,
26 including a pregnant woman or a fetus.
27 2. Serious impairment to bodily functions.
28 3. Serious dysfunction of any bodily organ or part.
29 (b) With respect to a pregnant woman:
30 1. That there is inadequate time to effect safe
31 transfer to another hospital prior to delivery;
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1 2. That a transfer may pose a threat to the health and
2 safety of the patient or fetus; or
3 3. That there is evidence of the onset and persistence
4 of uterine contractions or rupture of the membranes.
5 (9)(8) "Emergency services and care" means medical
6 screening, examination, and evaluation by a physician, or, to
7 the extent permitted by applicable law, by other appropriate
8 personnel under the supervision of a physician, to determine
9 if an emergency medical condition exists and, if it does, the
10 care, treatment, or surgery for a covered service by a
11 physician necessary to relieve or eliminate the emergency
12 medical condition, within the service capability of a
13 hospital.
14 (10)(9) "Entity" means any legal entity with
15 continuing existence, including, but not limited to, a
16 corporation, association, trust, or partnership.
17 (11)(10) "Geographic area" means the county or
18 counties, or any portion of a county or counties, within which
19 the health maintenance organization provides or arranges for
20 comprehensive health care services to be available to its
21 subscribers.
22 (12)(11) "Guaranteeing organization" is an
23 organization which is domiciled in the United States; which
24 has authorized service of process against it; and which has
25 appointed the Insurance Commissioner and Treasurer as its
26 agent for service of process issuing upon any cause of action
27 arising in this state, based upon any guarantee entered into
28 under this part.
29 (13)(12) "Health maintenance contract" means any
30 contract entered into by a health maintenance organization
31 with a subscriber or group of subscribers to provide
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1 comprehensive health care services in exchange for a prepaid
2 per capita or prepaid aggregate fixed sum.
3 (14)(13) "Health maintenance organization" means any
4 organization authorized under this part which:
5 (a) Provides emergency care, inpatient hospital
6 services, physician care including care provided by physicians
7 licensed under chapters 458, 459, 460, and 461, ambulatory
8 diagnostic treatment, and preventive health care services;
9 (b) Provides, either directly or through arrangements
10 with other persons, health care services to persons enrolled
11 with such organization, on a prepaid per capita or prepaid
12 aggregate fixed-sum basis;
13 (c) Provides, either directly or through arrangements
14 with other persons, comprehensive health care services which
15 subscribers are entitled to receive pursuant to a contract;
16 (d) Provides physician services, by physicians
17 licensed under chapters 458, 459, 460, and 461, directly
18 through physicians who are either employees or partners of
19 such organization or under arrangements with a physician or
20 any group of physicians; and
21 (e) If offering services through a managed care
22 system, then the managed care system must be a system in which
23 a primary physician licensed under chapter 458 or chapter 459
24 and chapters 460 and 461 is designated for each subscriber
25 upon request of a subscriber requesting service by a physician
26 licensed under any of those chapters, and is responsible for
27 coordinating the health care of the subscriber of the
28 respectively requested service and for referring the
29 subscriber to other providers of the same discipline when
30 necessary. Each female subscriber may select as her primary
31 physician an obstetrician/gynecologist who has agreed to serve
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1 as a primary physician and is in the health maintenance
2 organization's provider network.
3 (15)(14) "Insolvent" or "insolvency" means that all
4 the statutory assets of the health maintenance organization,
5 if made immediately available, would not be sufficient to
6 discharge all of its liabilities or that the health
7 maintenance organization is unable to pay its debts as they
8 become due in the usual course of business. In the event that
9 all the assets of the health maintenance organization, if made
10 immediately available, would not be sufficient to discharge
11 all of its liabilities, but the organization has a written
12 guarantee of the type and subject to the same provisions as
13 outlined in s. 641.225, the organization shall not be
14 considered insolvent unless it is unable to pay its debts as
15 they become due in the usual course of business.
16 (16) "Noncovered services" means health care services
17 that are not covered services, including but not limited to
18 those services the organization determines are not medically
19 necessary or not a medical necessity.
20 (17)(15) "Provider" means any physician, hospital, or
21 other institution, organization, or person that furnishes
22 health care services and is licensed or otherwise authorized
23 to practice in the state.
24 (18)(16) "Reporting period" means the annual
25 accounting period or any part thereof or the fiscal year of
26 the health maintenance organization.
27 (19)(17) "Statutory accounting principles" means
28 generally accepted accounting principles, except as modified
29 by this part.
30 (20)(18) "Subscriber" means an entity or individual
31 who has contracted, or on whose behalf a contract has been
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1 entered into, with a health maintenance organization for
2 health care services or other persons who also receive health
3 care services as a result of the contract.
4 (21) "Subscriber expenses" means any amounts due for
5 health care services which are the subscriber's responsibility
6 in accordance with the health maintenance contract, including
7 copayments, coinsurance, and deductibles and expenses for
8 those services determined by the organization to be noncovered
9 services.
10 (22)(19) "Surplus" means total statutory assets in
11 excess of total liabilities, except that assets pledged to
12 secure debts not reflected on the books of the health
13 maintenance organization shall not be included in surplus.
14 Surplus includes capital stock, capital in excess of par,
15 other contributed capital, retained earnings, and surplus
16 notes.
17 (23)(20) "Surplus notes" means debt which has been
18 guaranteed by the United States Government or its agencies, or
19 debt which has been subordinated to all claims of subscribers
20 and general creditors of the organization.
21 (24)(21) "Uncovered expenditures" means the cost of
22 health care services that are covered by a health maintenance
23 organization, for which a subscriber would also be liable in
24 the event of the insolvency of the organization.
25 Section 2. Section 641.315, Florida Statutes, is
26 amended to read:
27 641.315 Provider contracts.--
28 (1) 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 authorized
31 covered services already rendered to a subscriber, the health
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1 maintenance organization shall be liable for such fee or fees
2 rather than the subscriber; and the contract shall so state.
3 (2) Authorization for a covered service provided by a
4 health maintenance organization's contracted physician or by a
5 health maintenance organization's employee or by an entity
6 contracting with or acting on behalf of the health maintenance
7 organization is binding upon the health maintenance
8 organization, and payment may not be denied.
9 (3)(2) No subscriber of an HMO shall be liable to any
10 provider of health care services for any services covered by
11 the HMO.
12 (4)(3) No provider of services or any representative
13 of such provider shall collect or attempt to collect from an
14 HMO subscriber any money for services covered by an HMO and no
15 provider or representative of such provider may maintain any
16 action at law against a subscriber of an HMO to collect money
17 owed to such provider by an HMO.
18 (5)(4) Every contract between an HMO and a provider of
19 health care services shall be in writing and shall contain a
20 provision that the subscriber shall not be liable to the
21 provider for any services covered by the subscriber's contract
22 with the HMO.
23 (6)(5) The provisions of this section shall not be
24 construed to apply to the amount of any deductible or
25 copayment which is not covered by the contract of the HMO.
26 (7)(6)(a) For all provider contracts executed after
27 October 1, 1991, and within 180 days after October 1, 1991,
28 for contracts in existence as of October 1, 1991:
29 1. The contracts must provide that the provider shall
30 provide 60 days' advance written notice to the health
31 maintenance organization and the department before canceling
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1 the contract with the health maintenance organization for any
2 reason; and
3 2. The contract must also provide that nonpayment for
4 goods or services rendered by the provider to the health
5 maintenance organization shall not be a valid reason for
6 avoiding the 60-day advance notice of cancellation.
7 (b) For all provider contracts executed after October
8 1, 1996, and within 180 days after October 1, 1996, for
9 contracts in existence as of October 1, 1996, the contracts
10 must provide that the health maintenance organization will
11 provide 60 days' advance written notice to the provider and
12 the department before canceling, without cause, the contract
13 with the provider, except in a case in which a patient's
14 health is subject to imminent danger or a physician's ability
15 to practice medicine is effectively impaired by an action by
16 the Board of Medicine or other governmental agency.
17 (8)(7) Upon receipt by the health maintenance
18 organization of a 60-day cancellation notice, the health
19 maintenance organization may, if requested by the provider,
20 terminate the contract in less than 60 days if the health
21 maintenance organization is not financially impaired or
22 insolvent.
23 (9)(8) A contract between a health maintenance
24 organization and a provider of health care services shall not
25 contain any provision restricting the provider's ability to
26 communicate information to the provider's patient regarding
27 medical care or treatment options for the patient when the
28 provider deems knowledge of such information by the patient to
29 be in the best interest of the health of the patient.
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1 (10)(9) A contract between a health maintenance
2 organization and a provider of health care services may not
3 contain any provision that in any way prohibits or restricts:
4 (a) The health care provider from entering into a
5 commercial contract with any other health maintenance
6 organization; or
7 (b) The health maintenance organization from entering
8 into a commercial contract with any other health care
9 provider.
10 (11)(10) A health maintenance organization or health
11 care provider may not terminate a contract with a health care
12 provider or health maintenance organization unless the party
13 terminating the contract provides the terminated party with a
14 written reason for the contract termination, which may include
15 termination for business reasons of the terminating party. The
16 reason provided in the notice required in this section or any
17 other information relating to the reason for termination does
18 not create any new administrative or civil action and may not
19 be used as substantive evidence in any such action, but may be
20 used for impeachment purposes. As used in this subsection, the
21 term "health care provider" means a physician licensed under
22 chapter 458, chapter 459, chapter 460, or chapter 461, or a
23 dentist licensed under chapter 466.
24 (12) A health maintenance organization may not deny
25 payment for covered services provided by a contracted hospital
26 provider, or pay for a lower level of care than rendered, when
27 such service is ordered by a contracted physician.
28 Section 3. Section 641.3155, Florida Statutes, is
29 amended to read:
30 641.3155 Provider contracts; payment of claims.--
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1 (1)(a) A health maintenance organization shall pay any
2 claim or any portion of a claim made by a contract provider
3 for services or goods provided under a contract with the
4 health maintenance organization which the organization does
5 not contest or deny within 35 days after receipt of the claim
6 by the health maintenance organization which is mailed or
7 electronically transferred by the provider.
8 (b) A health maintenance organization shall notify the
9 provider that a claim has been received within 2 days, if the
10 claim has been electronically transmitted to the health
11 maintenance organization or its agent, or within 10 days if
12 the claim was mailed or otherwise delivered. If receipt of a
13 claim is not acknowledged within the applicable timeframe, the
14 provider may resubmit the claim, and such resubmission will
15 not constitute a fraudulent claim.
16 (c) A health maintenance organization shall notify the
17 provider within 15 days after a claim has been received if the
18 claim is incomplete, if the patient receiving the service is
19 no longer an eligible subscriber, of if the service was not
20 authorized.
21 (d)(b) A health maintenance organization that denies
22 or contests a provider's claim shall notify the contract
23 provider, in writing, within 35 days after receipt of the
24 claim by the health maintenance organization that the claim is
25 contested or denied. The notice that the claim is denied or
26 contested must identify the contested portion of the claim and
27 the specific reason for contesting or denying the claim, and
28 may include a request for additional information. If the
29 health maintenance organization requests additional
30 information, the provider shall, within 35 days after receipt
31 of such request, mail or electronically transfer the
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1 information to the health maintenance organization. The health
2 maintenance organization shall acknowledge receiving the
3 additional information within 5 days after its receipt. The
4 health maintenance organization shall pay or deny the claim or
5 portion of the claim within 45 days after receipt of the
6 information.
7 (e) In order for a health maintenance organization to
8 contest a portion of a provider's claim, the health
9 maintenance organization must pay to the provider the
10 uncontested portion of the claim within 35 days after receipt
11 of claim by the health maintenance organization. The failure
12 to pay the uncontested portion of a claim constitutes a waiver
13 of the health maintenance organization's right to deny any
14 part of the claim.
15 (2) Payment of a claim is considered made on the date
16 the payment was received or electronically transferred or
17 otherwise delivered. An overdue payment of a claim bears
18 simple interest at the rate of 10 percent per year. Overdue
19 payments, either after 35 days for complete, uncontested
20 claims, or after 120 days for all other claims, revert to the
21 billed charges for facilities licensed under chapter 395 and
22 to the usual and customary charges for other providers.
23 Failure of a health maintenance organization to pay in a
24 timely manner constitutes waiver of a discount contractually
25 agreed to by the provider and the health maintenance
26 organization.
27 (3) A health maintenance organization shall pay or
28 deny any claim no later than 120 days after receiving the
29 claim.
30 (4) Any retroactive reductions of payments or demands
31 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 (5) For the purposes of claims payment, a hospital's
10 charges shall be determined to be the usual and customary
11 charge.
12 Section 4. Section 641.3156, Florida Statutes, is
13 created to read:
14 641.3156 Clean claims standards.--
15 (1)(a) As used in this section the term "clean claim"
16 means either:
17 1. An institutional claim that is a properly completed
18 billing instrument, paper or electronic, consisting of the
19 UB-92 data set or its successor, and submitted on the
20 designated paper or electronic format adopted by the National
21 Uniform Billing Committee (NUBC) with entries designated as
22 mandatory by the NUBC, together with any data required by the
23 state uniform billing committee and included in the UB-92
24 manual that is in effect at the time of service; or
25 2. The definition established within an executed and
26 current provider contract.
27 (b) The term "clean claim" as used in this section
28 does not involve coordination of benefits for third-party
29 liability or subrogation as evidenced by the information
30 provided on the claim related to coordination of benefits.
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1 (c) The definition prescribed in paragraph (a) is
2 inapplicable to claims against a physician's practice. With
3 respect to a physician's practice, the definition of the term
4 "clean claim" must be agreed upon by contract.
5 (2) The Department of Insurance and the Agency for
6 Health Care Administration shall require all health plans to
7 adopt the standards developed by the National Uniform Billing
8 Committee and the National Uniform Claims Committee, when
9 adopted.
10 (3) All health plans and providers must meet the
11 standards of the Health Insurance Portability and
12 Accountability Act, as approved by the Health Care Financing
13 Administration. The standards of the Health Insurance
14 Portability and Accountability Act must be implemented by
15 December 31, 2001, and must include the electronic processing
16 of claims for all health plans. However, the Agency for Health
17 Care Administration and the Department of Insurance may grant
18 exceptions to this subsection for rural providers and solo
19 practitioners.
20 (4) Failure to comply with the standards set forth in
21 this section is an unfair method of competition under s.
22 641.3903.
23 Section 5. Subsections (4) and (5) of section
24 641.3903, Florida Statutes, are amended to read:
25 641.3903 Unfair methods of competition and unfair or
26 deceptive acts or practices defined.--The following are
27 defined as unfair methods of competition and unfair or
28 deceptive acts or practices:
29 (4) FALSE STATEMENTS AND ENTRIES.--
30 (a) Knowingly:
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1 1. Filing with any supervisory or other public
2 official,
3 2. Making, publishing, disseminating, or circulating,
4 3. Delivering to any person,
5 4. Placing before the public, or
6 5. Causing, directly or indirectly, to be made,
7 published, disseminated, circulated, or delivered to any
8 person, or place before the public,
9
10 any material false statement.
11 (b) Knowingly making any false entry of a material
12 fact in any book, report, or statement of any person.
13 (c) Denying a subscriber's or provider's claim for
14 which an authorization has been obtained under s. 641.315(2).
15 (5) UNFAIR CLAIM SETTLEMENT PRACTICES.--
16 (a) Attempting to settle claims on the basis of an
17 application or any other material document which was altered
18 without notice to, or knowledge or consent of, a health
19 maintenance organization, the subscriber or group of
20 subscribers to a health maintenance organization, or the
21 providers of the service;
22 (b) Making a material misrepresentation to the
23 subscriber for the purpose and with the intent of effecting
24 settlement of claims, loss, or damage under a health
25 maintenance contract on less favorable terms than those
26 provided in, and contemplated by, the contract; or
27 (c) Committing or performing against a subscriber or
28 provider with such frequency as to indicate a general business
29 practice any of the following:
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1 1. Failing to adopt and implement claims standards
2 defined in this chapter for the proper processing, payment,
3 and investigation of claims;
4 2. Misrepresenting pertinent facts or contract
5 provisions relating to coverage at issue;
6 3. Failing to acknowledge and act promptly upon any
7 communications from a subscriber or provider with respect to
8 claims;
9 4. Denying of a subscriber's or provider's claims or
10 portions of claims without conducting reasonable
11 investigations based upon available information;
12 5. Failing to affirm or deny coverage of claims upon
13 written request of the subscriber or provider within a
14 reasonable time not to exceed 30 days after a claim or
15 proof-of-loss statements have been completed and documents
16 pertinent to the claim have been requested in a timely manner
17 and received by the health maintenance organization;
18 6. Failing to promptly provide a reasonable
19 explanation in writing to the subscriber of the basis in the
20 health maintenance contract in relation to the facts or
21 applicable law for denial of a claim or for the offer of a
22 compromise settlement, or failing to promptly provide a
23 reasonable explanation in writing to the provider of the basis
24 in the health maintenance contract in relation to the facts or
25 applicable law, or in the case of a contracted provider the
26 basis in the provision of the provider's contract for denial
27 of a claim or partial payment of a claim;
28 7. Failing to provide, upon written request of a
29 subscriber, itemized statements verifying that services and
30 supplies were furnished, where such statement is necessary for
31 the submission of other insurance claims covered by individual
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1 specified disease or limited benefit policies, provided that
2 the organization may receive from the subscriber a reasonable
3 administrative charge for the cost of preparing such
4 statement; or
5 8. Failing to provide any subscriber with services,
6 care, or treatment contracted for pursuant to any health
7 maintenance contract without a reasonable basis to believe
8 that a legitimate defense exists for not providing such
9 services, care, or treatment. To the extent that a national
10 disaster, war, riot, civil insurrection, epidemic, or any
11 other emergency or similar event not within the control of the
12 health maintenance organization results in the inability of
13 the facilities, personnel, or financial resources of the
14 health maintenance organization to provide or arrange for
15 provision of a health service in accordance with requirements
16 of this part, the health maintenance organization is required
17 only to make a good faith effort to provide or arrange for
18 provision of the service, taking into account the impact of
19 the event. For the purposes of this paragraph, an event is
20 not within the control of the health maintenance organization
21 if the health maintenance organization cannot exercise
22 influence or dominion over its occurrence.
23 Section 6. Subsection (3) is added to section
24 641.3909, to read:
25 641.3909 Cease and desist and penalty orders.--After
26 the hearing provided in s. 641.3907, the department shall
27 enter a final order in accordance with s. 120.569. If it is
28 determined that the person, entity, or health maintenance
29 organization charged has engaged in an unfair or deceptive act
30 or practice or the unlawful operation of a health maintenance
31 organization without a subsisting certificate of authority,
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1 the department shall also issue an order requiring the
2 violator to cease and desist from engaging in such method of
3 competition, act, or practice or unlawful operation of a
4 health maintenance organization. Further, if the act or
5 practice constitutes a violation of s. 641.3901 or s.
6 641.3903, the department may, at its discretion, order any one
7 or more of the following:
8 (3) A monetary penalty of not more than $50,000 per
9 violation of s. 641.3901 or s. 641.3903. Monetary penalties
10 assessed by the department under this subsection must be
11 allocated one-half to the department for the specific purpose
12 of monitoring and enforcing the provisions of ss. 641.3901 and
13 641.3903, and one-half to the Agency for Health Care
14 Administration, Bureau of Managed Care.
15 Section 7. Section 641.495, Florida Statutes, is
16 amended to read:
17 641.495 Requirements for issuance and maintenance of
18 certificate.--
19 (1) The agency shall issue a health care provider
20 certificate to an applicant filing a completed application in
21 conformity with ss. 641.48 and 641.49, upon payment of the
22 prescribed fee, and upon the agency's being satisfied that the
23 applicant has the ability to provide quality of care
24 consistent with the prevailing professional standards of care
25 and which applicant otherwise meets the requirements of this
26 part.
27 (2) A certificate, unless sooner suspended or revoked,
28 shall automatically expire 2 years from the date of issuance,
29 or at any time accreditation is withdrawn, unless renewed by
30 the organization. The certificate shall be renewed upon
31 application for renewal and payment of a renewal fee of
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1 $1,000, provided that the organization is in compliance with
2 the requirements of this part and all rules adopted under this
3 part. An application for renewal of a certificate shall be
4 made 90 days prior to expiration of the certificate, on forms
5 provided by the agency. The renewal application shall not
6 require the resubmission of any documents previously filed
7 with the agency if such documents have remained valid and
8 unchanged since their original filing.
9 (3) The organization shall demonstrate its capability
10 to provide health care services in the geographic area that it
11 proposes to service. In addition, each health maintenance
12 organization shall notify the agency of its intent to expand
13 its geographic area at least 60 days prior to the date it
14 plans to begin providing health care services in the new area.
15 Prior to the date the health maintenance organization begins
16 enrolling members in the new area, it must submit a notarized
17 affidavit, signed by two officers of the organization who have
18 the authority to legally bind the organization, to the agency
19 describing and affirming its existing and projected capability
20 to provide health care services to its projected number of
21 subscribers in the new area. The notarized affidavit shall
22 further assure that, 15 days prior to providing health care
23 services in the new area, the health maintenance organization
24 shall be able, through documentation or otherwise, to
25 demonstrate that it shall be capable of providing services to
26 its projected subscribers for at least the first 60 days of
27 operation. If the agency determines that the organization is
28 not capable of providing health care services to its projected
29 number of subscribers in the new area, the agency may issue an
30 order as required under chapter 120 prohibiting the
31 organization from expanding into the new area. In any
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1 proceeding under chapter 120, the agency shall have the burden
2 of establishing that the organization is not capable of
3 providing health care services to its projected number of
4 subscribers in the new area.
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.
13 (5) Each organization shall maintain on-line and
14 telephone services 24 hours a day, 7 days a week, for purposes
15 of providers confirming subscriber eligibility and
16 authorization for services. Each organization shall make
17 available communications to a live person for authorizations
18 and information on the coverage status. In no circumstance may
19 an organization give a provider a pending authorization.
20 (6)(5) The organization shall exercise reasonable care
21 in assuring that delivered health care services are performed
22 by appropriately licensed providers.
23 (7)(6) The organization shall have a system for
24 verification and examination of the credentials of each of its
25 providers. The organization shall maintain in a central file
26 the credentials, including a copy of the current Florida
27 license, of each of its physicians.
28 (8)(7) Every organization shall establish standards
29 and procedures reasonably necessary to provide for the
30 maintenance of a readily accessible medical records system
31 which is adequate to accommodate necessary information
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1 including an accurate documentation of all services provided
2 for every enrolled subscriber.
3 (9)(8) Each organization's contracts, certificates,
4 and subscriber handbooks shall contain a provision, if
5 applicable, disclosing that, for certain types of described
6 medical procedures, services may be provided by physician
7 assistants, nurse practitioners, or other individuals who are
8 not licensed physicians.
9 (10)(9) Every organization shall have a subscriber
10 grievance procedure, including, as appropriate, a procedure
11 for disenrolling for cause, which is outlined in all master
12 group and individual contracts as well as in any certificate
13 or handbook provided to subscribers.
14 (11)(10) The organization shall provide, through
15 contract or otherwise, for periodic review of its medical
16 facilities and services, as required under s. 641.512.
17 (12)(11) The organization shall designate a medical
18 director who is a physician licensed under chapter 458 or
19 chapter 459.
20 (13)(12) The provisions of part I of chapter 395 do
21 not apply to a health maintenance organization that, on or
22 before January 1, 1991, provides not more than 10 outpatient
23 holding beds for short-term and hospice-type patients in an
24 ambulatory care facility for its members, provided that such
25 health maintenance organization maintains current
26 accreditation by the Joint Commission on Accreditation of
27 Health Care Organizations, the Accreditation Association for
28 Ambulatory Health Care, or the National Committee for Quality
29 Assurance.
30 Section 8. Present subsections (4), (5), (6), (7),
31 (8), (9), and (10) of section 641.51, Florida Statutes, are
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1 redesignated as subsections (5), (6), (7), (8), (9), (10), and
2 (11), respectively, and a new subsection (4) is added to that
3 section to read:
4 641.51 Quality assurance program; second medical
5 opinion requirement.--
6 (4) The organization shall ensure that only a
7 physician licensed under chapter 458 or chapter 459 may render
8 an adverse determination regarding a service provided by a
9 physician licensed under chapter 458 or chapter 459 and shall
10 require the physician to submit to the provider and the
11 subscriber the facts and documentation regarding the
12 organization's adverse determination within 2 working days
13 after the subscriber or provider is notified of the adverse
14 determination. The facts and documentation must be written,
15 include the utilization-review criteria or benefits provisions
16 used in the adverse determination, and be signed by the
17 physician rendering the adverse determination. The
18 organization must include with the notification of an adverse
19 determination information concerning the appeal process for
20 adverse determinations.
21 Section 9. This act shall take effect July 1, 2000.
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2 SENATE SUMMARY
3 Provides definitions applicable to the Health Maintenance
Organization Act. Provides that authorization for a
4 covered service provided by an HMO's physician, employee,
or contractee is binding on the HMO, and that payment may
5 not be denied. Prohibits the denial of payments by an HMO
for covered services provided by a hospital provider.
6 Requires an HMO to notify contract providers that a claim
has been received within a specified time. Provides
7 conditions under which an HMO may contest a contract
provider's claim. Provides for a reversion to charges for
8 facilities and providers of overdue payments for claims.
Provides for the adoption of claims standards. Prohibits
9 specified false statements and unfair claim settlement
practices. Authorizes the Department of Insurance to
10 impose a monetary penalty for unfair methods of
competition or unfair and deceptive acts or practices.
11 Provides an additional requirement for the issuance and
maintenance of a health care provider certificate.
12 Requires an HMO to ensure that only licensed physicians
may render an adverse determination relating to service
13 provided by a licensed physician. Requires the physician
to submit to the provider and the subscriber facts and
14 documentation relating to the HMO's adverse
determination.
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