SENATE AMENDMENT
    Bill No. CS for CS for SB 1202
    Amendment No. ___   Barcode 604654
                            CHAMBER ACTION
              Senate                               House
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       04/30/2003 11:07 AM         .                    
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11  Senator Bennett moved the following amendment:
12  
13         Senate Amendment (with title amendment) 
14         On page 29, line 26, through
15            page 75, line 24, delete those lines
16  
17  and insert:  
18         Section 8.  Section 408.7058, Florida Statutes, is
19  created to read:
20         408.7058  Statewide health care practitioner and
21  personal injury protection insurer claim dispute resolution
22  program.--
23         (1)  As used in this section:
24         (a)  "Agency" means the Agency for Health Care
25  Administration.
26         (b)  "Resolution organization" means a qualified
27  independent third-party claim dispute resolution entity
28  selected by and contracted with the Agency for Health Care
29  Administration.
30         (c)  "Health care practitioner" means a health care
31  practitioner defined in s. 456.001(4).
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    3:10 PM   04/28/03                              s1202c2c-21k0k

SENATE AMENDMENT Bill No. CS for CS for SB 1202 Amendment No. ___ Barcode 604654 1 (d) "Claim" means a claim for payment for services 2 submitted under s. 627.736(5). 3 (e) "Claim dispute" means a dispute between a health 4 care practitioner and an insurer as to the proper coding of a 5 charge submitted on a claim under s. 627.736(5) by a health 6 care practitioner, or as to the reasonableness of the amount 7 charged by the health care practitioner. 8 (f) "Insurer" means an insurer providing benefits 9 under s. 627.736. 10 (2)(a) The agency shall establish a program by January 11 1, 2004, to provide assistance to health care practitioners 12 and insurers for resolution of claim disputes that are not 13 resolved by the health care practitioner and the insurer. The 14 agency shall contract with a resolution organization to timely 15 review and consider claim disputes submitted by health care 16 practitioners and insurers and recommend to the agency an 17 appropriate resolution of those disputes. 18 (b) The resolution organization shall review claim 19 disputes filed by health care practitioners and insurers 20 pursuant to this section when a notice of participation is 21 submitted pursuant to subsection (3), unless a demand letter 22 has been submitted to the insurer under s. 627.736(11) or a 23 suit has been filed on the claim against the insurer relating 24 to the disputed claim. 25 (3) Resolutions by the resolution organization shall 26 be initiated as follows: 27 (a) A health care practitioner may initiate a dispute 28 resolution by submitting a notice of dispute within 10 days 29 after receipt of a payment under s. 627.736(5)(b), which 30 payment is less than the amount of the charge submitted on the 31 claim. The notice of dispute shall be submitted to both the 2 3:10 PM 04/28/03 s1202c2c-21k0k
SENATE AMENDMENT Bill No. CS for CS for SB 1202 Amendment No. ___ Barcode 604654 1 agency and the insurer by United States certified mail or 2 registered mail, return receipt requested. The health care 3 practitioner shall include with the notice of dispute any 4 documentation that the health care practitioner wishes the 5 resolution organization to consider which demonstrates that 6 the charge or charges submitted on the claim are reasonable. 7 The insurer shall have 10 days after the date of receipt of 8 the notice of dispute within which to submit both to the 9 resolution organization and the health care practitioner by 10 United States certified mail or registered mail, return 11 receipt requested, a notice of participation in the dispute 12 resolution and any documentation that the insurer wishes the 13 resolution organization to consider which demonstrates that 14 the charge or charges submitted on the claim are not 15 reasonable. 16 (b) An insurer may initiate a dispute resolution prior 17 to the claim being overdue, including any additional time the 18 insurer has to pay the claim pursuant to paragraph (4)(b), by 19 submitting a notice of dispute together with a payment to the 20 health care practitioner under s. 627.736(5)(b) of the amount 21 the insurer contends is the highest proper reasonable charge 22 for the claim. The notice of dispute shall be submitted to 23 both the agency and the health care practitioner by United 24 States certified mail or registered mail, return receipt 25 requested. The insurer shall include with the notice of 26 dispute any documentation that the insurer wishes the 27 resolution organization to consider which demonstrates that 28 the charge or charges submitted on the claim are not 29 reasonable. The health care practitioner shall have 10 days 30 after the date of receipt of the notice of dispute within 31 which to submit both to the resolution organization and the 3 3:10 PM 04/28/03 s1202c2c-21k0k
SENATE AMENDMENT Bill No. CS for CS for SB 1202 Amendment No. ___ Barcode 604654 1 insurer by United States certified mail or registered mail, 2 return receipt requested, a notice of participation in the 3 dispute resolution and any documentation that the health care 4 practitioner wishes the resolution organization to consider 5 which demonstrates that the charge or charges submitted on the 6 claim are reasonable. 7 (c) An insurer or health care practitioner may refuse 8 to participate in a dispute resolution by not submitting a 9 notice of participation in the dispute resolution pursuant to 10 paragraph (a) or (b). An insurer or health care practitioner 11 shall not be liable for the review costs, as established 12 pursuant to subsection (8), of the dispute resolution 13 conducted pursuant to this section unless it has participated 14 in the dispute resolution pursuant to this subsection and is 15 liable for such costs pursuant to subsection (6). 16 (d) Upon initiation of a dispute resolution pursuant 17 to this section, no demand letter under s. 627.736(11) may be 18 sent in regard to the subject matter of the dispute resolution 19 unless: 20 1. A notice of participation has not been timely 21 submitted pursuant to paragraphs (a) or (b); 22 2. The dispute resolution organization or the agency 23 has not been able to issue a notice of resolution or final 24 order within the time provided pursuant to subsection (6); or 25 3. The insurer has failed to pay the reasonable amount 26 pursuant to the final order adopting the notice of resolution 27 together with the interest and penalties specified in 28 subsection (6), if applicable. 29 (e) The applicable statute of limitations shall be 30 tolled while a dispute resolution is pending and for a period 31 of 15 business days following: 4 3:10 PM 04/28/03 s1202c2c-21k0k
SENATE AMENDMENT Bill No. CS for CS for SB 1202 Amendment No. ___ Barcode 604654 1 1. Expiration of time for the submission of a notice 2 of participation pursuant to paragraphs (a) or (b); 3 2. Expiration of time for the filing of the final 4 order adopting the notice of resolution pursuant to subsection 5 (6); or 6 3. The filing, with the agency clerk, of the final 7 order adopting the notice of resolution. 8 (4)(a) The resolution organization shall issue a 9 notice of resolution within 10 business days after the date 10 the organization receives all documentation from the health 11 care practitioner or the insurer pursuant to subsection (3). 12 (b) The resolution organization shall dismiss a notice 13 of dispute if: 14 1. The resolution organization has not received a 15 notice of participation pursuant to subsection (3) within 15 16 days after receiving a notice of dispute; or 17 2. The dispute resolution organization is unable to 18 issue a notice of resolution within the time provided by 19 subsection (5); however, the parties may with mutual agreement 20 extend the time for the issuance of the notice of resolution 21 by sending the dispute resolution organization a written 22 notice of extension signed by both parties and specifying the 23 date by which a notice of resolution must be issued or the 24 notice of dispute will be deemed dismissed. 25 (c) The resolution organization may, in its 26 discretion, schedule and conduct a telephone conference with 27 the health care practitioner and the insurer to facilitate the 28 dispute resolution in a cost-effective, efficient manner. 29 (d) In determining the reasonableness of a charge or 30 charges, the resolution organization may consider whether a 31 billing code or codes submitted on the claim are the codes 5 3:10 PM 04/28/03 s1202c2c-21k0k
SENATE AMENDMENT Bill No. CS for CS for SB 1202 Amendment No. ___ Barcode 604654 1 that accurately reflect the diagnostic or treatment service on 2 the claim or whether the billing code or codes should be 3 bundled or unbundled. 4 (e) In determining the reasonableness of a charge or 5 charges, the resolution organization shall determine whether 6 the charge or charges are less than or equal to the highest 7 reasonable charge or charges that represent the usual and 8 customary rates charged by similar health care practitioners 9 licensed under the same chapter for the geographic area of the 10 health care practitioner involved in the dispute, and, if the 11 charges in dispute are less than or equal to such charges, the 12 resolution organization shall find them reasonable. In 13 determining the usual and customary rates in accordance with 14 this paragraph, the dispute resolution organization may not 15 take into consideration any information relating to, or based 16 wholly or partially on, any governmentally set fee schedule or 17 any contracted-for or discounted rates charged by health care 18 practitioners who contract with health insurers, health 19 maintenance organizations, or managed care organizations. 20 (f) A health care practitioner, who must be licensed 21 under the same chapter as the health care practitioner 22 involved in the dispute, may be used to advise the resolution 23 organization if such advice will assist the resolution 24 organization in resolving the dispute in a more 25 cost-effective, efficient manner. 26 (5)(a) The resolution organization shall issue a 27 notice of resolution within 10 business days after receipt of 28 the notice of participation pursuant to subsection (3). The 29 notice of resolution shall be based upon findings of fact and 30 shall be considered a recommended order. The notice of 31 resolution shall be submitted to the health care practitioner 6 3:10 PM 04/28/03 s1202c2c-21k0k
SENATE AMENDMENT Bill No. CS for CS for SB 1202 Amendment No. ___ Barcode 604654 1 and the insurer by United States certified mail or registered 2 mail, return receipt requested, and to the agency. 3 (b) The notice of resolution shall state: 4 1. Whether the charge or charges submitted on the 5 claim are reasonable; or 6 2. If the resolution organization finds that any 7 charge or charges submitted on the claim are not reasonable, 8 the highest amount for such charge or charges that the 9 resolution organization finds to be reasonable. 10 (6)(a) In the event that the notice of resolution 11 finds that any charge or charges submitted on the claim are 12 not reasonable but that the highest reasonable charge or 13 charges are more than the amount or amounts paid by the 14 insurer, the insurer shall pay the additional amount found to 15 be reasonable within 10 business days after receipt of the 16 final order adopting the notice of resolution, together with 17 applicable interest under s. 627.736(4)(c) and a penalty of 10 18 percent of the additional amount found to be reasonable, 19 subject to a maximum penalty of $250. 20 (b) In the event that the notice of resolution finds 21 that the charge or charges submitted on the claim are 22 reasonable, the insurer shall pay the additional amount or 23 amounts found to be reasonable within 10 business days after 24 receipt of the final order adopting the notice of resolution, 25 together with applicable interest under s. 627.736(4)(c) and a 26 penalty of 20 percent of the additional amount found to be 27 reasonable, subject to a maximum penalty of $500. 28 (c) In the event that the final order adopting the 29 notice of resolution finds that the amount or amounts paid by 30 the insurer are equal to or greater than the highest 31 reasonable charge, the insurer shall not be liable for any 7 3:10 PM 04/28/03 s1202c2c-21k0k
SENATE AMENDMENT Bill No. CS for CS for SB 1202 Amendment No. ___ Barcode 604654 1 interest or penalties. 2 (d) The agency shall issue a final order adopting the 3 notice of resolution within 10 days after receipt of the 4 notice of resolution. The final order shall be submitted to 5 the health care practitioner and the insurer by United States 6 certified mail or registered mail, return receipt requested. 7 (7)(a) If the insurer has paid the highest reasonable 8 amount or amounts as determined by the final order adopting 9 the notice of resolution, together with the interest and 10 penalties provided in subsection (6), if applicable, then no 11 civil action by the health care practitioner shall lie against 12 the insurer on the basis of the reasonableness of the charge 13 or charges, and no attorney's fees may be awarded for legal 14 assistance related to the charge or charges. The injured party 15 is not liable for, and the health care practitioner shall not 16 bill the injured party for, any amounts other than the 17 copayment and any applicable deductible based on the highest 18 reasonable amount as determined by the final order adopting 19 the notice of resolution. 20 (b) The notice of dispute and all documents submitted 21 by the health care practitioner and the insurer, together with 22 the notice of resolution and the final order adopting the 23 notice of resolution, may be introduced into evidence in any 24 civil action if such documents are admissible pursuant to the 25 Florida Evidence Code. 26 (8) The insurer shall be responsible for payment of 27 the entirety of the review costs established pursuant to 28 subsection (9). 29 (9) The agency shall adopt rules to establish a 30 process to be used by the resolution organization in 31 considering claim disputes submitted by a health care 8 3:10 PM 04/28/03 s1202c2c-21k0k
SENATE AMENDMENT Bill No. CS for CS for SB 1202 Amendment No. ___ Barcode 604654 1 practitioner or insurer and the fees that may be charged by 2 the agency for processing disputes under this section. Such 3 fees may not exceed $75.00 for each review. 4 5 (Redesignate subsequent sections.) 6 7 8 ================ T I T L E A M E N D M E N T =============== 9 And the title is amended as follows: 10 On page 2, line 10, through 11 page 3, line 2, delete those lines 12 13 and insert: 14 vehicle insurance fraud; creating s. 408.7058, 15 F.S.; providing definitions; creating a dispute 16 resolution organization for disputes between 17 health care practitioners and insurers; 18 providing duties of the Agency for Health Care 19 Administration; providing duties of the dispute 20 resolution organization; providing procedures, 21 requirements, limitations, and restrictions for 22 resolving disputes; providing agency rulemaking 23 authority; amending 24 25 26 27 28 29 30 31 9 3:10 PM 04/28/03 s1202c2c-21k0k