House Bill hb0181
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Florida House of Representatives - 2002 HB 181
By Representative Negron
1 A bill to be entitled
2 An act relating to health maintenance
3 organization contracts with health care
4 providers; creating s. 408.7058, F.S.;
5 providing definitions; requiring the Agency for
6 Health Care Administration to establish a
7 statewide health care provider and health
8 maintenance organization qualification dispute
9 resolution program; providing criteria and
10 requirements; requiring the agency to contract
11 with a resolution organization for certain
12 purposes; requiring the agency to establish
13 procedures for the resolution organization's
14 consideration of qualification disputes;
15 providing for final orders by the agency;
16 providing for payment of review costs under
17 certain circumstances; providing a penalty
18 under certain circumstances; authorizing the
19 agency to adopt rules; amending s. 641.315,
20 F.S.; deleting obsolete provisions relating to
21 provider contracts; revising provisions
22 providing for termination of a provider
23 contract by a health maintenance organization;
24 providing criteria, requirements, and
25 limitations; specifying notice requirements;
26 amending s. 627.6474, F.S.; specifying
27 requirements for certain contracts; prohibiting
28 certain insurers from refusing to enter into or
29 renew contracts with certain health care
30 providers; specifying requirements and
31 limitations for terminating certain contracts;
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1 specifying notice requirements; providing
2 application; providing an effective date.
3
4 Be It Enacted by the Legislature of the State of Florida:
5
6 Section 1. Section 408.7058, Florida Statutes, is
7 created to read:
8 408.7058 Statewide health care provider and health
9 maintenance organization qualification dispute resolution
10 program.--
11 (1) As used in this section:
12 (a) "Agency" means the Agency for Health Care
13 Administration.
14 (b) "Health care provider" or "provider" means any
15 health care practitioner as defined in s. 456.001.
16 (c) "Health insurer" or "insurer" means an entity
17 licensed under chapter 627.
18 (d) "Health maintenance organization" or
19 "organization" means an organization certified under part I of
20 chapter 641.
21 (e) "Qualification dispute" means any dispute between
22 an organization and a provider as to whether the provider
23 meets the organization's written qualification requirements
24 provided to the provider pursuant to s. 641.315(10).
25 (f) "Resolution organization" means a qualified
26 independent third-party claim dispute resolution entity
27 selected by and contracted with the agency.
28 (2)(a) The agency shall establish a program by January
29 1, 2003, to provide assistance to contracted and noncontracted
30 providers for resolution of qualification disputes that are
31 not resolved by a provider and an organization. The agency
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1 shall contract with a resolution organization to timely review
2 and consider qualification disputes submitted by providers and
3 recommend to the agency an appropriate resolution of those
4 disputes.
5 (b) The resolution organization shall review
6 qualification disputes filed by contracted and noncontracted
7 providers unless the dispute is the basis for an action
8 pending in state or federal court.
9 (3) The agency shall adopt rules to establish a
10 process to be used by the resolution organization in
11 considering qualification disputes submitted by a provider
12 which must include the issuance by the resolution organization
13 of a written recommendation, supported by findings of fact, to
14 the agency within 60 days after receipt of the dispute
15 submission. The written recommendation may include a
16 recommendation that a contract between the provider and the
17 organization not be terminated by the organization.
18 (4) Within 30 days after receipt of the recommendation
19 of the resolution organization, the agency shall adopt the
20 recommendation as a final order.
21 (5) The entity that does not prevail in the agency's
22 order shall pay a review cost to the review organization, as
23 determined by agency rule. If the nonprevailing party fails to
24 pay the ordered review cost within 35 days after the agency's
25 order, the nonpaying party is subject to a penalty of not more
26 than $500 per day until the penalty is paid.
27 (6) The agency may adopt rules to administer this
28 section.
29 Section 2. Section 641.315, Florida Statutes, is
30 amended to read:
31 641.315 Provider contracts.--
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1 (1) Each contract between a health maintenance
2 organization and a provider of health care services must be in
3 writing and must contain a provision that the subscriber is
4 not liable to the provider for any services for which the
5 health maintenance organization is liable as specified in s.
6 641.3154.
7 (2)(a) For All provider contracts executed after
8 October 1, 1991, and within 180 days after October 1, 1991,
9 for contracts in existence as of October 1, 1991:
10 1. The contracts must require the provider to give 60
11 days' advance written notice to the health maintenance
12 organization and the department before canceling the contract
13 with the health maintenance organization for any reason; and
14 2. The contract must also provide that nonpayment for
15 goods or services rendered by the provider to the health
16 maintenance organization is not a valid reason for avoiding
17 the 60-day advance notice of cancellation.
18 (b) All provider contracts must provide that the
19 health maintenance organization will provide 60 days' advance
20 written notice to the provider and the department before
21 canceling, without cause, the contract with the provider,
22 except in a case in which a patient's health is subject to
23 imminent danger or a physician's ability to practice medicine
24 is effectively impaired by an action by the Board of Medicine
25 or other governmental agency.
26 (3) Upon receipt by the health maintenance
27 organization of a 60-day cancellation notice, the health
28 maintenance organization may, if requested by the provider,
29 terminate the contract in less than 60 days if the health
30 maintenance organization is not financially impaired or
31 insolvent.
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1 (3)(4) Whenever a contract exists between a health
2 maintenance organization and a provider, the health
3 maintenance organization shall disclose to the provider:
4 (a) The mailing address or electronic address where
5 claims should be sent for processing;
6 (b) The telephone number that a provider may call to
7 have questions and concerns regarding claims addressed; and
8 (c) The address of any separate claims-processing
9 centers for specific types of services.
10
11 A health maintenance organization shall provide to its
12 contracted providers no less than 30 calendar days' prior
13 written notice of any changes in the information required in
14 this subsection.
15 (4)(5) A contract between a health maintenance
16 organization and a provider of health care services shall not
17 contain any provision restricting the provider's ability to
18 communicate information to the provider's patient regarding
19 medical care or treatment options for the patient when the
20 provider deems knowledge of such information by the patient to
21 be in the best interest of the health of the patient.
22 (5)(6) A contract between a health maintenance
23 organization and a provider of health care services may not
24 contain any provision that in any way prohibits or restricts:
25 (a) The health care provider from entering into a
26 commercial contract with any other health maintenance
27 organization; or
28 (b) The health maintenance organization from entering
29 into a commercial contract with any other health care
30 provider.
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1 (6)(a)(7) A health maintenance organization or health
2 care provider may not terminate a contract with a health care
3 provider or health maintenance organization unless the party
4 terminating the contract provides the terminated party with a
5 written reason for the proposed contract termination, which
6 may include termination for business reasons of the
7 terminating party. The reason provided in the notice required
8 in this section or any other information relating to the
9 reason for termination does not create any new administrative
10 or civil action and may not be used as substantive evidence in
11 any such action, but may be used for impeachment purposes. As
12 used in this subsection, the term "health care provider" means
13 a physician licensed under chapter 458, chapter 459, chapter
14 460, or chapter 461, or a dentist licensed under chapter 466.
15 (b) A health maintenance organization may terminate a
16 contract with a health care provider only if the provider
17 fails to comply with the organization's written terms and
18 conditions provided to the provider pursuant to subsection
19 (10). If an organization proposes to terminate a contract with
20 a provider, the organization shall provide the provider with
21 60 days' advance written notice of its intent to terminate the
22 provider's contract. This paragraph does not apply in cases
23 involving imminent harm to patient health or a final
24 disciplinary action by the provider's licensing board or other
25 governmental agency which impairs the provider's ability to
26 practice within the jurisdiction.
27 (c) If a health maintenance organization proposes to
28 terminate a contract of a health care provider pursuant to
29 this subsection, the organization shall not notify the
30 provider's patients of the proposed termination until the
31 effective date of the termination or the conclusion of the
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1 review or hearing provided in this section, whichever occurs
2 later. If a provider's contract is terminated for reasons
3 related to imminent harm to patient health, or a final
4 disciplinary action by the provider's licensing board or other
5 governmental agency, which impairs the provider's ability to
6 practice within the jurisdiction, the organization may notify
7 the provider's patients immediately.
8 (d) The notice of the proposed contract termination
9 provided by the health maintenance organization to the health
10 care provider shall include:
11 1. The specific term and condition established by the
12 organization that the organization alleges has been breached
13 by the provider which serves as the reason for the proposed
14 termination.
15 2. Notice that the provider has the right to request a
16 review before the statewide provider and health maintenance
17 organization qualification dispute resolution program created
18 under s. 408.7058.
19 3. A time limit of not less than 30 days within which
20 a provider may request a review.
21 (e) If a health care provider requests a review as
22 provided in paragraph (d), the health maintenance organization
23 shall provide to the provider a written notice that states the
24 names of the witnesses, if any, expected to testify at the
25 hearing on behalf of the organization.
26 (7)(8) The health maintenance organization must
27 establish written procedures for a contract provider to
28 request and the health maintenance organization to grant
29 authorization for utilization of health care services. The
30 health maintenance organization must give written notice to
31 the contract provider prior to any change in these procedures.
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1 (8)(9) A contract between a health maintenance
2 organization and a contracted primary care or admitting
3 physician may not contain any provision that prohibits such
4 physician from providing inpatient services in a contracted
5 hospital to a subscriber if such services are determined by
6 the organization to be medically necessary and covered
7 services under the organization's contract with the contract
8 holder.
9 (9)(10) A health maintenance organization shall not
10 require a contracted health care practitioner as defined in s.
11 456.001(4) to accept the terms of other health care
12 practitioner contracts with the health maintenance
13 organization or any insurer, or other health maintenance
14 organization, under common management and control with the
15 health maintenance organization, including Medicare and
16 Medicaid practitioner contracts and those authorized by s.
17 627.6471, s. 627.6472, or s. 641.315, except for a
18 practitioner in a group practice as defined in s. 456.053 who
19 must accept the terms of a contract negotiated for the
20 practitioner by the group, as a condition of continuation or
21 renewal of the contract. Any contract provision that violates
22 this section is void. A violation of this section is not
23 subject to the criminal penalty specified in s. 624.15.
24 (10) Each contract between a health maintenance
25 organization and a health care provider shall contain the
26 organization's terms and conditions that must be met by
27 providers contracting with the organization. The
28 organization's terms and conditions for contracting with the
29 organization may not be modified or amended, in any way, by
30 the organization during the term of the contract between the
31 organization and the provider. The provisions of this
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1 subsection may not be waived, voided, or nullified by
2 contract.
3 (11) A health maintenance organization which has a
4 market share of over 25 percent in a county in any of its
5 health maintenance organization plans shall not refuse to
6 enter into or renew a contract under such plan with any
7 licensed health care provider who is willing to meet the terms
8 and conditions established by the organization pursuant to
9 subsection (10), who practices within the geographic area
10 served by the organization, and whose credentials are verified
11 and examined by the organization pursuant to s. 641.495(6).
12 Section 3. Section 627.6474, Florida Statutes, is
13 amended to read:
14 627.6474 Provider contracts.--
15 (1) A health insurer shall not require a contracted
16 health care practitioner as defined in s. 456.001(4) to accept
17 the terms of other health care practitioner contracts with the
18 insurer or any other insurer, or health maintenance
19 organization, under common management and control with the
20 insurer, including Medicare and Medicaid practitioner
21 contracts and those authorized by s. 627.6471, s. 627.6472, or
22 s. 641.315, except for a practitioner in a group practice as
23 defined in s. 456.053 who must accept the terms of a contract
24 negotiated for the practitioner by the group, as a condition
25 of continuation or renewal of the contract. Any contract
26 provision that violates this subsection section is void. A
27 violation of this subsection section is not subject to the
28 criminal penalty specified in s. 624.15.
29 (2) Each contract between a health insurer and a
30 health care provider shall contain the insurer's terms and
31 conditions that must be met by providers contracting with the
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1 insurer. The insurer's terms and conditions for contracting
2 with a provider may not be modified or amended, in any way, by
3 the insurer during the term of the contract between the
4 insurer and the provider.
5 (3) A health insurer which has a market share of over
6 25 percent in a county in any of its plans shall not refuse to
7 enter into or renew a contract under such plan with any
8 licensed health care provider who is willing to meet the terms
9 and conditions established by the insurer pursuant to
10 subsection (2), who practices within the geographic area
11 served by the insurer, and whose credentials are verified and
12 examined by the insurer's system for verification and
13 examination of the credentials of each of its providers.
14 (4)(a) A health insurer or health care provider may
15 not terminate a contract with a health care provider or health
16 insurer unless the party terminating the contract provides the
17 terminated party with a written reason for the proposed
18 termination.
19 (b) A health insurer may terminate a contract with a
20 health care provider only if the provider fails to comply with
21 the insurer's written terms and conditions that have been
22 provided to the provider pursuant to subsection (2). If an
23 insurer proposes to terminate a contract with a provider, the
24 insurer shall provide the provider with 60 days' advance
25 written notice of the insurer's intent to terminate the
26 provider's contract. This paragraph does not apply in cases
27 involving imminent harm to patient health or a final
28 disciplinary action by the provider's licensing board or other
29 governmental agency which impairs the provider's ability to
30 practice within the jurisdiction.
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1 (c) If a health insurer proposes to terminate a
2 contract of a health care provider, the insurer shall not
3 notify the provider's patients of the proposed termination
4 until the effective date of the termination or the conclusion
5 of the review or hearing provided in this section, whichever
6 occurs later. If a provider's contract is terminated for
7 reasons related to imminent harm to patient health or a final
8 disciplinary action by the provider's licensing board or other
9 governmental agency which impairs the provider's ability to
10 practice within the jurisdiction, the insurer may notify the
11 provider's patients immediately.
12 (d) The notice of the proposed contract termination
13 provided by the health insurer to the health care provider
14 shall include:
15 1. The specific term and condition established by the
16 insurer that the insurer alleges has been breached by the
17 provider which serves as the reason for the proposed
18 termination.
19 2. Notice that the provider has the right to request a
20 review before the statewide provider and insurer qualification
21 dispute resolution program created pursuant to s. 408.7058.
22 3. A time limit of not less than 30 days within which
23 a provider may request a review.
24 (e) If the health care provider requests a review, the
25 provider shall be provided a written notice that states the
26 names of the witnesses, if any, expected to testify at the
27 hearing on behalf of the insurer.
28 (5) The provisions of this section shall apply to
29 contracts entered into pursuant to s. 627.6471 or s. 627.6472.
30 The provisions of this section may not be waived, voided, or
31 nullified by contract.
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1 Section 4. This act shall take effect July 1, 2002.
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4 HOUSE SUMMARY
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Requires the Agency for Health Care Administration to
6 establish a statewide health care provider and health
maintenance organization qualification dispute resolution
7 program to resolve contract disputes between health care
providers and health maintenance organizations. Revises
8 provisions for termination by a health maintenance
organization of a contract with a health care provider.
9 See bill for details.
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