House Bill 2427
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
By the Committee on Health Care Services and
Representatives Peaden and Casey
1 A bill to be entitled
2 An act relating to managed care organizations;
3 amending s. 641.315, F.S.; deleting provisions
4 relating to provider billings; revising
5 provisions relating to provider contracts;
6 providing for certain disclosures and requiring
7 notice; requiring procedures for requesting and
8 granting authorization for utilization of
9 services; creating s. 641.3154, F.S.; providing
10 for health maintenance organization liability
11 for payment for services rendered to
12 subscribers; prohibiting provider billing of
13 subscribers under specified circumstances;
14 amending s. 641.3155, F.S.; defining the term
15 "clean claim"; specifying the basis for
16 determining when a claim is to be considered
17 clean or not clean; requiring the Department of
18 Insurance to adopt rules to establish a claim
19 form; providing requirements; providing the
20 Department of Insurance with discretionary
21 rulemaking authority for coding standards;
22 providing requirements; providing for payment
23 of clean claims; providing requirements for
24 denying or contesting a portion of a claim;
25 providing for interest accrual and payment of
26 interest; providing an uncontestable obligation
27 to pay a claim; requiring a health maintenance
28 organization to make a claim for overpayment;
29 prohibiting an organization from reducing
30 payment for other services; providing
31 exceptions; requiring a provider to pay a claim
1
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 for overpayment within a specified timeframe;
2 providing a procedure and timeframes for a
3 provider to notify a health maintenance
4 organization that it is denying or contesting a
5 claim for overpayment; specifying when a
6 provider payment of a claim for overpayment is
7 to be considered made; providing for assessment
8 of simple interest against overdue payment of a
9 claim; specifying when interest on overdue
10 payments of claims for overpayment begins to
11 accrue; specifying a timeframe for a provider
12 to deny or contest a claim for overpayment;
13 providing an uncontestable obligation to pay a
14 claim; specifying when a provider claim that is
15 electronically transmitted or mailed is
16 considered received; specifying when a health
17 maintenance organization claim for overpayment
18 is considered received; mandating
19 acknowledgment of receipts for electronically
20 submitted provider claims; prescribing a
21 timeframe for a health maintenance organization
22 to retroactively deny a claim for services
23 provided to an ineligible subscriber; creating
24 s. 641.3156, F.S.; providing for treatment
25 authorization and payment of claims by a health
26 maintenance organization; clarifying that
27 treatment authorization and payment of a claim
28 for emergency services is subject to another
29 provision of law; providing a cross reference;
30 amending s. 641.3903, F.S.; providing that
31 certain actions by a health maintenance
2
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 organization are unfair methods of competition
2 and unfair or deceptive acts or practices;
3 amending s. 641.3909, F.S.; authorizing the
4 Department of Insurance to issue a cease and
5 desist order for a violation of certain payment
6 of claims requirements; amending s. 641.495,
7 F.S.; revising provisions relating to
8 treatment-authorization capabilities; requiring
9 agreement to pending authorizations and
10 tracking numbers as a precondition to such an
11 authorization; creating s. 408.7057, F.S.;
12 providing for the establishment of a statewide
13 provider and managed care organization claim
14 dispute resolution program; providing
15 rulemaking authority to the Agency for Health
16 Care Administration; amending s. 395.1065,
17 F.S.; authorizing administrative sanctions
18 against a hospital's license for improper
19 subscriber billing and violations of
20 requirements relating to claims payment;
21 amending s. 817.234, F.S.; providing for
22 administrative fines against providers for
23 certain actions; providing that certain actions
24 by a provider are fraud, punishable as a
25 felony; amending s. 817.50, F.S.; expanding
26 applicability of certain provisions relating to
27 fraud against hospitals to health care
28 providers; providing a cross reference;
29 providing applicability; amending ss. 395.0193
30 and 395.0197, F.S.; providing cross references;
31 providing effective dates.
3
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 Be It Enacted by the Legislature of the State of Florida:
2
3 Section 1. Section 641.315, Florida Statutes, is
4 amended to read:
5 641.315 Provider contracts.--
6 (1) Whenever a contract exists between a health
7 maintenance organization and a provider and the organization
8 fails to meet its obligations to pay fees for services already
9 rendered to a subscriber, the health maintenance organization
10 shall be liable for such fee or fees rather than the
11 subscriber; and the contract shall so state.
12 (2) No subscriber of an HMO shall be liable to any
13 provider of health care services for any services covered by
14 the HMO.
15 (3) No provider of services or any representative of
16 such provider shall collect or attempt to collect from an HMO
17 subscriber any money for services covered by an HMO and no
18 provider or representative of such provider may maintain any
19 action at law against a subscriber of an HMO to collect money
20 owed to such provider by an HMO.
21 (1)(4) Each Every contract between a health
22 maintenance organization an HMO and a provider of health care
23 services shall be in writing and shall contain a provision
24 that the subscriber shall not be liable to the provider for
25 any services for which the health maintenance organization is
26 liable, as specified in s. 641.3154 covered by the
27 subscriber's contract with the HMO.
28 (5) The provisions of this section shall not be
29 construed to apply to the amount of any deductible or
30 copayment which is not covered by the contract of the HMO.
31
4
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 (2)(6)(a) For all provider contracts executed after
2 October 1, 1991, and within 180 days after October 1, 1991,
3 for contracts in existence as of October 1, 1991:
4 1. The contracts must require provide that the
5 provider to give shall provide 60 days' advance written notice
6 to the health maintenance organization and the department
7 before canceling the contract with the health maintenance
8 organization for any reason; and
9 2. The contract must also provide that nonpayment for
10 goods or services rendered by the provider to the health
11 maintenance organization is shall not be a valid reason for
12 avoiding the 60-day advance notice of cancellation.
13 (b) For all provider contracts executed after October
14 1, 1996, and within 180 days after October 1, 1996, for
15 contracts in existence as of October 1, 1996, the contracts
16 must provide that the health maintenance organization will
17 provide 60 days' advance written notice to the provider and
18 the department before canceling, without cause, the contract
19 with the provider, except in a case in which a patient's
20 health is subject to imminent danger or a physician's ability
21 to practice medicine is effectively impaired by an action by
22 the Board of Medicine or other governmental agency.
23 (3)(7) Upon receipt by the health maintenance
24 organization of a 60-day cancellation notice, the health
25 maintenance organization may, if requested by the provider,
26 terminate the contract in less than 60 days if the health
27 maintenance organization is not financially impaired or
28 insolvent.
29 (4) Whenever a contract exists between a health
30 maintenance organization and a provider, the health
31 maintenance organization shall disclose to the provider:
5
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 (a) The mailing address or electronic address where
2 claims should be sent for processing.
3 (b) The telephone number that a provider may call to
4 have questions and concerns regarding claims addressed.
5 (c) The address of any separate claims processing
6 centers for specific types of services.
7
8 A health maintenance organization shall provide to its
9 contracted providers in no less than 30 calendar days, prior
10 written notice of any changes in the information required in
11 this subsection.
12 (5)(8) A contract between a health maintenance
13 organization and a provider of health care services shall not
14 contain any provision restricting the provider's ability to
15 communicate information to the provider's patient regarding
16 medical care or treatment options for the patient when the
17 provider deems knowledge of such information by the patient to
18 be in the best interest of the health of the patient.
19 (6)(9) A contract between a health maintenance
20 organization and a provider of health care services may not
21 contain any provision that in any way prohibits or restricts:
22 (a) The health care provider from entering into a
23 commercial contract with any other health maintenance
24 organization; or
25 (b) The health maintenance organization from entering
26 into a commercial contract with any other health care
27 provider.
28 (7)(10) A health maintenance organization or health
29 care provider may not terminate a contract with a health care
30 provider or health maintenance organization unless the party
31 terminating the contract provides the terminated party with a
6
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 written reason for the contract termination, which may include
2 termination for business reasons of the terminating party. The
3 reason provided in the notice required by in this section or
4 any other information relating to the reason for termination
5 does not create any new administrative or civil action and may
6 not be used as substantive evidence in any such action, but
7 may be used for impeachment purposes. As used in this
8 subsection, the term "health care provider" means a physician
9 licensed under chapter 458, chapter 459, chapter 460, or
10 chapter 461, or a dentist licensed under chapter 466.
11 (8) The health maintenance organization shall
12 establish written procedures for a contract provider to
13 request and the health maintenance organization to grant
14 authorization for utilization of health care services. The
15 health maintenance organization shall give written notice to
16 the contract provider prior to any changes in such procedures.
17 Section 2. Section 641.3154, Florida Statutes, is
18 created to read:
19 641.3154 Organization liability; provider billing
20 prohibited.--
21 (1) If a health maintenance organization is liable for
22 services rendered to a subscriber by a provider, whether a
23 contract exists between the organization and the provider or
24 not, the organization is liable for payment of fees to the
25 provider, and the subscriber is not liable for payment of fees
26 to the provider.
27 (2) For purposes of this section, a health maintenance
28 organization is liable for services rendered to an eligible
29 subscriber by a provider if a provider follows the health
30 maintenance organization's authorization procedures and
31 receives authorization for a covered service for an eligible
7
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 subscriber, unless the provider provided information to the
2 health maintenance organization with the willful intention to
3 misinform the health maintenance organization.
4 (3) The liability of an organization for payment of
5 fees for services is not affected by any contract the
6 organization has with a third party for the functions of
7 authorizing, processing, or paying claims.
8 (4) A provider, whether under contract with the health
9 maintenance organization or not, or any representative of such
10 provider, may not collect or attempt to collect money from,
11 maintain any action at law against, or report to a credit
12 agency a subscriber of an organization for payment of services
13 for which the organization is liable, if the provider in good
14 faith knows or should know that the organization is liable.
15 This prohibition applies during the pendency of any claim for
16 payment made by the provider to the organization for payment
17 of the services and any legal proceedings or dispute
18 resolution process to determine whether the organization is
19 liable for the services if the provider is informed that such
20 proceedings are taking place. It shall be presumed that a
21 provider does not know and should not know that an
22 organization is liable unless:
23 (a) The provider is informed by the organization that
24 it accepts liability;
25 (b) A court of competent jurisdiction determines that
26 the organization is liable; or
27 (c) The department or agency makes a final
28 determination that the organization is required to pay for
29 such services subsequent to a recommendation made by the
30 Statewide Provider and Subscriber Assistance Panel pursuant to
31 s. 408.7056.
8
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 (5) An organization and the department shall report
2 any suspected violation of this section by a health care
3 practitioner to the Department of Health and by a facility to
4 the agency which shall take such actions as authorized by law.
5 Section 3. Section 641.3155, Florida Statutes, is
6 amended to read:
7 641.3155 Provider contracts; Payment of claims.--
8 (1)(a) As used in this section, the term "clean claim"
9 for a noninstitutional provider means a claim submitted on a
10 HCFA 1500 form that has no defect or impropriety, including
11 lack of required substantiating documentation for
12 noncontracted providers and suppliers, or particular
13 circumstances requiring special treatment which prevent timely
14 payment from being made on the claim. A claim may not be
15 considered not clean solely because a health maintenance
16 organization refers the claim to a medical specialist within
17 the health maintenance organization for examination. If
18 additional substantiating documentation, such as the medical
19 record or encounter data, is required from a source outside
20 the health maintenance organization, the claim is considered
21 not clean. This definition of "clean claim" is repealed on the
22 effective date of rules adopted by the department which define
23 the term "clean claim."
24 (b) Absent a written definition that is agreed upon
25 through contract, the term "clean claim" for an institutional
26 claim is a properly and accurately completed paper or
27 electronic billing instrument that consists of the UB-92 data
28 set or its successor with entries stated as mandatory by the
29 National Uniform Billing Committee.
30 (c) The department shall adopt rules to establish
31 claim forms consistent with federal claim filing standards for
9
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 health maintenance organizations required by the federal
2 Health Care Financing Administration. The department may adopt
3 rules relating to coding standards consistent with Medicare
4 coding standards adopted by the federal Health Care Financing
5 Administration.
6 (2)(1)(a) A health maintenance organization shall pay
7 any clean claim or any portion of a clean claim made by a
8 contract provider for services or goods provided under a
9 contract with the health maintenance organization or a clean
10 claim made by a noncontract provider which the organization
11 does not contest or deny within 35 days after receipt of the
12 claim by the health maintenance organization which is mailed
13 or electronically transferred by the provider.
14 (b) A health maintenance organization that denies or
15 contests a provider's claim or any portion of a claim shall
16 notify the contract provider, in writing, within 35 days after
17 receipt of the claim by the health maintenance organization
18 receives the claim that the claim is contested or denied. The
19 notice that the claim is denied or contested must identify the
20 contested portion of the claim and the specific reason for
21 contesting or denying the claim, and, if contested, shall may
22 include a request for additional information. If the provider
23 submits health maintenance organization requests additional
24 information, the provider shall, within 35 days after receipt
25 of such request, mail or electronically transfer the
26 information to the health maintenance organization. The health
27 maintenance organization shall pay or deny the claim or
28 portion of the claim within 45 days after receipt of the
29 information.
30 (3)(2) Payment of a claim is considered made on the
31 date the payment was received or electronically transferred or
10
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 otherwise delivered. An overdue payment of a claim bears
2 simple interest at the rate of 10 percent per year. Interest
3 on an overdue payment for a clean claim or for any uncontested
4 portion of a clean claim begins to accrue on the 36th day
5 after the claim has been received. The interest is payable
6 with the payment of the claim.
7 (4)(3) A health maintenance organization shall pay or
8 deny any claim no later than 120 days after receiving the
9 claim. Failure to do so creates an uncontestable obligation
10 for the health maintenance organization to pay the claim to
11 the provider.
12 (5)(a) If, as a result of retroactive review of
13 coverage decisions or payment levels, a health maintenance
14 organization determines that it has made an overpayment to a
15 provider for services rendered to a subscriber, the
16 organization must make a claim for such overpayment. The
17 organization may not reduce payment to that provider for other
18 services unless the provider agrees to the reduction or fails
19 to respond to the organization's claim as required in this
20 subsection.
21 (b) A provider shall pay a claim for an overpayment
22 made by a health maintenance organization which the provider
23 does not contest or deny within 35 days after receipt of the
24 claim that is mailed or electronically transferred to the
25 provider.
26 (c) A provider that denies or contests an
27 organization's claim for overpayment or any portion of a claim
28 shall notify the organization, in writing, within 35 days
29 after the provider receives the claim that the claim for
30 overpayment is contested or denied. The notice that the claim
31 for overpayment is denied or contested must identify the
11
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 contested portion of the claim and the specific reason for
2 contesting or denying the claim, and, if contested, must
3 include a request for additional information. If the
4 organization submits additional information, the organization
5 must, within 35 days after receipt of the request, mail or
6 electronically transfer the information to the provider. The
7 provider shall pay or deny the claim for overpayment within 45
8 days after receipt of the information.
9 (d) Payment of a claim for overpayment is considered
10 made on the date payment was received or electronically
11 transferred or otherwise delivered to the organization, or the
12 date that the provider receives a payment from the
13 organization that reduces or deducts the overpayment. An
14 overdue payment of a claim bears simple interest at the rate
15 of 10 percent a year. Interest on an overdue payment of a
16 claim for overpayment or for any uncontested portion of a
17 claim for overpayment begins to accrue on the 36th day after
18 the claim for overpayment has been received.
19 (e) A provider shall pay or deny any claim for
20 overpayment no later than 120 days after receiving the claim.
21 Failure to do so creates an uncontestable obligation for the
22 provider to pay the claim to the organization.
23 (6)(4) Any retroactive reductions of payments or
24 demands for refund of previous overpayments which are due to
25 retroactive review-of-coverage decisions or payment levels
26 must be reconciled to specific claims unless the parties agree
27 to other reconciliation methods and terms. Any retroactive
28 demands by providers for payment due to underpayments or
29 nonpayments for covered services must be reconciled to
30 specific claims unless the parties agree to other
31
12
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 reconciliation methods and terms. The look-back period may be
2 specified by the terms of the contract.
3 (7)(a) A provider claim for payment shall be
4 considered received by the health maintenance organization, if
5 the claim has been electronically transmitted to the health
6 maintenance organization, when receipt is verified
7 electronically or, if the claim is mailed to the address
8 disclosed by the organization, on the date indicated on the
9 return receipt. A provider must wait 45 days after receipt of
10 a claim before submitting a duplicate claim.
11 (b) A health maintenance organization claim for
12 overpayment shall be considered received by a provider, if the
13 claim has been electronically transmitted to the provider,
14 when receipt is verified electronically or, if the claim is
15 mailed to the address disclosed by the provider, on the date
16 indicated on the return receipt. An organization must wait 45
17 days from the provider's receipt of a claim for overpayment
18 before submitting a duplicate claim.
19 (c) Nothing in this section precludes the health
20 maintenance organization and provider from agreeing to other
21 methods of transmission and receipt of claims.
22 (8) A provider, or the provider's designee, who bills
23 electronically is entitled to electronic acknowledgement of
24 the receipt of a claim within 72 hours.
25 (9) A health maintenance organization may not
26 retroactively deny a claim more than 1 year after the date of
27 service because of subscriber ineligibility.
28 Section 4. Section 641.3156, Florida Statutes, is
29 created to read:
30 641.3156 Treatment authorization; payment of claims.--
31
13
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 (1) A health maintenance organization must pay any
2 hospital service or referral service claim for treatment for
3 an eligible subscriber which was authorized by a provider
4 empowered by contract with the health maintenance organization
5 to authorize or direct the patient's utilization of health
6 care services and which was also authorized in accordance with
7 the health maintenance organization's current and communicated
8 procedures, unless the provider provided information to the
9 health maintenance organization with the willful intention to
10 misinform the health maintenance organization.
11 (2) A claim for treatment may not be denied if a
12 provider follows the health maintenance organization's
13 authorization procedures and receives authorization for a
14 covered service for an eligible subscriber, unless the
15 provider provided information to the health maintenance
16 organization with the willful intention to misinform the
17 health maintenance organization.
18 (3) Emergency services are subject to the provisions
19 of s. 641.513 and are not subject to the provisions of this
20 section.
21 Section 5. Paragraph (c) of subsection (5) of section
22 641.3903, Florida Statutes, is amended to read:
23 641.3903 Unfair methods of competition and unfair or
24 deceptive acts or practices defined.--The following are
25 defined as unfair methods of competition and unfair or
26 deceptive acts or practices:
27 (5) UNFAIR CLAIM SETTLEMENT PRACTICES.--
28 (c) Committing or performing with such frequency as to
29 indicate a general business practice any of the following:
30 1. Failing to adopt and implement standards for the
31 proper investigation of claims;
14
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 2. Misrepresenting pertinent facts or contract
2 provisions relating to coverage at issue;
3 3. Failing to acknowledge and act promptly upon
4 communications with respect to claims;
5 4. Denying of claims without conducting reasonable
6 investigations based upon available information;
7 5. Failing to affirm or deny coverage of claims upon
8 written request of the subscriber within a reasonable time not
9 to exceed 30 days after a claim or proof-of-loss statements
10 have been completed and documents pertinent to the claim have
11 been requested in a timely manner and received by the health
12 maintenance organization;
13 6. Failing to promptly provide a reasonable
14 explanation in writing to the subscriber of the basis in the
15 health maintenance contract in relation to the facts or
16 applicable law for denial of a claim or for the offer of a
17 compromise settlement;
18 7. Failing to provide, upon written request of a
19 subscriber, itemized statements verifying that services and
20 supplies were furnished, where such statement is necessary for
21 the submission of other insurance claims covered by individual
22 specified disease or limited benefit policies, provided that
23 the organization may receive from the subscriber a reasonable
24 administrative charge for the cost of preparing such
25 statement; or
26 8. Failing to provide any subscriber with services,
27 care, or treatment contracted for pursuant to any health
28 maintenance contract without a reasonable basis to believe
29 that a legitimate defense exists for not providing such
30 services, care, or treatment. To the extent that a national
31 disaster, war, riot, civil insurrection, epidemic, or any
15
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 other emergency or similar event not within the control of the
2 health maintenance organization results in the inability of
3 the facilities, personnel, or financial resources of the
4 health maintenance organization to provide or arrange for
5 provision of a health service in accordance with requirements
6 of this part, the health maintenance organization is required
7 only to make a good faith effort to provide or arrange for
8 provision of the service, taking into account the impact of
9 the event. For the purposes of this paragraph, an event is
10 not within the control of the health maintenance organization
11 if the health maintenance organization cannot exercise
12 influence or dominion over its occurrence.
13 9. Systematic downcoding with the intent to deny
14 reimbursement otherwise due.
15 Section 6. Section 641.3909, Florida Statutes, is
16 amended to read:
17 641.3909 Cease and desist and penalty orders.--After
18 the hearing provided in s. 641.3907, the department shall
19 enter a final order in accordance with s. 120.569. If it is
20 determined that the person, entity, or health maintenance
21 organization charged has engaged in an unfair or deceptive act
22 or practice or the unlawful operation of a health maintenance
23 organization without a subsisting certificate of authority,
24 the department shall also issue an order requiring the
25 violator to cease and desist from engaging in such method of
26 competition, act, or practice or unlawful operation of a
27 health maintenance organization. Further, if the act or
28 practice constitutes a violation of s. 641.3155, s. 641.3901,
29 or s. 641.3903, the department may, at its discretion, order
30 any one or more of the following:
31
16
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 (1) Suspension or revocation of the health maintenance
2 organization's certificate of authority if it knew, or
3 reasonably should have known, it was in violation of this
4 part.
5 (2) If it is determined that the person or entity
6 charged has engaged in the business of operating a health
7 maintenance organization without a certificate of authority,
8 an administrative penalty not to exceed $1,000 for each health
9 maintenance contract offered or effectuated.
10 Section 7. Subsection (4) of section 641.495, Florida
11 Statutes, is amended to read:
12 641.495 Requirements for issuance and maintenance of
13 certificate.--
14 (4) The organization shall ensure that the health care
15 services it provides to subscribers, including physician
16 services as required by s. 641.19(13)(d) and (e), are
17 accessible to the subscribers, with reasonable promptness,
18 with respect to geographic location, hours of operation,
19 provision of after-hours service, and staffing patterns within
20 generally accepted industry norms for meeting the projected
21 subscriber needs. The health maintenance organization must
22 provide treatment authorization 24 hours a day, 7 days a week.
23 Requests for treatment authorization may not be held pending
24 unless the requesting provider contractually agrees to take a
25 pending or tracking number.
26 Section 8. Effective January 1, 2001, section
27 408.7057, Florida Statutes, is created to read:
28 408.7057 Statewide provider and managed care
29 organization claim dispute resolution program.--
30 (1) As used in this section, the term:
31
17
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 (a) "Managed care organization" means a health
2 maintenance organization or a prepaid health clinic certified
3 under chapter 641, a prepaid health plan authorized under s.
4 409.912, or an exclusive provider organization certified under
5 s. 627.6472.
6 (b) "Resolution organization" means a qualified
7 independent third-party claims dispute resolution entity
8 selected by and contracted with the Agency for Health Care
9 Administration.
10 (2)(a) The Agency for Health Care Administration shall
11 establish a program to provide assistance to contracted and
12 noncontracted providers and managed care organizations for
13 resolution of claim disputes that are not resolved by the
14 provider and the managed care organization. The program must
15 include the agency contracting with a resolution organization
16 to timely review and consider claims disputes submitted by
17 providers and managed care organizations and to recommend to
18 the agency an appropriate resolution of those disputes. The
19 agency shall establish by rule jurisdictional amounts and
20 methods of aggregation for claims disputes that may be
21 considered by the resolution organization.
22 (b) The resolution organization shall review claim
23 disputes filed by contracted and noncontracted providers and
24 managed care organizations unless the disputed claim:
25 1. Is related to interest payment;
26 2. Does not meet the jurisdictional amounts or the
27 methods of aggregation established by agency rule, as provided
28 in paragraph (a);
29 3. Is part of an internal grievance in a Medicare
30 managed care organization or a reconsideration appeal through
31 the Medicare appeals process;
18
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 4. Is related to a health plan that is not regulated
2 by the state;
3 5. Is part of a Medicaid fair hearing pursued under 42
4 C.F.R. ss. 431.220 et seq.;
5 6. Is the basis for an action pending in state or
6 federal court; or
7 7. Is subject to a binding claims dispute resolution
8 process provided by contract entered into prior to July 1,
9 2000, between the provider and the managed care organization.
10 (c) Contracts entered into or renewed on or after July
11 1, 2000, may require exhaustion of an internal resolution
12 dispute process as a prerequisite to the submission of a claim
13 by a provider or health maintenance organization to the
14 dispute resolution organization.
15 (d) A contracted or noncontracted provider or health
16 maintenance organization may not file a claim dispute with the
17 resolution organization more than 12 months after a final
18 determination on a claim by a health maintenance organization
19 has occurred.
20 (3) The agency shall adopt rules to establish a
21 process for the consideration by the resolution organization
22 of claims disputes submitted by either a provider or managed
23 care organization which shall include the issuance by the
24 resolution organization of a written recommendation, supported
25 by findings of fact, to the agency within 60 days after
26 receipt of the claims dispute submission.
27 (4) Within 30 days after receipt of the recommendation
28 of the resolution organization the agency shall adopt the
29 recommendation as a final order.
30 (5) The entity that does not prevail in the agency's
31 order must pay a review cost to the review organization as
19
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 determined by agency rule, which shall include an
2 apportionment of the review fee in those cases where both
3 parties may prevail in part. The failure of the nonprevailing
4 party to pay the ordered review cost within 35 days after the
5 agency's order will subject the nonpaying party to a penalty
6 of no more than $500 per day until the penalty is paid.
7 (6) The Agency for Health Care Administration may
8 adopt rules necessary to administer this section.
9 Section 9. Subsection (2) of section 395.1065, Florida
10 Statutes, is amended to read:
11 395.1065 Criminal and administrative penalties;
12 injunctions; emergency orders; moratorium.--
13 (2)(a) The agency may deny, revoke, or suspend a
14 license or impose an administrative fine, not to exceed $1,000
15 per violation, per day, for the violation of any provision of
16 this part or rules adopted under this part promulgated
17 hereunder. Each day of violation constitutes a separate
18 violation and is subject to a separate fine.
19 (b) If sufficient claims due to a provider from a
20 health maintenance organization do not exist to enable the
21 take back of an overpayment as provided under s. 641.3155, the
22 agency may impose an administrative fine for the violation of
23 s. 641.3154 or s. 641.3155 in amounts specified in s. 641.52
24 and the provisions of paragraph (a) do not apply.
25 (c)(b) In determining the amount of fine to be levied
26 for a violation, as provided in paragraph (a), the following
27 factors shall be considered:
28 1. The severity of the violation, including the
29 probability that death or serious harm to the health or safety
30 of any person will result or has resulted, the severity of the
31
20
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 actual or potential harm, and the extent to which the
2 provisions of this part were violated.
3 2. Actions taken by the licensee to correct the
4 violations or to remedy complaints.
5 3. Any previous violations of the licensee.
6 (d)(c) All amounts collected pursuant to this section
7 shall be deposited into the Planning and Regulation Trust
8 Fund, as created by s. 395.004.
9 Section 10. Subsection (2) of section 817.234, Florida
10 Statutes, is amended to read:
11 817.234 False and fraudulent insurance claims.--
12 (2)(a) Any physician licensed under chapter 458,
13 osteopathic physician licensed under chapter 459, chiropractic
14 physician licensed under chapter 460, or other practitioner
15 licensed under the laws of this state who knowingly and
16 willfully assists, conspires with, or urges any insured party
17 to fraudulently violate any of the provisions of this section
18 or part XI of chapter 627, or any person who, due to such
19 assistance, conspiracy, or urging by said physician,
20 osteopathic physician, chiropractic physician, or
21 practitioner, knowingly and willfully benefits from the
22 proceeds derived from the use of such fraud, commits insurance
23 fraud, punishable as provided in subsection (11). In the event
24 that a physician, osteopathic physician, chiropractic
25 physician, or practitioner is adjudicated guilty of a
26 violation of this section, the Board of Medicine as set forth
27 in chapter 458, the Board of Osteopathic Medicine as set forth
28 in chapter 459, the Board of Chiropractic Medicine as set
29 forth in chapter 460, or other appropriate licensing authority
30 shall hold an administrative hearing to consider the
31 imposition of administrative sanctions as provided by law
21
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 against said physician, osteopathic physician, chiropractic
2 physician, or practitioner.
3 (b) In addition to any other provision of law,
4 systematic upcoding by a provider, as defined in s.
5 641.19(15), with the intent to obtain reimbursement otherwise
6 not due from an insurer is punishable as provided in s.
7 641.52(5).
8 (11) If the value of any property involved in a
9 violation of this section:
10 (a) Is less than $20,000, the offender commits a
11 felony of the third degree, punishable as provided in s.
12 775.082, s. 775.083, or s. 775.084.
13 (b) Is $20,000 or more, but less than $100,000, the
14 offender commits a felony of the second degree, punishable as
15 provided in s. 775.082, s. 775.083, or s. 775.084.
16 (c) Is $100,000 or more, the offender commits a felony
17 of the first degree, punishable as provided in s. 775.082, s.
18 775.083, or s. 775.084.
19 Section 11. Section 817.50, Florida Statutes, is
20 amended to read:
21 817.50 Fraudulently obtaining goods, services, etc.,
22 from a health care provider hospital.--
23 (1) Whoever shall, willfully and with intent to
24 defraud, obtain or attempt to obtain goods, products,
25 merchandise or services from any health care provider, as
26 defined in s. 641.19, hospital in this state shall be guilty
27 of a misdemeanor of the second degree, punishable as provided
28 in s. 775.082 or s. 775.083.
29 (2) If any person gives to any provider hospital in
30 this state a false or fictitious name or a false or fictitious
31 address or assigns to any provider hospital the proceeds of
22
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 any health maintenance contract or insurance contract, then
2 knowing that such contract is no longer in force, is invalid,
3 or is void for any reason, such action shall be prima facie
4 evidence of the intent of such person to defraud the provider
5 such hospital.
6 Section 12. Subsection (6) of section 395.0193,
7 Florida Statutes, is amended to read:
8 395.0193 Licensed facilities; peer review;
9 disciplinary powers; agency or partnership with physicians.--
10 (6) For a single incident or series of isolated
11 incidents that are nonwillful violations of the reporting
12 requirements of this section, the agency shall first seek to
13 obtain corrective action by the facility. If correction is not
14 demonstrated within the timeframe established by the agency or
15 if there is a pattern of nonwillful violations of this
16 section, the agency may impose an administrative fine, not to
17 exceed $5,000 for any violation of the reporting requirements
18 of this section. The administrative fine for repeated
19 nonwillful violations shall not exceed $10,000 for any
20 violation. The administrative fine for each intentional and
21 willful violation may not exceed $25,000 per violation, per
22 day. The fine for an intentional and willful violation of this
23 section may not exceed $250,000. In determining the amount of
24 fine to be levied, the agency shall be guided by s.
25 395.1065(2)(c)(b).
26 Section 13. Subsection (12) of section 395.0197,
27 Florida Statutes, is amended to read:
28 395.0197 Internal risk management program.--
29 (12) In addition to any penalty imposed pursuant to
30 this section, the agency shall require a written plan of
31 correction from the facility. For a single incident or series
23
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 of isolated incidents that are nonwillful violations of the
2 reporting requirements of this section, the agency shall first
3 seek to obtain corrective action by the facility. If the
4 correction is not demonstrated within the timeframe
5 established by the agency or if there is a pattern of
6 nonwillful violations of this section, the agency may impose
7 an administrative fine, not to exceed $5,000 for any violation
8 of the reporting requirements of this section. The
9 administrative fine for repeated nonwillful violations shall
10 not exceed $10,000 for any violation. The administrative fine
11 for each intentional and willful violation may not exceed
12 $25,000 per violation, per day. The fine for an intentional
13 and willful violation of this section may not exceed $250,000.
14 In determining the amount of fine to be levied, the agency
15 shall be guided by s. 395.1065(2)(c)(b). This subsection does
16 not apply to the notice requirements under subsection (7).
17 Section 14. Except as otherwise provided herein, this
18 act shall take effect October 1, 2000, and shall apply to
19 claims for services rendered after such date and to all
20 requests for claim dispute resolution which are submitted by a
21 provider or managed care organization 60 days after the
22 effective date of the contract between the resolution
23 organization and the agency.
24
25
26
27
28
29
30
31
24
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2000 HB 2427
169-457-00
1 *****************************************
2 HOUSE SUMMARY
3
Revises provisions relating to managed care
4 organizations. Provides for health maintenance
organization liability for payment for services rendered
5 to subscribers and prohibits provider billing of
subscribers under specified circumstances. Revises and
6 clarifies provisions relating to making, paying,
contesting, and denying claims. Provides for interest
7 accrual and payment of interest on claims. Provides for
treatment authorization and payment of claims by a health
8 maintenance organization. Providing that specified
actions by a health maintenance organization are unfair
9 methods of competition and unfair or deceptive acts or
practices. Provides for the establishment of a statewide
10 provider and managed care organization claim dispute
resolution program. Authorizes administrative sanctions
11 against a hospital's license for improper subscriber
billing and violations of requirements relating to claims
12 payment. Expands applicability of provisions relating to
fraud against hospitals to health care providers.
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
25