Senate Bill sb0256
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Florida Senate - 2002 SB 256
By the Committee on Health, Aging and Long-Term Care
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1 A bill to be entitled
2 An act relating to the Subscriber Assistance
3 Program; amending s. 408.7056, F.S.;
4 redesignating the Statewide Provider and
5 Subscriber Assistance Program as the Subscriber
6 Assistance Program; requiring the Agency for
7 Health Care Administration to adopt rules
8 governing the hearing of grievances by the
9 Subscriber Assistance Panel; specifying
10 circumstances under which the agency or the
11 Department of Insurance may decline to issue an
12 initial order or emergency order recommended by
13 the panel; authorizing the agency or department
14 to require that the panel reconsider a
15 recommendation; requiring that the Agency for
16 Health Care Administration develop a training
17 program for panel members; amending ss.
18 641.3154, 641.511, 641.58, F.S.; redesignating
19 the Statewide Provider and Subscriber
20 Assistance Panel as the Subscriber Assistance
21 Panel; requiring that a subscriber or the
22 provider acting on behalf of a subscriber be
23 notified of the right to submit a written
24 grievance if a case is unresolved; providing an
25 effective date.
26
27 Be It Enacted by the Legislature of the State of Florida:
28
29 Section 1. 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) "Agency" means the Agency for Health Care
5 Administration.
6 (b) "Department" means the Department of Insurance.
7 (c) "Grievance procedure" means an established set of
8 rules that specify a process for appeal of an organizational
9 decision.
10 (d) "Health care provider" or "provider" means a
11 state-licensed or state-authorized facility, a facility
12 principally supported by a local government or by funds from a
13 charitable organization that holds a current exemption from
14 federal income tax under s. 501(c)(3) of the Internal Revenue
15 Code, a licensed practitioner, a county health department
16 established under part I of chapter 154, a prescribed
17 pediatric extended care center defined in s. 400.902, a
18 federally supported primary care program such as a migrant
19 health center or a community health center authorized under s.
20 329 or s. 330 of the United States Public Health Services Act
21 that delivers health care services to individuals, or a
22 community facility that receives funds from the state under
23 the Community Alcohol, Drug Abuse, and Mental Health Services
24 Act and provides mental health services to individuals.
25 (e) "Managed care entity" means a health maintenance
26 organization or a prepaid health clinic certified under
27 chapter 641, a prepaid health plan authorized under s.
28 409.912, or an exclusive provider organization certified under
29 s. 627.6472.
30 (f) "Panel" means a statewide provider and subscriber
31 assistance panel selected as provided in subsection (11).
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1 (2) The agency shall adopt and implement a program to
2 provide assistance to subscribers and providers, including
3 those whose grievances are not resolved by the managed care
4 entity to the satisfaction of the subscriber or provider. The
5 program shall consist of one or more panels that meet as often
6 as necessary to timely review, consider, and hear grievances
7 and recommend to the agency or the department any actions that
8 should be taken concerning individual cases heard by the
9 panel. The panel shall hear every grievance filed by
10 subscribers and providers on behalf of subscribers, unless the
11 grievance:
12 (a) Relates to a managed care entity's refusal to
13 accept a provider into its network of providers;
14 (b) Is part of an internal grievance in a Medicare
15 managed care entity or a reconsideration appeal through the
16 Medicare appeals process which does not involve a quality of
17 care issue;
18 (c) Is related to a health plan not regulated by the
19 state such as an administrative services organization,
20 third-party administrator, or federal employee health benefit
21 program;
22 (d) Is related to appeals by in-plan suppliers and
23 providers, unless related to quality of care provided by the
24 plan;
25 (e) Is part of a Medicaid fair hearing pursued under
26 42 C.F.R. ss. 431.220 et seq.;
27 (f) Is the basis for an action pending in state or
28 federal court;
29 (g) Is related to an appeal by nonparticipating
30 providers, unless related to the quality of care provided to a
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1 subscriber by the managed care entity and the provider is
2 involved in the care provided to the subscriber;
3 (h) Was filed before the subscriber or provider
4 completed the entire internal grievance procedure of the
5 managed care entity, the managed care entity has complied with
6 its timeframes for completing the internal grievance
7 procedure, and the circumstances described in subsection (6)
8 do not apply;
9 (i) Has been resolved to the satisfaction of the
10 subscriber or provider who filed the grievance, unless the
11 managed care entity's initial action is egregious or may be
12 indicative of a pattern of inappropriate behavior;
13 (j) Is limited to seeking damages for pain and
14 suffering, lost wages, or other incidental expenses, including
15 accrued interest on unpaid balances, court costs, and
16 transportation costs associated with a grievance procedure;
17 (k) Is limited to issues involving conduct of a health
18 care provider or facility, staff member, or employee of a
19 managed care entity which constitute grounds for disciplinary
20 action by the appropriate professional licensing board and is
21 not indicative of a pattern of inappropriate behavior, and the
22 agency or department has reported these grievances to the
23 appropriate professional licensing board or to the health
24 facility regulation section of the agency for possible
25 investigation; or
26 (l) Is withdrawn by the subscriber or provider.
27 Failure of the subscriber or the provider to attend the
28 hearing shall be considered a withdrawal of the grievance.
29 (3) The agency shall review all grievances within 60
30 days after receipt and make a determination whether the
31 grievance shall be heard. Once the agency notifies the panel,
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1 the subscriber or provider, and the managed care entity that a
2 grievance will be heard by the panel, the panel shall hear the
3 grievance either in the network area or by teleconference no
4 later than 120 days after the date the grievance was filed.
5 The agency shall notify the parties, in writing, by facsimile
6 transmission, or by phone, of the time and place of the
7 hearing. The panel may take testimony under oath, request
8 certified copies of documents, and take similar actions to
9 collect information and documentation that will assist the
10 panel in making findings of fact and a recommendation. The
11 panel shall issue a written recommendation, supported by
12 findings of fact, to the provider or subscriber, to the
13 managed care entity, and to the agency or the department no
14 later than 15 working days after hearing the grievance. The
15 agency must establish, by rule, procedures for the panel's
16 deliberations, including requirements for a quorum, procedures
17 for resolving a tie in a vote cast by the panel, the election
18 of a chairperson who shall preside and conduct each meeting of
19 the panel, requirements for each party to take an oath before
20 presenting his or her case to the panel, and requirements for
21 the time allotted for each party making a presentation and
22 rebuttal to the panel. If at the hearing the panel requests
23 additional documentation or additional records, the time for
24 issuing a recommendation is tolled until the information or
25 documentation requested has been provided to the panel.
26 Except as provided in this section, the proceedings of the
27 panel are not subject to chapter 120.
28 (4) If, upon receiving a proper patient authorization
29 along with a properly filed grievance, the agency requests
30 medical records from a health care provider or managed care
31 entity, the health care provider or managed care entity that
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1 has custody of the records has 10 days to provide the records
2 to the agency. Failure to provide requested medical records
3 may result in the imposition of a fine of up to $500. Each
4 day that records are not produced is considered a separate
5 violation.
6 (5) Grievances that the agency determines pose an
7 immediate and serious threat to a subscriber's health must be
8 given priority over other grievances. The panel may meet at
9 the call of the chair to hear the grievances as quickly as
10 possible but no later than 45 days after the date the
11 grievance is filed, unless the panel receives a waiver of the
12 time requirement from the subscriber. The panel shall issue a
13 written recommendation, supported by findings of fact, to the
14 department or the agency within 10 days after hearing the
15 expedited grievance.
16 (6) When the agency determines that the life of a
17 subscriber is in imminent and emergent jeopardy, the chair of
18 the panel may convene an emergency hearing, within 24 hours
19 after notification to the managed care entity and to the
20 subscriber, to hear the grievance. The grievance must be
21 heard notwithstanding that the subscriber has not completed
22 the internal grievance procedure of the managed care entity.
23 The panel shall, upon hearing the grievance, issue a written
24 emergency recommendation, supported by findings of fact, to
25 the managed care entity, to the subscriber, and to the agency
26 or the department for the purpose of deferring the imminent
27 and emergent jeopardy to the subscriber's life. Within 24
28 hours after receipt of the panel's emergency recommendation,
29 the agency or department may issue an emergency order to the
30 managed care entity. An emergency order remains in force
31 until:
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1 (a) The grievance has been resolved by the managed
2 care entity;
3 (b) Medical intervention is no longer necessary; or
4 (c) The panel has conducted a full hearing under
5 subsection (3) and issued a recommendation to the agency or
6 the department, and the agency or department has issued a
7 final order.
8 (7) After hearing a grievance, the panel shall make a
9 recommendation to the agency or the department which may
10 include specific actions the managed care entity must take to
11 comply with state laws or rules regulating managed care
12 entities.
13 (8) A managed care entity, subscriber, or provider
14 that is affected by a panel recommendation may within 10 days
15 after receipt of the panel's recommendation, or 72 hours after
16 receipt of a recommendation in an expedited grievance, furnish
17 to the agency or department written evidence in opposition to
18 the recommendation or findings of fact of the panel.
19 (9) No later than 30 days after the issuance of the
20 panel's recommendation and, for an expedited grievance, no
21 later than 10 days after the issuance of the panel's
22 recommendation, the agency or the department shall may adopt
23 the panel's recommendation or findings of fact in an initial a
24 proposed order or an emergency order, as provided in chapter
25 120, which it shall issue to the managed care entity. However,
26 the agency or department may decline to issue an initial order
27 or emergency order if the agency or department finds that
28 additional investigative information is needed to resolve the
29 subscriber's grievance or if the agency or department finds
30 that the panel's recommendation or findings of facts have been
31 improvidently issued by the panel. The agency or department
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1 may issue an initial a proposed order or an emergency order,
2 as provided in chapter 120, imposing fines or sanctions,
3 including those contained in ss. 641.25 and 641.52. The
4 agency or the department may reject all or part of the panel's
5 recommendation if the agency or department determines that the
6 panel's recommendation was improvidently issued. Within 30
7 days after the issuance of the panel's recommendation and, for
8 an expedited grievance, within 10 days after the issuance of
9 the panel's recommendation, if the agency or department finds
10 that the panel's recommendation was improvidently issued, the
11 agency or department may refer the matter back to the panel
12 for reconsideration of the case as it considers necessary for
13 further deliberation by the panel. All fines collected under
14 this subsection must be deposited into the Health Care Trust
15 Fund.
16 (10) In determining any fine or sanction to be
17 imposed, the agency and the department may consider the
18 following factors:
19 (a) The severity of the noncompliance, including the
20 probability that death or serious harm to the health or safety
21 of the subscriber will result or has resulted, the severity of
22 the actual or potential harm, and the extent to which
23 provisions of chapter 641 were violated.
24 (b) Actions taken by the managed care entity to
25 resolve or remedy any quality-of-care grievance.
26 (c) Any previous incidents of noncompliance by the
27 managed care entity.
28 (d) Any other relevant factors the agency or
29 department considers appropriate in a particular grievance.
30 (11) The panel shall consist of members employed by
31 the agency and members employed by the department, chosen by
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1 their respective agencies; a consumer appointed by the
2 Governor; a physician appointed by the Governor, as a standing
3 member; and physicians who have expertise relevant to the case
4 to be heard, on a rotating basis. The agency may contract with
5 a medical director and a primary care physician who shall
6 provide additional technical expertise to the panel. The
7 medical director shall be selected from a health maintenance
8 organization with a current certificate of authority to
9 operate in Florida. The agency shall develop a training
10 program for persons appointed to membership on the panel. The
11 program shall familiarize such persons with the substantive
12 and procedural laws and rules regarding their responsibilities
13 on the panel, including training with respect to the panel's
14 past recommendations and any subsequent agency action by the
15 agency or department in such cases.
16 (12) Every managed care entity shall submit a
17 quarterly report to the agency and the department listing the
18 number and the nature of all subscribers' and providers'
19 grievances that which have not been resolved to the
20 satisfaction of the subscriber or provider after the
21 subscriber or provider follows the entire internal grievance
22 procedure of the managed care entity. The agency shall notify
23 all subscribers and providers included in the quarterly
24 reports of their right to file an unresolved grievance with
25 the panel.
26 (13) Any information that which would identify a
27 subscriber or the spouse, relative, or guardian of a
28 subscriber and that which is contained in a report obtained by
29 the 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 (14) An initial A proposed order issued by the agency
2 or department which only requires the managed care entity to
3 take a specific action under subsection (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 (15)(a) Any information that which would identify a
10 subscriber or the spouse, relative, or guardian of a
11 subscriber and that which is contained in a document, report,
12 or record prepared or reviewed by the panel or obtained by the
13 agency pursuant to this section is confidential and exempt
14 from the provisions of s. 119.07(1) and s. 24(a), Art. I of
15 the State 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 that which
22 constitutes a trade secret as defined by s. 812.081; or
23 information relating to internal risk-management risk
24 management programs as defined in s. 641.55(5)(c), (6), and
25 (8) may be revealed at the panel meeting, in which case that
26 portion of the meeting during which such sensitive personal
27 information, trade secret information, or internal
28 risk-management-program risk management program information is
29 discussed shall be exempt from the provisions of s. 286.011
30 and s. 24(b), Art. I of the State Constitution. All closed
31 meetings shall be recorded by a certified court reporter.
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1
2 This subsection is subject to the Open Government Sunset
3 Review Act of 1995 in accordance with s. 119.15, and shall
4 stand repealed on October 2, 2003, unless reviewed and saved
5 from repeal through reenactment by the Legislature.
6 Section 2. Subsection (4) of section 641.3154, Florida
7 Statutes, is amended to read:
8 641.3154 Organization liability; provider billing
9 prohibited.--
10 (4) A provider or any representative of a provider,
11 regardless of whether the provider is under contract with the
12 health maintenance organization, may not collect or attempt to
13 collect money from, maintain any action at law against, or
14 report to a credit agency a subscriber of an organization for
15 payment of services for which the organization is liable, if
16 the provider in good faith knows or should know that the
17 organization is liable. This prohibition applies during the
18 pendency of any claim for payment made by the provider to the
19 organization for payment of the services and any legal
20 proceedings or dispute resolution process to determine whether
21 the organization is liable for the services if the provider is
22 informed that such proceedings are taking place. It is
23 presumed that a provider does not know and should not know
24 that an organization is liable unless:
25 (a) The provider is informed by the organization that
26 it accepts liability;
27 (b) A court of competent jurisdiction determines that
28 the organization is liable; or
29 (c) The department or agency makes a final
30 determination that the organization is required to pay for
31 such services subsequent to a recommendation made by the
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1 Statewide Provider and Subscriber Assistance Panel pursuant to
2 s. 408.7056.
3 Section 3. Subsection (1), paragraphs (b) and (e) of
4 subsection (3), paragraph (d) of subsection (4), paragraph (g)
5 of subsection (6), and subsections (9), (10), and (11) of
6 section 641.511, Florida Statutes, are amended to read:
7 641.511 Subscriber grievance reporting and resolution
8 requirements.--
9 (1) Each Every organization must have a grievance
10 procedure available to its subscribers for the purpose of
11 addressing complaints and grievances. Each Every organization
12 must notify its subscribers that a subscriber must submit a
13 grievance within 1 year after the date of occurrence of the
14 action that initiated the grievance, and may submit the
15 grievance for review to the Statewide Provider and Subscriber
16 Assistance Program panel as provided in s. 408.7056 after
17 receiving a final disposition of the grievance through the
18 organization's grievance process. An organization shall
19 maintain records of all grievances and shall report annually
20 to the agency the total number of grievances handled, a
21 categorization of the cases underlying the grievances, and the
22 final disposition of the grievances.
23 (3) Each organization's grievance procedure, as
24 required under subsection (1), must include, at a minimum:
25 (b) The names of the appropriate employees or a list
26 of grievance departments that are responsible for implementing
27 the organization's grievance procedure. The list must include
28 the address and the toll-free telephone number of each
29 grievance department, the address of the agency and its
30 toll-free telephone hotline number, and the address of the
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1 Statewide Provider and Subscriber Assistance Program and its
2 toll-free telephone number.
3 (e) A notice that a subscriber may voluntarily pursue
4 binding arbitration in accordance with the terms of the
5 contract if offered by the organization, after completing the
6 organization's grievance procedure and as an alternative to
7 the Statewide Provider and Subscriber Assistance Program. Such
8 notice shall include an explanation that the subscriber may
9 incur some costs if the subscriber pursues binding
10 arbitration, depending upon the terms of the subscriber's
11 contract.
12 (4)
13 (d) In any case in which when the review process does
14 not resolve a difference of opinion between the organization
15 and the subscriber or the provider acting on behalf of the
16 subscriber, the subscriber or the provider acting on behalf of
17 the subscriber may submit a written grievance to the Statewide
18 Provider and Subscriber Assistance Program.
19 (6)
20 (g) In any case in which when the expedited review
21 process does not resolve a difference of opinion between the
22 organization and the subscriber or the provider acting on
23 behalf of the subscriber, the subscriber or the provider
24 acting on behalf of the subscriber may submit a written
25 grievance to the Statewide Provider and Subscriber Assistance
26 Program. In the letter of final decision for any case in which
27 the expedited review does not resolve a difference of opinion
28 between the organization and the subscriber or the provider
29 acting on behalf of the subscriber, the organization must
30 notify the subscriber or the provider acting on behalf of the
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1 subscriber of the right to submit the written grievance to the
2 Subscriber Assistance Program.
3 (9)(a) The agency shall advise subscribers with
4 grievances to follow their organization's formal grievance
5 process for resolution prior to review by the Statewide
6 Provider and Subscriber Assistance Program. The subscriber
7 may, however, submit a copy of the grievance to the agency at
8 any time during the process.
9 (b) Requiring completion of the organization's
10 grievance process before the Statewide Provider and Subscriber
11 Assistance Program panel's review does not preclude the agency
12 from investigating any complaint or grievance before the
13 organization makes its final determination.
14 (10) Each organization must notify the subscriber in a
15 final decision letter that the subscriber may request review
16 of the organization's decision concerning the grievance by the
17 Statewide Provider and Subscriber Assistance Program, as
18 provided in s. 408.7056, if the grievance is not resolved to
19 the satisfaction of the subscriber. The final decision letter
20 must inform the subscriber that the request for review must be
21 made within 365 days after receipt of the final decision
22 letter, must explain how to initiate such a review, and must
23 include the addresses and toll-free telephone numbers of the
24 agency and the Statewide Provider and Subscriber Assistance
25 Program.
26 (11) Each organization, as part of its contract with
27 any provider, must require the provider to post a consumer
28 assistance notice prominently displayed in the reception area
29 of the provider and clearly noticeable by all patients. The
30 consumer assistance notice must state the addresses and
31 toll-free telephone numbers of the Agency for Health Care
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1 Administration, the Statewide Provider and Subscriber
2 Assistance Program, and the Department of Insurance. The
3 consumer assistance notice must also clearly state that the
4 address and toll-free telephone number of the organization's
5 grievance department shall be provided upon request. The
6 agency may adopt is authorized to promulgate rules necessary
7 to administer implement this section.
8 Section 4. Subsection (4) of section 641.58, Florida
9 Statutes, is amended to read:
10 641.58 Regulatory assessment; levy and amount; use of
11 funds; tax returns; penalty for failure to pay.--
12 (4) The moneys received and deposited into the Health
13 Care Trust Fund shall be used to defray the expenses of the
14 agency in the discharge of its administrative and regulatory
15 powers and duties under this part, including conducting an
16 annual survey of the satisfaction of members of health
17 maintenance organizations; contracting with physician
18 consultants for the Statewide Provider and Subscriber
19 Assistance Panel; maintaining offices and necessary supplies,
20 essential equipment, and other materials, salaries and
21 expenses of required personnel; and discharging the
22 administrative and regulatory powers and duties imposed under
23 this part.
24 Section 5. This act shall take effect July 1, 2002.
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2 SENATE SUMMARY
3 Redesignates the Statewide Provider and Subscriber
Assistance Program as the Subscriber Assistance Program
4 and the Statewide Provider and Subscriber Assistance
Panel as the Subscriber Assistance Panel. Requires that
5 the Agency for Health Care Administration adopt rules
governing the grievance hearings conducted by the panel.
6 Provides that the agency or the Department of Insurance
may decline to issue a recommendation of the panel if the
7 agency or department finds that additional information is
needed or that the panel's recommendation was issued
8 improvidently. Authorizes the agency or department to
require that the panel reconsider a recommendation.
9 Requires the Agency for Health Care Administration to
develop a training program for panel members. (See bill
10 for details.)
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