Senate Bill 0706
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Florida Senate - 2000 SB 706
By Senator Laurent
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1 A bill to be entitled
2 An act relating to health maintenance
3 organizations; amending s. 641.3155, F.S.;
4 defining the term "clean claim"; providing
5 prerequisites to an HMO's contesting such a
6 claim; providing procedures; providing
7 penalties for failure to pay part or all of a
8 clean claim; amending s. 408.7056, F.S.;
9 providing for the Agency for Health Care
10 Administration to review all provider
11 grievances alleging that an HMO has violated s.
12 641.3155, F.S.; providing for the appointment
13 of a review panel and specifying its
14 membership; providing applicability; providing
15 an effective date.
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17 Be It Enacted by the Legislature of the State of Florida:
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19 Section 1. Section 641.3155, Florida Statutes, is
20 amended to read:
21 641.3155 Provider contracts; payment of claims.--
22 (1) As used in this section, the term "clean claim"
23 means a completed claim, as determined under department rules
24 adopted under chapter 120, which claim is for medical care or
25 health care services under a health care plan and is submitted
26 by a physician on an HCFA 1500 claim form or by other
27 providers on a UB-92 claim form.
28 (2)(1)(a) A health maintenance organization shall pay
29 any clean claim or any portion of a clean claim made by a
30 contract provider for services or goods provided under a
31 contract with the health maintenance organization which the
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1 organization does not contest or deny within 35 days after
2 receipt of the claim by the health maintenance organization
3 receives the claim, which has been sent by mail or electronic
4 transfer from is mailed or electronically transferred by the
5 provider.
6 (b) A health maintenance organization that denies or
7 contests a provider's clean claim or any portion of a clean
8 claim shall notify the contract provider, in writing, within
9 35 days after receipt of the claim by the health maintenance
10 organization receives the claim that the claim is contested or
11 denied. The notice that the claim is denied or contested must
12 identify the contested portion of the claim and the specific
13 reason for contesting or denying the claim, and must may
14 include a request for additional information. If the provider
15 submits health maintenance organization requests additional
16 information, the provider shall, within 35 days after receipt
17 of such notice request, mail or electronically transfer the
18 information to the health maintenance organization. The
19 provider may charge the organization the reasonable costs of
20 copying and providing the additional information, including
21 the cost of reasonable staff time, as provided in ss. 395.3025
22 and 455.667. The health maintenance organization shall pay or
23 deny the claim or portion of the claim within 45 days after
24 receipt of the information.
25 (3) In order for a health maintenance organization to
26 contest a portion of a clean claim, the health maintenance
27 organization must pay to the provider the uncontested portion
28 of the claim. The failure to pay the uncontested portion of a
29 claim constitutes a complete waiver of the health maintenance
30 organization's right to deny any part of the claim. If the
31 health maintenance organization unreasonably denies the entire
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1 claim for the purpose of delaying payment of the uncontested
2 portion of the claim, the organization must pay to the
3 provider three times the amount of the claim which was
4 unreasonably contested.
5 (4)(2) Payment of a claim is considered made on the
6 date the payment was received or electronically transferred or
7 otherwise delivered. An overdue payment of a claim bears
8 simple interest at the rate of 10 percent per year.
9 (5) Failure to pay the amount of the undisputed clean
10 claim to a provider within 35 days after receipt of the claim
11 entitles the provider to the procedures set forth in s.
12 408.7056(4).
13 (6)(3) A health maintenance organization shall pay or
14 deny any clean claim no later than 120 days after receiving
15 the claim. The failure of a health maintenance organization to
16 pay any disputed clean claim or portion of a clean claim
17 within such period entitles the provider to the procedures
18 specified in s. 408.7056(4).
19 (7)(4) Any retroactive reductions of payments or
20 demands for refund of previous overpayments which are due to
21 retroactive review-of-coverage decisions or payment levels
22 must be reconciled to specific claims unless the parties agree
23 to other reconciliation methods and terms. Any retroactive
24 demands by providers for payment due to underpayments or
25 nonpayments for covered services must be reconciled to
26 specific claims unless the parties agree to other
27 reconciliation methods and terms. The look-back period may be
28 specified by the terms of the contract.
29 Section 2. Section 408.7056, Florida Statutes, is
30 amended to read:
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1 408.7056 Statewide Provider and Subscriber Assistance
2 Program.--
3 (1) As used in this section, the term:
4 (a) "Managed care entity" means a health maintenance
5 organization or a prepaid health clinic certified under
6 chapter 641, a prepaid health plan authorized under s.
7 409.912, or an exclusive provider organization certified under
8 s. 627.6472.
9 (b) "Panel" means a statewide provider and subscriber
10 assistance panel selected as provided in subsections (12) and
11 (13) subsection (11).
12 (2) The agency shall adopt and implement a program to
13 provide assistance to subscribers and providers, including
14 those whose grievances are not resolved by the managed care
15 entity to the satisfaction of the subscriber or provider. The
16 program shall consist of one or more panels that meet as often
17 as necessary to timely review, consider, and hear grievances
18 and recommend to the agency or the department any actions that
19 should be taken concerning individual cases heard by the
20 panel. The panel shall hear every grievance filed by
21 subscribers and providers on behalf of subscribers, unless the
22 grievance:
23 (a) Relates to a managed care entity's refusal to
24 accept a provider into its network of providers;
25 (b) Is part of an internal grievance in a Medicare
26 managed care entity or a reconsideration appeal through the
27 Medicare appeals process which does not involve a quality of
28 care issue;
29 (c) Is related to a health plan not regulated by the
30 state such as an administrative services organization,
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1 third-party administrator, or federal employee health benefit
2 program;
3 (d) Is related to appeals by in-plan suppliers and
4 providers, unless related to quality of care provided by the
5 plan or to the payment of claims submitted to the organization
6 by the providers;
7 (e) Is part of a Medicaid fair hearing pursued under
8 42 C.F.R. ss. 431.220 et seq.;
9 (f) Is the basis for an action pending in state or
10 federal court;
11 (g) Is related to an appeal by nonparticipating
12 providers, unless related to the quality of care provided to a
13 subscriber by the managed care entity and the provider is
14 involved in the care provided to the subscriber or to the
15 payment of claims submitted to the organization by the
16 provider;
17 (h) Was filed before the subscriber or provider
18 completed the entire internal grievance procedure of the
19 managed care entity, the managed care entity has complied with
20 its timeframes for completing the internal grievance
21 procedure, and the circumstances described in subsection (7)
22 (6) do not apply;
23 (i) Has been resolved to the satisfaction of the
24 subscriber or provider who filed the grievance, unless the
25 managed care entity's initial action is egregious or may be
26 indicative of a pattern of inappropriate behavior;
27 (j) Is limited to seeking damages for pain and
28 suffering, lost wages, or other incidental expenses, including
29 accrued interest on unpaid balances, court costs, and
30 transportation costs associated with a grievance procedure;
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1 (k) Is limited to issues involving conduct of a health
2 care provider or facility, staff member, or employee of a
3 managed care entity which constitute grounds for disciplinary
4 action by the appropriate professional licensing board and is
5 not indicative of a pattern of inappropriate behavior, and the
6 agency or department has reported these grievances to the
7 appropriate professional licensing board or to the health
8 facility regulation section of the agency for possible
9 investigation; or
10 (l) Is withdrawn by the subscriber or provider.
11 Failure of the subscriber or the provider to attend the
12 hearing shall be considered a withdrawal of the grievance.
13 (3) Except for grievances that are filed by providers
14 and that relate to the payment of claims by a health
15 maintenance organization, the agency shall review all
16 grievances within 60 days after receipt and make a
17 determination whether the grievance shall be heard. Once the
18 agency notifies the panel, the subscriber or provider, and the
19 managed care entity that a grievance will be heard by the
20 panel, the panel shall hear the grievance either in the
21 network area or by teleconference no later than 120 days after
22 the date the grievance was filed. The agency shall notify the
23 parties, in writing, by facsimile transmission, or by phone,
24 of the time and place of the hearing. The panel may take
25 testimony under oath, request certified copies of documents,
26 and take similar actions to collect information and
27 documentation that will assist the panel in making findings of
28 fact and a recommendation. The panel shall issue a written
29 recommendation, supported by findings of fact, to the provider
30 or subscriber, to the managed care entity, and to the agency
31 or the department no later than 15 working days after hearing
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1 the grievance. If at the hearing the panel requests
2 additional documentation or additional records, the time for
3 issuing a recommendation is tolled until the information or
4 documentation requested has been provided to the panel. The
5 proceedings of the panel are not subject to chapter 120.
6 (4) Within 15 days after receiving a grievance filed
7 by a provider against an organization, which grievance alleges
8 that the organization violated s. 641.3155, the agency must
9 review the grievance and make a determination as to whether
10 the grievance shall be heard. After the agency notifies the
11 panel created under subsection (13), the provider, and the
12 managed care entity that the panel will hear the grievance,
13 the panel must hear the grievance, either in the network area
14 or by teleconference, no later than 45 days after the date on
15 which the grievance was filed, unless that deadline is waived
16 by both the provider and the managed care entity. The agency
17 shall notify the parties, either in writing, by facsimile
18 transmission, or by telephone, of the time and place of the
19 hearing. The panel may take testimony under oath, request
20 certified copies of documents, and take similar actions to
21 collect information and documentation that will assist the
22 panel in making findings of fact and a recommendation. No
23 later than 15 working days after hearing the grievance, the
24 panel shall issue a written recommendation, supported by
25 findings of fact, to the provider, to the managed care entity,
26 and to the agency or the department. If, at the hearing, the
27 panel requests additional documentation or additional records,
28 the time for issuing a recommendation is tolled until the
29 requested information or documentation has been provided to
30 the panel. The proceedings of the panel are not subject to
31 chapter 120.
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1 (5)(4) If, upon receiving a proper patient
2 authorization along with a properly filed grievance, the
3 agency requests medical records from a health care provider or
4 managed care entity, the health care provider or managed care
5 entity that has custody of the records has 10 days to provide
6 the records to the agency. Failure to provide requested
7 medical records may result in the imposition of a fine of up
8 to $500. Each day that records are not produced is considered
9 a separate violation.
10 (6)(5) Grievances considered under subsection (3)
11 which that the agency determines pose an immediate and serious
12 threat to a subscriber's health must be given priority over
13 other grievances. The panel may meet at the call of the chair
14 to hear the grievances as quickly as possible but no later
15 than 45 days after the date the grievance is filed, unless the
16 panel receives a waiver of the time requirement from the
17 subscriber. The panel shall issue a written recommendation,
18 supported by findings of fact, to the department or the agency
19 within 10 days after hearing the expedited grievance.
20 (7)(6) When the agency determines that the life of a
21 subscriber is in imminent and emergent jeopardy, the chair of
22 the panel may convene an emergency hearing, within 24 hours
23 after notification to the managed care entity and to the
24 subscriber, to hear the grievance. The grievance must be
25 heard notwithstanding that the subscriber has not completed
26 the internal grievance procedure of the managed care entity.
27 The panel shall, upon hearing the grievance, issue a written
28 emergency recommendation, supported by findings of fact, to
29 the managed care entity, to the subscriber, and to the agency
30 or the department for the purpose of deferring the imminent
31 and emergent jeopardy to the subscriber's life. Within 24
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1 hours after receipt of the panel's emergency recommendation,
2 the agency or department may issue an emergency order to the
3 managed care entity. An emergency order remains in force
4 until:
5 (a) The grievance has been resolved by the managed
6 care entity;
7 (b) Medical intervention is no longer necessary; or
8 (c) The panel has conducted a full hearing under
9 subsection (3) and issued a recommendation to the agency or
10 the department, and the agency or department has issued a
11 final order.
12 (8)(7) After hearing a grievance, the panel shall make
13 a recommendation to the agency or the department which may
14 include specific actions the managed care entity must take to
15 comply with state laws or rules regulating managed care
16 entities.
17 (9)(8) A managed care entity, subscriber, or provider
18 that is affected by a panel recommendation may within 10 days
19 after receipt of the panel's recommendation, or 72 hours after
20 receipt of a recommendation in an expedited grievance, furnish
21 to the agency or department written evidence in opposition to
22 the recommendation or findings of fact of the panel.
23 (10)(9) No later than 30 days after the issuance of
24 the panel's recommendation and, for an expedited grievance or
25 a grievance conducted under subsection (4), no later than 10
26 days after the issuance of the panel's recommendation, the
27 agency or the department may adopt the panel's recommendation
28 or findings of fact in a proposed order or an emergency order,
29 as provided in chapter 120, which it shall issue to the
30 managed care entity. The agency or department may issue a
31 proposed order or an emergency order, as provided in chapter
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1 120, imposing fines or sanctions, including those contained in
2 ss. 641.25 and 641.52, and, for hearings conducted under
3 subsection (4), requiring payment of the unpaid portion of any
4 claim not paid by the organization, which shall bear a simple
5 interest rate of 10 percent from the date the provider filed
6 the grievance under this section. The agency or the department
7 may reject all or part of the panel's recommendation as
8 provided in s. 120.57. All fines collected under this
9 subsection must be deposited into the Health Care Trust Fund.
10 (11)(10) In determining any fine or sanction to be
11 imposed, the agency and the department may consider the
12 following factors:
13 (a) The severity of the noncompliance, including the
14 probability that death or serious harm to the health or safety
15 of the subscriber will result or has resulted, the severity of
16 the actual or potential harm, and the extent to which
17 provisions of chapter 641 were violated.
18 (b) Actions taken by the managed care entity to
19 resolve or remedy any quality-of-care grievance.
20 (c) Any previous incidents of noncompliance by the
21 managed care entity.
22 (d) Any other relevant factors the agency or
23 department considers appropriate in a particular grievance.
24 (12)(11) Except for the panel created under subsection
25 (13), the panel shall consist of members employed by the
26 agency and members employed by the department, chosen by their
27 respective agencies; a consumer appointed by the Governor; a
28 physician appointed by the Governor, as a standing member; and
29 physicians who have expertise relevant to the case to be
30 heard, on a rotating basis. The agency may contract with a
31 medical director and a primary care physician who shall
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1 provide additional technical expertise to the panel. The
2 medical director shall be selected from a health maintenance
3 organization with a current certificate of authority to
4 operate in Florida.
5 (13) The panel created to hear grievances filed by
6 providers under subsection (4) shall be composed of five
7 members, consisting of a medical director of an organization
8 that holds a current certificate of authority to operate in
9 this state, a physician licensed under chapter 458 or chapter
10 459, a member who represents a hospital, a member employed by
11 the agency, and a member employed by the department. The
12 Governor shall appoint the three members of the panel who are
13 not employed by the agency or the department. The remaining
14 two members of the panel shall be chosen by mutual agreement
15 of the agency and the department. Each member of the panel
16 must be proficient in coding methodology.
17 (14)(12) Every managed care entity shall submit a
18 quarterly report to the agency and the department listing the
19 number and the nature of all subscribers' and providers'
20 grievances which have not been resolved to the satisfaction of
21 the subscriber or provider after the subscriber or provider
22 follows the entire internal grievance procedure of the managed
23 care entity. The agency shall notify all subscribers and
24 providers included in the quarterly reports of their right to
25 file an unresolved grievance with the panel.
26 (15)(13) Any information which would identify a
27 subscriber or the spouse, relative, or guardian of a
28 subscriber and which is contained in a report obtained by the
29 Department of Insurance pursuant to this section is
30 confidential and exempt from the provisions of s. 119.07(1)
31 and s. 24(a), Art. I of the State Constitution.
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1 (16)(14) A proposed order issued by the agency or
2 department which only requires the managed care entity to take
3 a specific action under subsection (8) (7) is subject to a
4 summary hearing in accordance with s. 120.574, unless all of
5 the parties agree otherwise. If the managed care entity does
6 not prevail at the hearing, the managed care entity must pay
7 reasonable costs and attorney's fees of the agency or the
8 department incurred in that proceeding.
9 (17)(15)(a) Any information which would identify a
10 subscriber or the spouse, relative, or guardian of a
11 subscriber which is contained in a document, report, or record
12 prepared or reviewed by the panel or obtained by the agency
13 pursuant to this section is confidential and exempt from the
14 provisions of s. 119.07(1) and s. 24(a), Art. I of the State
15 Constitution.
16 (b) Meetings of the panel shall be open to the public
17 unless the provider or subscriber whose grievance will be
18 heard requests a closed meeting or the agency or the
19 Department of Insurance determines that information of a
20 sensitive personal nature which discloses the subscriber's
21 medical treatment or history; or information which constitutes
22 a trade secret as defined by s. 812.081; or information
23 relating to internal risk management programs as defined in s.
24 641.55(5)(c), (6), and (8) may be revealed at the panel
25 meeting, in which case that portion of the meeting during
26 which such sensitive personal information, trade secret
27 information, or internal risk management program information
28 is discussed shall be exempt from the provisions of s. 286.011
29 and s. 24(b), Art. I of the State Constitution. All closed
30 meetings shall be recorded by a certified court reporter.
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1 This subsection is subject to the Open Government Sunset
2 Review Act of 1995 in accordance with s. 119.15, and shall
3 stand repealed on October 2, 2003, unless reviewed and saved
4 from repeal through reenactment by the Legislature.
5 Section 3. This act shall take effect July 1, 2000,
6 and shall apply to all claims submitted by a provider to a
7 health maintenance organization after June 30, 2000.
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10 SENATE SUMMARY
11 Provides procedures that a health maintenance
organization must follow in contesting certain claims
12 made by providers. Provides penalties for failure to pay
part or all of a "clean claim," as that term is defined
13 in the bill. Provides for the Agency for Health Care
Administration to review all provider grievances alleging
14 that a health maintenance organization has violated s.
641.3155, F.S. Provides for the appointment of a review
15 panel and specifies panel membership. Provides
applicability. Provides an effective date.
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