Senate Bill sb1202c2
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By the Committees on Appropriations; Banking and Insurance;
and Senator Alexander
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1 A bill to be entitled
2 An act relating to motor vehicle insurance
3 costs; providing a short title; providing
4 legislative findings and purpose; amending s.
5 119.105, F.S.; prohibiting disclosure of
6 confidential police reports for purposes of
7 commercial solicitation; amending s. 316.066,
8 F.S.; requiring the filing of a sworn statement
9 as a condition to accessing a crash report
10 stating the report will not be used for
11 commercial solicitation; providing a penalty;
12 creating part XIII of ch. 400, F.S., entitled
13 the Health Care Clinic Act; providing for
14 definitions and exclusions; providing for the
15 licensure, inspection, and regulation of health
16 care clinics by the Agency for Health Care
17 Administration; requiring licensure and
18 background screening; providing for clinic
19 inspections; providing rulemaking authority;
20 providing licensure fees; providing fines and
21 penalties for operating an unlicensed clinic;
22 providing for clinic responsibilities with
23 respect to personnel and operations; providing
24 accreditation requirements; providing for
25 injunctive proceedings and agency actions;
26 providing administrative penalties; amending s.
27 456.0375, F.S.; excluding certain entities from
28 clinic registration requirements; providing
29 retroactive application; amending s. 456.072,
30 F.S.; providing that making a claim with
31 respect to personal injury protection which is
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1 upcoded or which is submitted for payment of
2 services not rendered constitutes grounds for
3 disciplinary action; amending s. 626.7451,
4 F.S.; providing a per-policy fee to be remitted
5 to the insurer's Special Investigations Unit,
6 the Division of Insurance Fraud of the
7 Department of Financial Services, and the
8 Office of Statewide Prosecution for purposes of
9 preventing, detecting, and prosecuting motor
10 vehicle insurance fraud; amending s. 627.732,
11 F.S.; providing definitions; amending s.
12 627.736, F.S.; requiring that medical services
13 be lawfully rendered; providing allowable
14 amounts for specified services; requiring the
15 Department of Health, in consultation with
16 medical boards, to identify certain diagnostic
17 tests; specifying effective dates; providing
18 for application of fee schedules; specifying
19 effective dates; deleting certain provisions
20 governing arbitration; providing for compliance
21 with billing procedures; prohibiting insurers
22 from authorizing physicians to change opinion
23 in reports; providing requirements for
24 physicians with respect to maintaining such
25 reports; expanding provisions providing for a
26 demand letter; providing a medical peer review
27 process; providing requirements for alternative
28 dispute resolution; limiting attorney's fees if
29 matters are not resolved by medical peer review
30 and alternative dispute resolution; authorizing
31 the Financial Services Commission to determine
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1 cost savings under personal injury protection
2 benefits under specified conditions; amending
3 s. 627.739, F.S.; specifying application of a
4 deductible amount; amending s. 768.79, F.S.;
5 specifying applicability of provisions relating
6 to offer of judgment and demand for judgment;
7 amending s. 817.234, F.S.; providing that it is
8 a material omission and insurance fraud for a
9 physician or other provider to waive a
10 deductible or copayment or not collect the
11 total amount of a charge; increasing the
12 penalties for certain acts of solicitation of
13 accident victims; providing mandatory minimum
14 penalties; prohibiting certain solicitation of
15 accident victims; providing penalties;
16 prohibiting a person from participating in an
17 intentional motor vehicle accident for the
18 purpose of making motor vehicle tort claims;
19 providing penalties, including mandatory
20 minimum penalties; amending s. 817.236, F.S.;
21 increasing penalties for false and fraudulent
22 motor vehicle insurance application; creating
23 s. 817.2361, F.S.; prohibiting the creation or
24 use of false or fraudulent motor vehicle
25 insurance cards; providing penalties; amending
26 s. 921.0022, F.S.; revising the offense
27 severity ranking chart of the Criminal
28 Punishment Code to reflect changes in penalties
29 and the creation of additional offenses under
30 the act; providing legislative intent with
31 respect to the retroactive application of
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1 certain provisions; repealing s. 456.0375,
2 F.S., relating to the regulation of clinics by
3 the Department of Health; requiring certain
4 insurers to make a rate filing to conform the
5 per-policy fee to the requirements of the act;
6 specifying the application of any increase in
7 benefits approved by the Financial Services
8 Commission; providing for application of other
9 provisions of the act; requiring reports;
10 providing an appropriation and authorizing
11 additional positions; providing effective
12 dates.
13
14 Be It Enacted by the Legislature of the State of Florida:
15
16 Section 1. Florida Motor Vehicle Insurance
17 Affordability Reform Act; legislative findings; purpose.--
18 (1) This act may be cited as the "Florida Motor
19 Vehicle Insurance Affordability Reform Act."
20 (2) The Legislature finds and declares that:
21 (a) The Florida Motor Vehicle No-Fault Law, enacted 32
22 years ago, has provided valuable benefits over the years to
23 consumers in this state. The principle underlying the
24 philosophical basis of the no-fault or personal injury
25 protection (PIP) insurance system is that of a trade-off of
26 one benefit for another, specifically providing medical and
27 other benefits in return for a limitation on the right to sue
28 for nonserious injuries.
29 (b) The PIP insurance system has provided benefits in
30 the form of medical payments, lost wages, replacement
31
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1 services, funeral payments, and other benefits, without regard
2 to fault, to consumers injured in automobile accidents.
3 (c) However, the goals behind the adoption of the
4 no-fault law in 1971, which were to quickly and efficiently
5 compensate accident victims regardless of fault, to reduce the
6 volume of lawsuits by eliminating minor injuries from the tort
7 system, and to reduce overall motor vehicle insurance costs,
8 have been significantly compromised due to the fraud and abuse
9 that has permeated the PIP insurance market.
10 (d) Motor vehicle insurance fraud and abuse, other
11 than in the hospital setting, whether in the form of
12 inappropriate medical treatments, inflated claims, staged
13 accidents, solicitation of accident victims, falsification of
14 records, or in any other form, has increased premiums for
15 consumers and must be uncovered and vigorously prosecuted. The
16 problem of inappropriate medical treatment and inflated claims
17 for PIP have generally not occurred in the hospital setting.
18 (e) The no-fault system has been weakened in part due
19 to certain insurers not adequately or timely compensating
20 injured accident victims or health care providers. In
21 addition, the system has become increasingly litigious with
22 attorneys obtaining large fees by litigating, in certain
23 instances, over relatively small amounts that are in dispute.
24 There is an overwhelming public necessity to expand the
25 provisions of the demand letter, to establish an expedited
26 peer review process for medical issues and an expedited
27 alternative dispute resolution process for other issues, and
28 to minimize litigation costs and fees in order to encourage
29 settlements, decrease litigation, and maintain a healthy
30 insurance market.
31
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1 (f) It is a matter of great public importance that, in
2 order to provide a healthy and competitive automobile
3 insurance market, consumers be able to obtain affordable
4 coverage, insurers be entitled to earn an adequate rate of
5 return, and providers of services be compensated fairly.
6 (g) It is further a matter of great public importance
7 that, in order to protect the public's health, safety, and
8 welfare, it is necessary to enact the provisions contained in
9 this act in order to prevent PIP insurance fraud and abuse and
10 to curb escalating medical, legal, and other related costs,
11 and the Legislature finds that the provisions of this act are
12 the least restrictive actions necessary to achieve this goal.
13 (h) Therefore, the purpose of this act is to restore
14 the health of the PIP insurance market in Florida by
15 addressing these issues, preserving the no-fault system, and
16 realizing cost-savings for all people in this state.
17 Section 2. Section 119.105, Florida Statutes, is
18 amended to read:
19 119.105 Protection of victims of crimes or
20 accidents.--Police reports are public records except as
21 otherwise made exempt or confidential by general or special
22 law. Every person is allowed to examine nonexempt or
23 nonconfidential police reports. A No person who comes into
24 possession of exempt or confidential information contained in
25 police reports may not inspects or copies police reports for
26 the purpose of obtaining the names and addresses of the
27 victims of crimes or accidents shall use that any information
28 contained therein for any commercial solicitation of the
29 victims or relatives of the victims of the reported crimes or
30 accidents and may not knowingly disclose such information to
31 any third party for the purpose of such solicitation during
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1 the period of time that information remains exempt or
2 confidential. This section does not Nothing herein shall
3 prohibit the publication of such information to the general
4 public by any news media legally entitled to possess that
5 information or the use of such information for any other data
6 collection or analysis purposes by those entitled to possess
7 that information.
8 Section 3. Paragraph (c) of subsection (3) of section
9 316.066, Florida Statutes, is amended, and paragraph (f) is
10 added to that subsection, to read:
11 316.066 Written reports of crashes.--
12 (3)
13 (c) Crash reports required by this section which
14 reveal the identity, home or employment telephone number or
15 home or employment address of, or other personal information
16 concerning the parties involved in the crash and which are
17 received or prepared by any agency that regularly receives or
18 prepares information from or concerning the parties to motor
19 vehicle crashes are confidential and exempt from s. 119.07(1)
20 and s. 24(a), Art. I of the State Constitution for a period of
21 60 days after the date the report is filed. However, such
22 reports may be made immediately available to the parties
23 involved in the crash, their legal representatives, their
24 licensed insurance agents, their insurers or insurers to which
25 they have applied for coverage, persons under contract with
26 such insurers to provide claims or underwriting information,
27 prosecutorial authorities, radio and television stations
28 licensed by the Federal Communications Commission, newspapers
29 qualified to publish legal notices under ss. 50.011 and
30 50.031, and free newspapers of general circulation, published
31 once a week or more often, available and of interest to the
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1 public generally for the dissemination of news. For the
2 purposes of this section, the following products or
3 publications are not newspapers as referred to in this
4 section: those intended primarily for members of a particular
5 profession or occupational group; those with the primary
6 purpose of distributing advertising; and those with the
7 primary purpose of publishing names and other personally
8 identifying information concerning parties to motor vehicle
9 crashes. Any local, state, or federal agency, agent, or
10 employee that is authorized to have access to such reports by
11 any provision of law shall be granted such access in the
12 furtherance of the agency's statutory duties notwithstanding
13 the provisions of this paragraph. Any local, state, or federal
14 agency, agent, or employee receiving such crash reports shall
15 maintain the confidential and exempt status of those reports
16 and shall not disclose such crash reports to any person or
17 entity. As a condition precedent to accessing a Any person
18 attempting to access crash report reports within 60 days after
19 the date the report is filed, a person must present a valid
20 driver's license or other photographic identification, proof
21 of status legitimate credentials or identification that
22 demonstrates his or her qualifications to access that
23 information, and file a written sworn statement with the state
24 or local agency in possession of the information stating that
25 information from a crash report made confidential by this
26 section will not be used for any commercial solicitation of
27 accident victims, or knowingly disclosed to any third party
28 for the purpose of such solicitation, during the period of
29 time that the information remains confidential. In lieu of
30 requiring such photographic identification, proof of
31 qualifications, and written sworn statement, an agency may
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1 provide crash reports by electronic means to third-party
2 vendors approved by the Division of Insurance Fraud of the
3 Department of Financial Services, which vendors contractually
4 agree and represent that information from a crash report made
5 confidential by this section will not be used for any
6 commercial solicitation of accident victims by the vendors, or
7 knowingly disclosed to any third party for the purpose of such
8 solicitation, during the period of time that the information
9 remains confidential, and which vendors contractually agree
10 with the division to provide such crash reports solely to
11 insurers and to obtain from such insurers their agreement and
12 representation to use such reports solely for the adjustment
13 and investigations of claims and underwriting purposes. This
14 subsection does not prevent the dissemination or publication
15 of news to the general public by any legitimate media entitled
16 to access confidential information pursuant to this section. A
17 law enforcement officer as defined in s. 943.10(1) may enforce
18 this subsection. This exemption is subject to the Open
19 Government Sunset Review Act of 1995 in accordance with s.
20 119.15, and shall stand repealed on October 2, 2006, unless
21 reviewed and saved from repeal through reenactment by the
22 Legislature.
23 (d) Any employee of a state or local agency in
24 possession of information made confidential by this section
25 who knowingly discloses such confidential information to a
26 person not entitled to access such information under this
27 section is guilty of a felony of the third degree, punishable
28 as provided in s. 775.082, s. 775.083, or s. 775.084.
29 (e) Any person, knowing that he or she is not entitled
30 to obtain information made confidential by this section, who
31 obtains or attempts to obtain such information is guilty of a
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1 felony of the third degree, punishable as provided in s.
2 775.082, s. 775.083, or s. 775.084.
3 (f) Any person who knowingly uses confidential
4 information in violation of a filed written sworn statement or
5 contractual agreement required by this section commits a
6 felony of the third degree, punishable as provided in s.
7 775.082, s. 775.083, or s. 775.084.
8 Section 4. Effective October 1, 2003, part XIII of
9 chapter 400, Florida Statutes, consisting of sections 400.901,
10 400.903, 400.905, 400.907, 400.909, 400.911, 400.913, 400.915,
11 400.917, 400.919, and 400.921 is created to read:
12 400.901 Short title; legislative findings.--
13 (1) This part, consisting of ss. 400.901-400.921, may
14 be cited as the "Health Care Clinic Act."
15 (2) The Legislature finds that the regulation of
16 health care clinics must be strengthened to prevent
17 significant cost and harm to consumers. The purpose of this
18 part is to provide for the licensure, establishment, and
19 enforcement of basic standards for health care clinics and to
20 provide administrative oversight by the Agency for Health Care
21 Administration.
22 400.903 Definitions.--
23 (1) "Agency" means the Agency for Health Care
24 Administration.
25 (2) "Applicant" means an individual owner,
26 corporation, partnership, firm, business, association, or
27 other entity that owns or controls, directly or indirectly, 5
28 percent or more of an interest in the clinic and that applies
29 for a clinic license.
30 (3) "Clinic" means an entity at which health care
31 services are provided to individuals and which tenders charges
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1 for reimbursement for such services. For purposes of this part
2 the term does not include and the licensure requirements of
3 this part do not apply to:
4 (a) Entities licensed or registered by the state under
5 chapter 390, chapter 394, chapter 395, chapter 397, this
6 chapter, chapter 463, chapter 465, chapter 466, chapter 478,
7 chapter 480, chapter 484, or chapter 651.
8 (b) Entities that own, directly or indirectly,
9 entities licensed or registered by the state pursuant to
10 chapter 390, chapter 394, chapter 395, chapter 397, this
11 chapter, chapter 463, chapter 465, chapter 466, chapter 478,
12 chapter 480, chapter 484, or chapter 651.
13 (c) Entities that are owned, directly or indirectly,
14 by an entity licensed or registered by the state pursuant to
15 chapter 390, chapter 394, chapter, 395, chapter 397, this
16 chapter, chapter 463, chapter 465, chapter 466, chapter 478,
17 chapter 480, chapter 484, or chapter 651.
18 (d) Entities that are under common ownership, directly
19 or indirectly, with an entity licensed or registered by the
20 state pursuant to chapter 390, chapter 394, chapter 395,
21 chapter 397, this chapter, chapter 463, chapter 465, chapter
22 466, chapter 478, chapter 480, chapter 484, or chapter 651.
23 (e) An entity that is exempt from federal taxation
24 under 26 U.S.C. s. 501(c)(3) and any community college or
25 university clinic.
26 (f) A sole proprietorship, group practice,
27 partnership, or corporation that provides health care services
28 by licensed health care practitioners under chapter 457,
29 chapter 458, chapter 459, chapter 460, chapter 461, chapter
30 462, chapter 463, chapter 466, chapter 467, chapter 484,
31 chapter 486, chapter 490, chapter 491, or part I, part III,
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1 part X, part XIII, or part XIV of chapter 468, or s. 464.012,
2 which are wholly owned by a licensed health care practitioner,
3 or the licensed health care practitioner and the spouse,
4 parent, or child of a licensed health care practitioner, so
5 long as one of the owners who is a licensed health care
6 practitioner is supervising the services performed therein and
7 is legally responsible for the entity's compliance with all
8 federal and state laws. However, a health care practitioner
9 may not supervise services beyond the scope of the
10 practitioner's license.
11 (g) Clinical facilities affiliated with an accredited
12 medical school at which training is provided for medical
13 students, residents, or fellows.
14 (4) "Medical director" means a physician who is
15 employed or under contract with a clinic and who maintains a
16 full and unencumbered physician license in accordance with
17 chapter 458, chapter 459, chapter 460, or chapter 461.
18 However, if the clinic is limited to providing health care
19 services pursuant to chapter 457, chapter 484, chapter 486,
20 chapter 490, or chapter 491 or part I, part III, part X, part
21 XIII, or part XIV of chapter 468, the clinic may appoint a
22 health care practitioner licensed under that chapter to serve
23 as a clinic director who is responsible for the clinic's
24 activities. A health care practitioner may not serve as the
25 clinic director if the services provided at the clinic are
26 beyond the scope of that practitioner's license.
27 400.905 License requirements; background screenings;
28 prohibitions.--
29 (1) Each clinic, as defined in s. 400.903, must be
30 licensed and shall at all times maintain a valid license with
31 the agency. Each clinic location shall be licensed separately
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1 regardless of whether the clinic is operated under the same
2 business name or management as another clinic. Mobile clinics
3 must perform health care services only at a single location.
4 (2) The initial clinic license application shall be
5 filed with the agency by all clinics, as defined in s.
6 400.903, on or before March 1, 2004. A clinic license must be
7 renewed biennially.
8 (3) Applicants that submit an application on or before
9 March 1, 2004, which meets all requirements for initial
10 licensure as specified in this section shall receive a
11 temporary license until the completion of an initial
12 inspection verifying that the applicant meets all requirements
13 in rules authorized by s. 400.911. However, a clinic engaged
14 in magnetic resonance imaging services may not receive a
15 temporary license unless it presents evidence satisfactory to
16 the agency that such clinic is making a good-faith effort and
17 substantial progress in seeking accreditation required under
18 s. 400.915.
19 (4) Application for an initial clinic license or for
20 renewal of an existing license shall be notarized on forms
21 furnished by the agency and must be accompanied by the
22 appropriate license fee as provided in s. 400.911. The agency
23 shall take final action on an initial license application
24 within 60 days after receipt of all required documentation.
25 (5) The application shall contain information that
26 includes, but need not be limited to, information pertaining
27 to the name, residence and business address, phone number,
28 social security number, and license number of the medical or
29 clinic director, of the licensed medical providers employed or
30 under contract with the clinic, and of each person who,
31
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1 directly or indirectly, owns or controls 5 percent or more of
2 an interest in the clinic.
3 (6) The applicant must file with the application
4 satisfactory proof that the clinic is in compliance with this
5 part and applicable rules, including:
6 (a) A listing of services to be provided either
7 directly by the applicant or through contractual arrangements
8 with existing providers;
9 (b) The number and discipline of each professional
10 staff member to be employed; and
11 (c) Proof of financial ability to operate. An
12 applicant must demonstrate financial ability to operate a
13 clinic by submitting a balance sheet and an income and expense
14 statement for the first year of operation which provide
15 evidence of the applicant's having sufficient assets, credit,
16 and projected revenues to cover liabilities and expenses. The
17 applicant shall have demonstrated financial ability to operate
18 if the applicant's assets, credit, and projected revenues meet
19 or exceed projected liabilities and expenses. All documents
20 required under this subsection must be prepared in accordance
21 with generally accepted accounting principles, may be in a
22 compilation form, and the financial statement must be signed
23 by a certified public accountant.
24 (7) Each applicant for licensure shall comply with the
25 following requirements:
26 (a) As used in this subsection, the term "applicant"
27 means individuals owning or controlling, directly or
28 indirectly, 5 percent or more of an interest in a clinic; the
29 medical or clinic director, or a similarly titled person who
30 is responsible for the day-to-day operation of the licensed
31 clinic; the financial officer or similarly titled individual
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1 who is responsible for the financial operation of the clinic;
2 and licensed medical providers at the clinic.
3 (b) Upon receipt of a completed, signed, and dated
4 application, the agency shall require background screening of
5 the applicant, in accordance with the level 2 standards for
6 screening set forth in chapter 435. Proof of compliance with
7 the level 2 background screening requirements of chapter 435
8 which has been submitted within the previous 5 years in
9 compliance with any other health care licensure requirements
10 of this state is acceptable in fulfillment of this paragraph.
11 (c) Each applicant must submit to the agency, with the
12 application, a description and explanation of any exclusions,
13 permanent suspensions, or terminations of an applicant from
14 the Medicare or Medicaid programs. Proof of compliance with
15 the requirements for disclosure of ownership and control
16 interest under the Medicaid or Medicare programs may be
17 accepted in lieu of this submission. The description and
18 explanation may indicate whether such exclusions, suspensions,
19 or terminations were voluntary or not voluntary on the part of
20 the applicant.
21 (d) A license may not be granted to a clinic if the
22 applicant has been found guilty of, regardless of
23 adjudication, or has entered a plea of nolo contendere or
24 guilty to, any offense prohibited under the level 2 standards
25 for screening set forth in chapter 435, or a violation of
26 insurance fraud under s. 817.234, within the past 5 years. If
27 the applicant has been convicted of an offense prohibited
28 under the level 2 standards or insurance fraud in any
29 jurisdiction, the applicant must show that his or her civil
30 rights have been restored prior to submitting an application.
31
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1 (e) The agency may deny or revoke licensure if the
2 applicant has falsely represented any material fact or omitted
3 any material fact from the application required by this part.
4 (8) Requested information omitted from an application
5 for licensure, license renewal, or transfer of ownership must
6 be filed with the agency within 21 days after receipt of the
7 agency's request for omitted information, or the application
8 shall be deemed incomplete and shall be withdrawn from further
9 consideration.
10 (9) The failure to file a timely renewal application
11 shall result in a late fee charged to the facility in an
12 amount equal to 50 percent of the current license fee.
13 400.907 Clinic inspections; emergency suspension;
14 costs.--
15 (1) Any authorized officer or employee of the agency
16 shall make inspections of the clinic as part of the initial
17 license application or renewal application. The application
18 for a clinic license issued under this part or for a renewal
19 license constitutes permission for an appropriate agency
20 inspection to verify the information submitted on or in
21 connection with the application or renewal.
22 (2) An authorized officer or employee of the agency
23 may make unannounced inspections of clinics licensed pursuant
24 to this part as are necessary to determine that the clinic is
25 in compliance with this part and with applicable rules. A
26 licensed clinic shall allow full and complete access to the
27 premises and to billing records or information to any
28 representative of the agency who makes an inspection to
29 determine compliance with this part and with applicable rules.
30 (3) Failure by a clinic licensed under this part to
31 allow full and complete access to the premises and to billing
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1 records or information to any representative of the agency who
2 makes a request to inspect the clinic to determine compliance
3 with this part or failure by a clinic to employ a qualified
4 medical director or clinic director constitutes a ground for
5 emergency suspension of the license by the agency pursuant to
6 s. 120.60(6).
7 (4) In addition to any administrative fines imposed,
8 the agency may assess a fee equal to the cost of conducting a
9 complaint investigation.
10 400.909 License renewal; transfer of ownership;
11 provisional license.--
12 (1) An application for license renewal must contain
13 information as required by the agency.
14 (2) Ninety days before the expiration date, an
15 application for renewal must be submitted to the agency.
16 (3) The clinic must file with the renewal application
17 satisfactory proof that it is in compliance with this part and
18 applicable rules. If there is evidence of financial
19 instability, the clinic must submit satisfactory proof of its
20 financial ability to comply with the requirements of this
21 part.
22 (4) When transferring the ownership of a clinic, the
23 transferee must submit an application for a license at least
24 60 days before the effective date of the transfer.
25 (5) The license may not be sold, leased, assigned, or
26 otherwise transferred, voluntarily or involuntarily, and is
27 valid only for the clinic owners and location for which
28 originally issued.
29 (6) A clinic against whom a revocation or suspension
30 proceeding is pending at the time of license renewal may be
31 issued a provisional license effective until final disposition
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1 by the agency of such proceedings. If judicial relief is
2 sought from the final disposition, the agency that has
3 jurisdiction may issue a temporary permit for the duration of
4 the judicial proceeding.
5 400.911 Rulemaking authority; license fees.--
6 (1) The agency shall adopt rules necessary to
7 administer the clinic administration, regulation, and
8 licensure program, including rules establishing the specific
9 licensure requirements, procedures, forms, and fees. It shall
10 adopt rules establishing a procedure for the biennial renewal
11 of licenses. The rules shall specify the expiration dates of
12 licenses, the process of tracking compliance with financial
13 responsibility requirements, and any other conditions of
14 renewal required by law or rule.
15 (2) The agency shall adopt rules specifying
16 limitations on the number of licensed clinics and licensees
17 for which a medical director or a clinic director may assume
18 responsibility for purposes of this part. In determining the
19 quality of supervision a medical director or a clinic director
20 can provide, the agency shall consider the number of clinic
21 employees, the clinic location, and the health care services
22 provided by the clinic.
23 (3) License application and renewal fees must be
24 reasonably calculated by the agency to cover its costs in
25 carrying out its responsibilities under this part, including
26 the cost of licensure, inspection, and regulation of clinics,
27 and must be of such amount that the total fees collected do
28 not exceed the cost of administering and enforcing compliance
29 with this part. Clinic licensure fees are nonrefundable and
30 may not exceed $2,000. The agency shall adjust the license fee
31 annually by not more than the change in the Consumer Price
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1 Index based on the 12 months immediately preceding the
2 increase. All fees collected under this part must be deposited
3 in the Health Care Trust Fund for the administration of this
4 part.
5 400.913 Unlicensed clinics; penalties; fines;
6 verification of licensure status.--
7 (1) It is unlawful to own, operate, or maintain a
8 clinic without obtaining a license under this part.
9 (2) Any person who owns, operates, or maintains an
10 unlicensed clinic commits a felony of the third degree,
11 punishable as provided in s. 775.082, s. 775.083, or s.
12 775.084. Each day of continued operation is a separate
13 offense.
14 (3) Any person found guilty of violating subsection
15 (2) a second or subsequent time commits a felony of the second
16 degree, punishable as provided under s. 775.082, s. 775.083,
17 or s. 775.084. Each day of continued operation is a separate
18 offense.
19 (4) Any person who owns, operates, or maintains an
20 unlicensed clinic due to a change in this part or a
21 modification in agency rules within 6 months after the
22 effective date of such change or modification and who, within
23 10 working days after receiving notification from the agency,
24 fails to cease operation or apply for a license under this
25 part commits a felony of the third degree, punishable as
26 provided in s. 775.082, s. 775.083, or s. 775.084. Each day of
27 continued operation is a separate offense.
28 (5) Any clinic that fails to cease operation after
29 agency notification may be fined for each day of noncompliance
30 pursuant to this part.
31
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1 (6) When a person has an interest in more than one
2 clinic, and fails to obtain a license for any one of these
3 clinics, the agency may revoke the license, impose a
4 moratorium, or impose a fine pursuant to this part on any or
5 all of the licensed clinics until such time as the unlicensed
6 clinic is licensed or ceases operation.
7 (7) Any person aware of the operation of an unlicensed
8 clinic must report that facility to the agency.
9 (8) Any health care provider who is aware of the
10 operation of an unlicensed clinic shall report that facility
11 to the agency. Failure to report a clinic that the provider
12 knows or has reasonable cause to suspect is unlicensed shall
13 be reported to the provider's licensing board.
14 (9) The agency may not issue a license to a clinic
15 that has any unpaid fines assessed under this part.
16 400.915 Clinic responsibilities.--
17 (1) Each clinic shall appoint a medical director or
18 clinic director who shall agree in writing to accept legal
19 responsibility for the following activities on behalf of the
20 clinic. The medical director or the clinic director shall:
21 (a) Have signs identifying the medical director or
22 clinic director posted in a conspicuous location within the
23 clinic readily visible to all patients.
24 (b) Ensure that all practitioners providing health
25 care services or supplies to patients maintain a current
26 active and unencumbered Florida license.
27 (c) Review any patient referral contracts or
28 agreements executed by the clinic.
29 (d) Ensure that all health care practitioners at the
30 clinic have active appropriate certification or licensure for
31 the level of care being provided.
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1 (e) Serve as the clinic records owner as defined in s.
2 456.057.
3 (f) Ensure compliance with the recordkeeping, office
4 surgery, and adverse incident reporting requirements of
5 chapter 456, the respective practice acts, and rules adopted
6 under this part.
7 (g) Conduct systematic reviews of clinic billings to
8 ensure that the billings are not fraudulent or unlawful. Upon
9 discovery of an unlawful charge, the medical director or
10 clinic director shall take immediate corrective action.
11 (2) Any business that becomes a clinic after
12 commencing operations must, within 5 days after becoming a
13 clinic, file a license application under this part and shall
14 be subject to all provisions of this part applicable to a
15 clinic.
16 (3) Any contract to serve as a medical director or a
17 clinic director entered into or renewed by a physician or a
18 licensed health care practitioner in violation of this part is
19 void as contrary to public policy. This subsection shall apply
20 to contracts entered into or renewed on or after March 1,
21 2004.
22 (4) All charges or reimbursement claims made by or on
23 behalf of a clinic that is required to be licensed under this
24 part, but that is not so licensed, or that is otherwise
25 operating in violation of this part, are unlawful charges, and
26 therefore are noncompensable and unenforceable.
27 (5) Any person establishing, operating, or managing an
28 unlicensed clinic otherwise required to be licensed under this
29 part, or any person who knowingly files a false or misleading
30 license application or license renewal application, or false
31 or misleading information related to such application or
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1 department rule, commits a felony of the third degree,
2 punishable as provided in s. 775.082, s. 775.083, or s.
3 775.084.
4 (6) Any licensed health care provider who violates
5 this part is subject to discipline in accordance with this
6 chapter and his or her respective practice act.
7 (7) The agency may fine, or suspend or revoke the
8 license of, any clinic licensed under this part for operating
9 in violation of the requirements of this part or the rules
10 adopted by the agency.
11 (8) The agency shall investigate allegations of
12 noncompliance with this part and the rules adopted under this
13 part.
14 (9) Any person or entity providing health care
15 services which is not a clinic, as defined under s. 400.903,
16 may voluntarily apply for licensure under its exempt status
17 with the agency on a form that sets forth its name or names
18 and addresses, a statement of the reasons why it cannot be
19 defined as a clinic, and other information deemed necessary by
20 the agency.
21 (10) The clinic shall display its license in a
22 conspicuous location within the clinic readily visible to all
23 patients.
24 (11)(a) Each clinic engaged in magnetic resonance
25 imaging services must be accredited by the Joint Commission on
26 Accreditation of Healthcare Organizations, the American
27 College of Radiology, or the Accreditation Association for
28 Ambulatory Health Care, within 1 year after licensure.
29 However, a clinic may request a single, 6-month extension if
30 it provides evidence to the agency establishing that, for good
31 cause shown, such clinic can not be accredited within 1 year
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1 after licensure, and that such accreditation will be completed
2 within the 6-month extension.
3 (b) The agency may disallow the application of any
4 entity formed for the purpose of avoiding compliance with the
5 accreditation provisions of this subsection and whose
6 principals were previously principals of an entity that was
7 unable to meet the accreditation requirements within the
8 specified timeframes. The agency may adopt rules as to the
9 accreditation of magnetic resonance imaging clinics.
10 (12) The agency shall give full faith and credit
11 pertaining to any past variance and waiver granted to a
12 magnetic resonance imaging clinic from Rule 64-2002, Florida
13 Administrative Code, by the Department of Health, until
14 September 2004. After that date, such clinic must request a
15 variance and waiver from the agency under s. 120.542.
16 400.917 Injunctions.--
17 (1) The agency may institute injunctive proceedings in
18 a court of competent jurisdiction in order to:
19 (a) Enforce the provisions of this part or any minimum
20 standard, rule, or order issued or entered into pursuant to
21 this part if the attempt by the agency to correct a violation
22 through administrative fines has failed; if the violation
23 materially affects the health, safety, or welfare of clinic
24 patients; or if the violation involves any operation of an
25 unlicensed clinic.
26 (b) Terminate the operation of a clinic if a violation
27 of any provision of this part, or any rule adopted pursuant to
28 this part, materially affects the health, safety, or welfare
29 of clinic patients.
30 (2) Such injunctive relief may be temporary or
31 permanent.
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1 (3) If action is necessary to protect clinic patients
2 from life-threatening situations, the court may allow a
3 temporary injunction without bond upon proper proof being
4 made. If it appears by competent evidence or a sworn,
5 substantiated affidavit that a temporary injunction should
6 issue, the court, pending the determination on final hearing,
7 shall enjoin operation of the clinic.
8 400.919 Agency actions.--Administrative proceedings
9 challenging agency licensure enforcement action shall be
10 reviewed on the basis of the facts and conditions that
11 resulted in the agency action.
12 400.921 Agency administrative penalties.--
13 (1) The agency may impose administrative penalties
14 against clinics of up to $5,000 per violation for violations
15 of the requirements of this part. In determining if a penalty
16 is to be imposed and in fixing the amount of the fine, the
17 agency shall consider the following factors:
18 (a) The gravity of the violation, including the
19 probability that death or serious physical or emotional harm
20 to a patient will result or has resulted, the severity of the
21 action or potential harm, and the extent to which the
22 provisions of the applicable laws or rules were violated.
23 (b) Actions taken by the owner, medical director, or
24 clinic director to correct violations.
25 (c) Any previous violations.
26 (d) The financial benefit to the clinic of committing
27 or continuing the violation.
28 (2) Each day of continuing violation after the date
29 fixed for termination of the violation, as ordered by the
30 agency, constitutes an additional, separate, and distinct
31 violation.
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1 (3) Any action taken to correct a violation shall be
2 documented in writing by the owner, medical director, or
3 clinic director of the clinic and verified through followup
4 visits by agency personnel. The agency may impose a fine and,
5 in the case of an owner-operated clinic, revoke or deny a
6 clinic's license when a clinic medical director or clinic
7 director fraudulently misrepresents actions taken to correct a
8 violation.
9 (4) For fines that are upheld following administrative
10 or judicial review, the violator shall pay the fine, plus
11 interest at the rate as specified in s. 55.03, for each day
12 beyond the date set by the agency for payment of the fine.
13 (5) Any unlicensed clinic that continues to operate
14 after agency notification is subject to a $1,000 fine per day.
15 (6) Any licensed clinic whose owner, medical director,
16 or clinic director concurrently operates an unlicensed clinic
17 shall be subject to an administrative fine of $5,000 per day.
18 (7) Any clinic whose owner fails to apply for a
19 change-of-ownership license in accordance with s. 400.909 and
20 operates the clinic under the new ownership is subject to a
21 fine of $5,000.
22 (8) The agency, as an alternative to or in conjunction
23 with an administrative action against a clinic for violations
24 of this part and adopted rules, shall make a reasonable
25 attempt to discuss each violation and recommended corrective
26 action with the owner, medical director, or clinic director of
27 the clinic, prior to written notification. The agency, instead
28 of fixing a period within which the clinic shall enter into
29 compliance with standards, may request a plan of corrective
30 action from the clinic which demonstrates a good-faith effort
31
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1 to remedy each violation by a specific date, subject to the
2 approval of the agency.
3 (9) Administrative fines paid by any clinic under this
4 section shall be deposited into the Health Care Trust Fund.
5 Section 5. Paragraph (b) of subsection (1) of section
6 456.0375, Florida Statutes, is amended to read:
7 456.0375 Registration of certain clinics;
8 requirements; discipline; exemptions.--
9 (1)
10 (b) For purposes of this section, the term "clinic"
11 does not include and the registration requirements herein do
12 not apply to:
13 1. Entities licensed or registered by the state
14 pursuant to chapter 390, chapter 394, chapter 395, chapter
15 397, chapter 400, chapter 463, chapter 465, chapter 466,
16 chapter 478, chapter 480, or chapter 484, or chapter 651.
17 2. Entities that own, directly or indirectly, entities
18 licensed or registered by the state pursuant to chapter 390,
19 chapter 394, chapter 395, chapter 397, chapter 400, chapter
20 463, chapter 465, chapter 466, chapter 478, chapter 480,
21 chapter 484, or chapter 651.
22 3. Entities that are owned, directly or indirectly, by
23 an entity licensed or registered by the state pursuant to
24 chapter 390, chapter 394, chapter 395, chapter 397, chapter
25 400, chapter 463, chapter 465, chapter 466, chapter 478,
26 chapter 480, chapter 484, or chapter 651.
27 4. Entities that are under common ownership, directly
28 or indirectly, with an entity licensed or registered by the
29 state pursuant to chapter 390, chapter 394, chapter 395,
30 chapter 397, chapter 400, chapter 463, chapter 465, chapter
31 466, chapter 478, chapter 480, chapter 484, or chapter 651.
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1 5.2. Entities exempt from federal taxation under 26
2 U.S.C. s. 501(c)(3) and community college and university
3 clinics.
4 6.3. Sole proprietorships, group practices,
5 partnerships, or corporations that provide health care
6 services by licensed health care practitioners pursuant to
7 chapters 457, 458, 459, 460, 461, 462, 463, 466, 467, 484,
8 486, 490, 491, or part I, part III, part X, part XIII, or part
9 XIV of chapter 468, or s. 464.012, which are wholly owned by
10 licensed health care practitioners or the licensed health care
11 practitioner and the spouse, parent, or child of a licensed
12 health care practitioner, so long as one of the owners who is
13 a licensed health care practitioner is supervising the
14 services performed therein and is legally responsible for the
15 entity's compliance with all federal and state laws. However,
16 no health care practitioner may supervise services beyond the
17 scope of the practitioner's license.
18 7. Clinical facilities affiliated with an accredited
19 medical school at which training is provided for medical
20 students, residents, or fellows.
21 Section 6. Paragraphs (dd) and (ee) are added to
22 subsection (1) of section 456.072, Florida Statutes, to read:
23 456.072 Grounds for discipline; penalties;
24 enforcement.--
25 (1) The following acts shall constitute grounds for
26 which the disciplinary actions specified in subsection (2) may
27 be taken:
28 (dd) With respect to making a personal injury
29 protection claim as required by s. 627.736, intentionally
30 submitting a claim, statement, or bill that has been upcoded.
31 "Upcoding" means an action that submits a billing code that
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1 would result in payment greater in amount than would be paid
2 using a billing code that accurately describes the services
3 performed. "Upcoding" does not include an otherwise lawful
4 bill by an independent diagnostic testing facility, as defined
5 in s. 627.732, which globally combines both technical and
6 professional components for services listed in that
7 definition, if the amount of the global bill is not more than
8 the components if billed separately; however, payment of such
9 a bill constitutes payment in full for all components of such
10 service.
11 (ee) With respect to making a personal injury
12 protection claim as required by s. 627.736, intentionally
13 submitting a claim, statement, or bill for payment of services
14 that were not rendered.
15 Section 7. Subsection (11) of section 626.7451,
16 Florida Statutes, is amended to read:
17 626.7451 Managing general agents; required contract
18 provisions.--No person acting in the capacity of a managing
19 general agent shall place business with an insurer unless
20 there is in force a written contract between the parties which
21 sets forth the responsibility for a particular function,
22 specifies the division of responsibilities, and contains the
23 following minimum provisions:
24 (11) A licensed managing general agent, when placing
25 business with an insurer under this code, may charge a
26 per-policy fee not to exceed $40 $25. In no instance shall
27 the aggregate of per-policy fees for a placement of business
28 authorized under this section, when combined with any other
29 per-policy fee charged by the insurer, result in per-policy
30 fees which exceed the aggregate amount of $40 $25. The
31 per-policy fee shall be a component of the insurer's rate
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1 filing and shall be fully earned. A managing general agent
2 that collects a per-policy fee shall remit a minimum of $5 per
3 policy to the insurer for the funding of a Special
4 Investigations Unit dedicated to the prevention of insurance
5 fraud; $2 per policy to the Division of Insurance Fraud of the
6 Department of Financial Services, which shall be dedicated to
7 the prevention and detection of insurance fraud; and $3 per
8 policy to the Office of Statewide Prosecution, which shall be
9 dedicated to the prosecution of insurance fraud. Any insurer
10 that writes directly without a managing general agent and that
11 charges a per-policy fee may charge an additional policy fee
12 up to $5 per policy to fund its Special Investigations Unit,
13 which shall be dedicated to the prevention of insurance fraud;
14 up to $2 per policy to be remitted to the Division of
15 Insurance Fraud of the Department of Financial Services, which
16 shall be dedicated to the prevention and detection of
17 insurance fraud; and up to $3 per policy to the Office of
18 Statewide Prosecution, which shall be dedicated to the
19 prosecution of insurance fraud.
20
21 For the purposes of this section and ss. 626.7453 and
22 626.7454, the term "controlling person" or "controlling" has
23 the meaning set forth in s. 625.012(5)(b)1., and the term
24 "controlled person" or "controlled" has the meaning set forth
25 in s. 625.012(5)(b)2.
26 Section 8. Subsection (1) of section 627.732, Florida
27 Statutes, is amended, and subsections (8) through (19) are
28 added to that section, to read:
29 627.732 Definitions.--As used in ss. 627.730-627.7405,
30 the term:
31
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1 (1) "Broker" means any person not possessing a license
2 under chapter 395, chapter 400, chapter 458, chapter 459,
3 chapter 460, chapter 461, or chapter 641 who charges or
4 receives compensation for any use of medical equipment and is
5 not the 100-percent owner or the 100-percent lessee of such
6 equipment. For purposes of this section, such owner or lessee
7 may be an individual, a corporation, a partnership, or any
8 other entity and any of its 100-percent-owned affiliates and
9 subsidiaries. For purposes of this subsection, the term
10 "lessee" means a long-term lessee under a capital or operating
11 lease, but does not include a part-time lessee. The term
12 "broker" does not include a hospital or physician management
13 company whose medical equipment is ancillary to the practices
14 managed, a debt collection agency, or an entity that has
15 contracted with the insurer to obtain a discounted rate for
16 such services; nor does the term include a management company
17 that has contracted to provide general management services for
18 a licensed physician or health care facility and whose
19 compensation is not materially affected by the usage or
20 frequency of usage of medical equipment or an entity that is
21 100-percent owned by one or more hospitals or physicians. The
22 term "broker" does not include a person or entity that
23 certifies, upon request of an insurer, that:
24 (a) It is a clinic registered under s. 456.0375;
25 (b) It is a 100-percent owner of medical equipment;
26 and
27 (c) The owner's only part-time lease of medical
28 equipment for personal injury protection patients is on a
29 temporary basis not to exceed 30 days in a 12-month period,
30 and such lease is solely for the purposes of necessary repair
31 or maintenance of the 100-percent-owned medical equipment or
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1 pending the arrival and installation of the newly purchased or
2 a replacement for the 100-percent-owned medical equipment, or
3 for patients for whom, because of physical size or
4 claustrophobia, it is determined by the medical director or
5 clinical director to be medically necessary that the test be
6 performed in medical equipment that is open-style. The leased
7 medical equipment cannot be used by patients who are not
8 patients of the registered clinic for medical treatment of
9 services. Any person or entity making a false certification
10 under this subsection commits insurance fraud as defined in s.
11 817.234. However, the 30-day period provided in this paragraph
12 may be extended for an additional 60 days as applicable to
13 magnetic resonance imaging equipment if the owner certifies
14 that the extension otherwise complies with this paragraph.
15 (8) "Certify" means to swear or attest to being true
16 or represented in writing.
17 (9) "Countersigned" means a second or verifying
18 signature, as on a previously signed document, and is not
19 satisfied by the statement "signature on file" or any similar
20 statement.
21 (10) "Immediate personal supervision," as it relates
22 to the performance of medical services by nonphysicians not in
23 a hospital, means that an individual licensed to perform the
24 medical service or provide the medical supplies must be
25 present within the confines of the physical structure where
26 the medical services are performed or where the medical
27 supplies are provided such that the licensed individual can
28 physically see the activities of all employees and respond
29 immediately to any emergencies if needed.
30 (11) "Incident," with respect to services considered
31 as incident to a physician's professional service, for a
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1 physician licensed under chapter 458, chapter 459, chapter
2 460, or chapter 461, if not furnished in a hospital, means
3 such services must be an integral, even if incidental, part of
4 a covered physician's service.
5 (12) "Knowingly" means that a person, with respect to
6 information, has actual knowledge of the information; acts in
7 deliberate ignorance of the truth or falsity of the
8 information; or acts in reckless disregard of the information,
9 and proof of specific intent to defraud is not required.
10 (13) "Lawful" or "lawfully" means in compliance with
11 all applicable criminal, civil, and administrative
12 requirements of state and federal law related to the provision
13 of medical services or treatment.
14 (14) "Hospital" means a facility that, at the time
15 services or treatment were rendered, was licensed under
16 chapter 395.
17 (15) "Properly completed" means providing truthful,
18 complete, and accurate responses to each applicable request
19 for information or statement by a means that may lawfully be
20 provided and that complies with this section, or as agreed by
21 the parties.
22 (16) "Render," with respect to the license required in
23 the performance of medical services or treatment, means to
24 have properly licensed personnel actually physically perform
25 the medical service or physically transfer the supplies to the
26 insured incident to the provider's professional services. The
27 term does not include scheduling medical services or ordering
28 medical supplies for the insured.
29 (17) "Upcoding" means an action that submits a billing
30 code that would result in payment greater in amount than would
31 be paid using a billing code that accurately describes the
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1 services performed. The term does not include an otherwise
2 lawful bill by an independent diagnostic treating facility,
3 which globally combines both technical and professional
4 components for services listed in that definition, if the
5 amount of the global bill is not more than the components if
6 billed separately; however, payment of such a bill constitutes
7 payment in full for all components of such service.
8 (18) "Unbundling" means an action that submits a
9 billing code that is properly billed under one billing code,
10 but that has been separated into two or more billing codes,
11 and would result in payment greater in amount than would be
12 paid using one billing code.
13 (19) "Independent diagnostic testing facility" means a
14 fixed facility that performs the technical component of
15 magnetic resonance imaging, static radiographs (static X ray),
16 computer tomography, positron emission tomography, and also
17 provides the professional components of such services through
18 either an employee or independent contractor, if:
19 (a) No person ordering or prescribing such services
20 has any financial interest in the facility providing such
21 services and no such person receives any consideration
22 directly or indirectly from such facility for ordering or
23 prescribing such services; and
24 (b) The facility does not directly or indirectly
25 provide therapy or treatment services to patients for which it
26 also provides such diagnostic services.
27 Section 9. Subsections (3), (4), (5), (6), (7), (8),
28 (10), and (11) of section 627.736, Florida Statutes, are
29 amended, present subsection (12) of that section is
30 redesignated as subsection (14) and amended, and new
31
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1 subsections (12), (13), and (15) are added to that section, to
2 read:
3 627.736 Required personal injury protection benefits;
4 exclusions; priority; claims.--
5 (3) INSURED'S RIGHTS TO RECOVERY OF SPECIAL DAMAGES IN
6 TORT CLAIMS.--No insurer shall have a lien on any recovery in
7 tort by judgment, settlement, or otherwise for personal injury
8 protection benefits, whether suit has been filed or settlement
9 has been reached without suit. An injured party who is
10 entitled to bring suit under the provisions of ss.
11 627.730-627.7405, or his or her legal representative, shall
12 have no right to recover any damages for which personal injury
13 protection benefits are paid or payable. The plaintiff may
14 prove all of his or her special damages notwithstanding this
15 limitation, but if special damages are introduced in evidence,
16 the trier of facts, whether judge or jury, shall not award
17 damages for personal injury protection benefits paid or
18 payable. In all cases in which a jury is required to fix
19 damages, the court shall instruct the jury that the plaintiff
20 shall not recover such special damages for personal injury
21 protection benefits paid or payable.
22 (4) BENEFITS; WHEN DUE.--Benefits due from an insurer
23 under ss. 627.730-627.7405 shall be primary, except that
24 benefits received under any workers' compensation law shall be
25 credited against the benefits provided by subsection (1) and
26 shall be due and payable as loss accrues, upon receipt of
27 reasonable proof of such loss and the amount of expenses and
28 loss incurred which are covered by the policy issued under ss.
29 627.730-627.7405. When the Agency for Health Care
30 Administration provides, pays, or becomes liable for medical
31 assistance under the Medicaid program related to injury,
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1 sickness, disease, or death arising out of the ownership,
2 maintenance, or use of a motor vehicle, benefits under ss.
3 627.730-627.7405 shall be subject to the provisions of the
4 Medicaid program.
5 (a) An insurer may require written notice to be given
6 as soon as practicable after an accident involving a motor
7 vehicle with respect to which the policy affords the security
8 required by ss. 627.730-627.7405.
9 (b) Personal injury protection insurance benefits paid
10 pursuant to this section shall be overdue if not paid within
11 30 days after the insurer is furnished written notice of the
12 fact of a covered loss and of the amount of same. Written
13 notice for medical benefits, except for services or treatment
14 rendered in a hospital, shall not be considered to have been
15 provided to the insurer unless all the requirements of
16 paragraphs (5)(e) and (f) are met and all of the medical
17 treatment records applicable to the billing for which payment
18 is being requested have been provided to the insurer, to the
19 extent requested by the insurer pursuant to subsection (6). If
20 such written notice is not furnished to the insurer as to the
21 entire claim, any partial amount supported by written notice
22 is overdue if not paid within 30 days after such written
23 notice is furnished to the insurer. Any part or all of the
24 remainder of the claim that is subsequently supported by
25 written notice is overdue if not paid within 30 days after
26 such written notice is furnished to the insurer. When an
27 insurer pays only a portion of a claim or rejects a claim, the
28 insurer shall provide at the time of the partial payment or
29 rejection an itemized specification of each item that the
30 insurer had reduced, omitted, or declined to pay and any
31 information that the insurer desires the claimant to consider
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1 related to the medical necessity of the denied treatment or to
2 explain the reasonableness of the reduced charge, provided
3 that this shall not limit the introduction of evidence at
4 trial; and the insurer shall include the name and address of
5 the person to whom the claimant should respond and a claim
6 number to be referenced in future correspondence. However,
7 notwithstanding the fact that written notice has been
8 furnished to the insurer, any payment shall not be deemed
9 overdue when the insurer has reasonable proof to establish
10 that the insurer is not responsible for the payment. For the
11 purpose of calculating the extent to which any benefits are
12 overdue, payment shall be treated as being made on the date a
13 draft or other valid instrument which is equivalent to payment
14 was placed in the United States mail in a properly addressed,
15 postpaid envelope or, if not so posted, on the date of
16 delivery. This paragraph does not preclude or limit the
17 ability of the insurer to assert that the claim was unrelated,
18 was not medically necessary, or was unreasonable or that the
19 amount of the charge was in excess of that permitted under, or
20 in violation of, subsection (5). Such assertion by the insurer
21 may be made at any time, including after payment of the claim
22 or after the 30-day time period for payment set forth in this
23 paragraph.
24 (c) All overdue payments shall bear simple interest at
25 the rate established by the Comptroller under s. 55.03 or the
26 rate established in the insurance contract, whichever is
27 greater, for the year in which the payment became overdue,
28 calculated from the date the insurer was furnished with
29 written notice of the amount of covered loss. Interest shall
30 be due at the time payment of the overdue claim is made.
31
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1 (d) The insurer of the owner of a motor vehicle shall
2 pay personal injury protection benefits for:
3 1. Accidental bodily injury sustained in this state by
4 the owner while occupying a motor vehicle, or while not an
5 occupant of a self-propelled vehicle if the injury is caused
6 by physical contact with a motor vehicle.
7 2. Accidental bodily injury sustained outside this
8 state, but within the United States of America or its
9 territories or possessions or Canada, by the owner while
10 occupying the owner's motor vehicle.
11 3. Accidental bodily injury sustained by a relative of
12 the owner residing in the same household, under the
13 circumstances described in subparagraph 1. or subparagraph 2.,
14 provided the relative at the time of the accident is domiciled
15 in the owner's household and is not himself or herself the
16 owner of a motor vehicle with respect to which security is
17 required under ss. 627.730-627.7405.
18 4. Accidental bodily injury sustained in this state by
19 any other person while occupying the owner's motor vehicle or,
20 if a resident of this state, while not an occupant of a
21 self-propelled vehicle, if the injury is caused by physical
22 contact with such motor vehicle, provided the injured person
23 is not himself or herself:
24 a. The owner of a motor vehicle with respect to which
25 security is required under ss. 627.730-627.7405; or
26 b. Entitled to personal injury benefits from the
27 insurer of the owner or owners of such a motor vehicle.
28 (e) If two or more insurers are liable to pay personal
29 injury protection benefits for the same injury to any one
30 person, the maximum payable shall be as specified in
31 subsection (1), and any insurer paying the benefits shall be
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1 entitled to recover from each of the other insurers an
2 equitable pro rata share of the benefits paid and expenses
3 incurred in processing the claim.
4 (f) It is a violation of the insurance code for an
5 insurer to fail to timely provide benefits as required by this
6 section with such frequency as to constitute a general
7 business practice.
8 (g) Benefits shall not be due or payable to or on the
9 behalf of an insured person if that person has committed, by a
10 material act or omission, any insurance fraud relating to
11 personal injury protection coverage under his or her policy,
12 if the fraud is admitted to in a sworn statement by the
13 insured or if it is established in a court of competent
14 jurisdiction. Any insurance fraud shall void all coverage
15 arising from the claim related to such fraud under the
16 personal injury protection coverage of the insured person who
17 committed the fraud, irrespective of whether a portion of the
18 insured person's claim may be legitimate, and any benefits
19 paid prior to the discovery of the insured person's insurance
20 fraud shall be recoverable by the insurer from the person who
21 committed insurance fraud in their entirety. An insurer is
22 entitled to its costs and attorney's fees in any action in
23 which it prevails in enforcing its right of recovery under
24 this paragraph.
25 (5) CHARGES FOR TREATMENT OF INJURED PERSONS.--
26 (a) Any physician, hospital, clinic, or other person
27 or institution lawfully rendering treatment to an injured
28 person for a bodily injury covered by personal injury
29 protection insurance may charge the insurer and injured party
30 only a reasonable amount pursuant to this section for the
31 services and supplies rendered, and the insurer providing such
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1 coverage may pay for such charges directly to such person or
2 institution lawfully rendering such treatment, if the insured
3 receiving such treatment or his or her guardian has
4 countersigned the properly completed invoice, bill, or claim
5 form approved by the Department of Insurance upon which such
6 charges are to be paid for as having actually been rendered,
7 to the best knowledge of the insured or his or her guardian.
8 In no event, however, may such a charge be in excess of the
9 amount the person or institution customarily charges for like
10 services or supplies or has agreed to accept or intends to
11 collect as full reimbursement from the particular patient in
12 cases involving no insurance.
13 (b)1. An insurer or insured is not required to pay a
14 claim or charges:
15 a. Made by a broker or by a person making a claim on
16 behalf of a broker;.
17 b. For any service or treatment that was not lawful at
18 the time rendered;
19 c. To any person who knowingly submits a false or
20 misleading statement relating to the claim or charges;
21 d. With respect to a bill or statement that does not
22 meet the applicable requirements of paragraph (e);
23 e. For any treatment or service that is upcoded, or
24 that is unbundled when such treatment or services should be
25 bundled, in accordance with applicable billing standards. To
26 facilitate prompt payment of lawful services, an insurer may
27 change codes that it determines to have been improperly or
28 incorrectly upcoded or unbundled, and may make payment based
29 on the changed codes, without affecting the right of the
30 provider to dispute the change by the insurer, provided that
31 before doing so, the insurer must contact the health care
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1 provider and discuss the reasons for the insurer's change and
2 the health care provider's reason for the coding, or make a
3 reasonable good-faith effort to do so, as documented in the
4 insurer's file; and
5 f. For medical services or treatment billed by a
6 physician and not provided in a hospital unless such services
7 are rendered by the physician or are incident to his or her
8 professional services and are included on the physician's
9 bill, including documentation verifying that the physician is
10 responsible for the medical services that were rendered and
11 billed.
12 2. Charges for the professional and technical services
13 of medically necessary cephalic thermograms, peripheral
14 thermograms, spinal ultrasounds, extremity ultrasounds, video
15 fluoroscopy (including, but not limited to, cineradiography,
16 or motion X ray), range of motion testing, muscle strength
17 testing, functional capacity testing, and surface
18 electromyography shall not exceed the maximum reimbursement
19 allowance for such procedures as set forth in the applicable
20 fee schedule or other payment methodology established pursuant
21 to s. 440.13 and in effect for the date on which the services
22 were rendered. Such charges shall not be payable by the
23 insurer or insured if there is no reimbursement allowance
24 established pursuant to s. 440.13.
25 3. Allowable amounts that may be charged to a personal
26 injury protection insurance insurer and insured for the
27 professional and technical components of medically necessary
28 nerve conduction testing services when done in conjunction
29 with a needle electromyography procedure and both are
30 performed and billed solely by a physician licensed under
31 chapter 458, chapter 459, chapter 460, or chapter 461 who is
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1 also certified by the American Board of Electrodiagnostic
2 Medicine or by a board recognized by the American Board of
3 Medical Specialties or the American Osteopathic Association or
4 who holds diplomate status with the American Chiropractic
5 Neurology Board or its predecessors shall not exceed 200
6 percent of the allowable amount under the participating
7 physician fee schedule of Medicare Part B for year 2001, and
8 in effect for October 1, 2001, for the area in which the
9 treatment was rendered, adjusted annually by an additional
10 amount equal to the medical Consumer Price Index for Florida.
11 4. Effective for services and treatment on or after
12 October 1, 2003, allowable amounts that may be charged to a
13 personal injury protection insurance insurer and insured for
14 the technical and professional components of medically
15 necessary nerve conduction, H-reflex, neuromuscular,
16 somatosensory, and dermatonal testing, when any such testing
17 is done in conjunction with a needle electromyography
18 procedure and both are performed and billed solely by a
19 physician licensed under chapter 458, chapter 459, chapter
20 460, or chapter 461 who is also certified by the American
21 Board of Electrodiagnostic Medicine or by a board recognized
22 by the American Board of Medical Specialities or the American
23 Osteopathic Association or who holds diplomate status with the
24 American Chiropractic Neurology Board or its predecessors,
25 shall not exceed the amount allowable under paragraph (c).
26 5.4. Allowable amounts that may be charged to a
27 personal injury protection insurance insurer and insured for
28 the professional and technical components of medically
29 necessary nerve conduction, H-reflex, neuromuscular,
30 somatosensory, and dermatonal testing that does not meet the
31 requirements of subparagraph 3. shall not exceed the
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1 applicable fee schedule or other payment methodology
2 established pursuant to s. 440.13 and in effect on the date on
3 which the services were rendered. Such charges shall not be
4 payable by the insurer or insured if there is no reimbursement
5 allowance established pursuant to s. 440.13.
6 6.5. Effective for services and treatment rendered on
7 or after June 19, 2001, upon this act becoming a law and
8 before November 1, 2001, allowable amounts that may be charged
9 to a personal injury protection insurance insurer and insured
10 for magnetic resonance imaging services shall not exceed 200
11 percent of the allowable amount under the participating
12 physician fee schedule of Medicare Part B for year 2001, and
13 in effect on June 19, 2001, for the area in which the
14 treatment was rendered. Beginning November 1, 2001, allowable
15 amounts that may be charged to a personal injury protection
16 insurance insurer and insured for magnetic resonance imaging
17 services shall not exceed 175 percent of the allowable amount
18 under the participating physician fee schedule of Medicare
19 Part B for year 2001, and in effect on June 19, 2001, for the
20 area in which the treatment was rendered, adjusted annually by
21 an additional amount equal to the medical Consumer Price Index
22 for Florida, except that allowable amounts that may be charged
23 to a personal injury protection insurance insurer and insured
24 for magnetic resonance imaging services provided in facilities
25 accredited by the American College of Radiology or the Joint
26 Commission on Accreditation of Healthcare Organizations shall
27 not exceed 200 percent of the allowable amount under the
28 participating physician fee schedule of Medicare Part B for
29 year 2001, for the area in which the treatment was rendered,
30 adjusted annually by an additional amount equal to the medical
31 Consumer Price Index for Florida.
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1 7. Subparagraphs 3. through 6. do This paragraph does
2 not apply to charges for magnetic resonance imaging services
3 and nerve conduction, H-reflex, neuromuscular, somatosensory,
4 and dermatonal testing for inpatients and emergency services
5 and care as defined in chapter 395 rendered by facilities
6 licensed under chapter 395. Effective for services and
7 treatment on or after October 1, 2003, allowable amounts that
8 may be charged for services under subparagraph 6. may not
9 exceed the amount allowable under paragraph (c).
10 8. The Department of Health, in consultation with the
11 appropriate professional licensing boards, shall adopt, by
12 rule, a list of diagnostic tests deemed not be medically
13 necessary for use in the treatment of persons sustaining
14 bodily injury covered by personal injury protection benefits
15 under this section. The initial list shall be adopted by
16 January 1, 2004, and shall be revised from time to time as
17 determined by the Department of Health, in consultation with
18 the respective professional licensing boards. Inclusion of a
19 test on the list of invalid diagnostic tests shall be based on
20 lack of demonstrated medical value and a level of general
21 acceptance by the relevant provider community and shall not be
22 dependent for results entirely upon subjective patient
23 response. Notwithstanding its inclusion on a fee schedule in
24 this subsection, an insurer or insured is not required to pay
25 any charges or reimburse claims for any invalid diagnostic
26 test as determined by the Department of Health.
27 (c) Except as provided in paragraph (b), effective for
28 services and treatment beginning on October 1, 2003, other
29 than services and treatment rendered by a hospital:
30 1. A person or institution providing treatment,
31 accommodations, products, or services to an injured person for
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1 an injury covered by personal injury protection benefits shall
2 not require, request, charge, bill, or accept payment for the
3 treatment, accommodations, products, or services from the
4 insurer or insured in excess of 200 percent of the allowable
5 amount under the Medicare Part B participating physicians fee
6 schedule which is in effect on July 1, 2003, for the area in
7 which the services are rendered, without regard to whether a
8 fee is allowable for a particular provider under federal law
9 and regulations.
10 2. The allowable amount for services and treatment
11 subject to the Medicare Part B participating fee schedule
12 under this subsection shall be adjusted as provided in this
13 subparagraph. Commencing in 2004, the Financial Services
14 Commission shall at least annually review any changes made to
15 the Medicare Part B participating fee schedule and shall
16 determine the extent to which such changes shall apply under
17 this subsection in order to ensure the availability of quality
18 services to insureds and to maintain the affordability of
19 insurance under this section. Any changes approved by the
20 commission shall be effective for services and treatment
21 rendered 90 days after such determination is final.
22 3. If a charge has not been calculated under
23 subparagraph 1., the amount of the charge may not exceed the
24 applicable fee schedule or other payment established pursuant
25 to s. 440.13 in effect on the date the services were rendered.
26 4. If a charge has not been calculated under
27 subparagraph 1., or subparagraph 3., the treatment,
28 accommodation, product, or services is presumed to be not
29 reasonable and not reimbursable by the insurer and insured
30 pursuant to this section. Upon the request of any person, the
31 Financial Services Commission, in consultation with the Agency
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1 for Health Care Administration, may determine any charge that
2 it finds to be reasonable for reimbursement by the insurer and
3 insured pursuant to this section for services provided after
4 the determination becomes effective.
5 5. Allowable amounts that may be charged to a personal
6 injury protection insurance insurer and insured for magnetic
7 resonance imaging services provided in facilities accredited
8 by the American College of Radiology, the Accreditation
9 Association for Ambulatory Health Care, or the Joint
10 Commission on Accreditation of Healthcare Organizations may
11 not exceed 200 percent of the allowable amount under the
12 Medicare Part B participating physician fee schedule which is
13 in effect on the date the services are rendered for the area
14 in which the services are rendered.
15 6. If treatment is rendered out of state, the
16 allowable amounts shall be for the area where the insured
17 resides in this state.
18 (d)1.(c) With respect to any treatment or service,
19 other than medical services billed by a hospital or other
20 provider for emergency services as defined in s. 395.002 or
21 inpatient services rendered at a hospital-owned facility, the
22 statement of charges must be furnished to the insurer by the
23 provider and may not include, and the insurer is not required
24 to pay, charges for treatment or services rendered more than
25 35 days before the postmark date of the statement, except for
26 past due amounts previously billed on a timely basis under
27 this paragraph, and except that, if the provider submits to
28 the insurer a notice of initiation of treatment within 21 days
29 after its first examination or treatment of the claimant, the
30 statement may include charges for treatment or services
31 rendered up to, but not more than, 75 days before the postmark
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1 date of the statement. The injured party is not liable for,
2 and the provider shall not bill the injured party for, charges
3 that are unpaid because of the provider's failure to comply
4 with this paragraph. Any agreement requiring the injured
5 person or insured to pay for such charges is unenforceable.
6 2. If, however, the insured fails to furnish the
7 provider with the correct name and address of the insured's
8 personal injury protection insurer, the provider has 35 days
9 from the date the provider obtains the correct information to
10 furnish the insurer with a statement of the charges. The
11 insurer is not required to pay for such charges unless the
12 provider includes with the statement documentary evidence that
13 was provided by the insured during the 35-day period
14 demonstrating that the provider reasonably relied on erroneous
15 information from the insured and either:
16 a.1. A denial letter from the incorrect insurer; or
17 b.2. Proof of mailing, which may include an affidavit
18 under penalty of perjury, reflecting timely mailing to the
19 incorrect address or insurer.
20 3. For emergency services and care as defined in s.
21 395.002 rendered in a hospital emergency department or for
22 transport and treatment rendered by an ambulance provider
23 licensed pursuant to part III of chapter 401, the provider is
24 not required to furnish the statement of charges within the
25 time periods established by this paragraph; and the insurer
26 shall not be considered to have been furnished with notice of
27 the amount of covered loss for purposes of paragraph (4)(b)
28 until it receives a statement complying with paragraph (e), or
29 copy thereof, which specifically identifies the place of
30 service to be a hospital emergency department or an ambulance
31
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1 in accordance with billing standards recognized by the Health
2 Care Finance Administration.
3 4. Each notice of insured's rights under s. 627.7401
4 must include the following statement in type no smaller than
5 12 points:
6 BILLING REQUIREMENTS.--Florida Statutes provide
7 that with respect to any treatment or services,
8 other than certain hospital and emergency
9 services, the statement of charges furnished to
10 the insurer by the provider may not include,
11 and the insurer and the injured party are not
12 required to pay, charges for treatment or
13 services rendered more than 35 days before the
14 postmark date of the statement, except for past
15 due amounts previously billed on a timely
16 basis, and except that, if the provider submits
17 to the insurer a notice of initiation of
18 treatment within 21 days after its first
19 examination or treatment of the claimant, the
20 statement may include charges for treatment or
21 services rendered up to, but not more than, 75
22 days before the postmark date of the statement.
23 (d) Every insurer shall include a provision in its
24 policy for personal injury protection benefits for binding
25 arbitration of any claims dispute involving medical benefits
26 arising between the insurer and any person providing medical
27 services or supplies if that person has agreed to accept
28 assignment of personal injury protection benefits. The
29 provision shall specify that the provisions of chapter 682
30 relating to arbitration shall apply. The prevailing party
31 shall be entitled to attorney's fees and costs. For purposes
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1 of the award of attorney's fees and costs, the prevailing
2 party shall be determined as follows:
3 1. When the amount of personal injury protection
4 benefits determined by arbitration exceeds the sum of the
5 amount offered by the insurer at arbitration plus 50 percent
6 of the difference between the amount of the claim asserted by
7 the claimant at arbitration and the amount offered by the
8 insurer at arbitration, the claimant is the prevailing party.
9 2. When the amount of personal injury protection
10 benefits determined by arbitration is less than the sum of the
11 amount offered by the insurer at arbitration plus 50 percent
12 of the difference between the amount of the claim asserted by
13 the claimant at arbitration and the amount offered by the
14 insurer at arbitration, the insurer is the prevailing party.
15 3. When neither subparagraph 1. nor subparagraph 2.
16 applies, there is no prevailing party. For purposes of this
17 paragraph, the amount of the offer or claim at arbitration is
18 the amount of the last written offer or claim made at least 30
19 days prior to the arbitration.
20 4. In the demand for arbitration, the party requesting
21 arbitration must include a statement specifically identifying
22 the issues for arbitration for each examination or treatment
23 in dispute. The other party must subsequently issue a
24 statement specifying any other examinations or treatment and
25 any other issues that it intends to raise in the arbitration.
26 The parties may amend their statements up to 30 days prior to
27 arbitration, provided that arbitration shall be limited to
28 those identified issues and neither party may add additional
29 issues during arbitration.
30 (e) All statements and bills for medical services
31 rendered by any physician, hospital, clinic, or other person
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1 or institution shall be submitted to the insurer on a properly
2 completed Centers for Medicare and Medicaid Services (CMS)
3 Health Care Finance Administration 1500 form, UB 92 forms, or
4 any other standard form approved by the department for
5 purposes of this paragraph. All billings for such services
6 rendered by providers other than hospitals shall, to the
7 extent applicable, follow the Physicians' Current Procedural
8 Terminology (CPT) or Healthcare Correct Procedural Coding
9 System (HCPCS), or ICD-9 in effect for the year in which
10 services are rendered and comply with the Centers for Medicare
11 and Medicaid Services (CMS) 1500 form instructions and the
12 American Medical Association Current Procedural Terminology
13 (CPT) Editorial Panel and Healthcare Correct Procedural Coding
14 System (HCPCS). All providers other than hospitals shall
15 include on the applicable claim form the professional license
16 number of the provider in the line or space provided for
17 "Signature of Physician or Supplier, Including Degrees or
18 Credentials." In determining compliance with applicable CPT
19 and HCPCS coding, guidance shall be provided by the
20 Physicians' Current Procedural Terminology (CPT) or the
21 Healthcare Correct Procedural Coding System (HCPCS) in effect
22 for the year in which services were rendered, the Office of
23 the Inspector General (OIG), Physicians Compliance Guidelines,
24 and other authoritative treatises designated by rule by the
25 Agency for Health Care Administration. No statement of medical
26 services may include charges for medical services of a person
27 or entity that performed such services without possessing the
28 valid licenses required to perform such services. For purposes
29 of paragraph (4)(b), an insurer shall not be considered to
30 have been furnished with notice of the amount of covered loss
31 or medical bills due unless the statements or bills comply
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1 with this paragraph, and unless the statements or bills are
2 properly completed in their entirety as to all material
3 provisions, with all relevant information being provided
4 therein.
5 (f)1. Each physician, other licensed professional,
6 clinic, or other medical institution providing medical
7 services upon which a claim for personal injury protection
8 benefits is based shall require an insured person, or his or
9 her guardian, to execute a disclosure and acknowledgment form,
10 which reflects at a minimum that:
11 a. The insured, or his or her guardian, must
12 countersign the form attesting to the fact that the services
13 set forth therein were actually rendered;
14 b. The insured, or his or her guardian, has both the
15 right and affirmative duty to confirm that the services were
16 actually rendered;
17 c. The insured, or his or her guardian, was not
18 solicited by any person to seek any services from the medical
19 provider; and
20 d. That the physician, other licensed professional,
21 clinic, or other medical institution rendering services for
22 which payment is being claimed explained the services to the
23 insured or his or her guardian.
24 2. The physician, other licensed professional, clinic,
25 or other medical institution rendering services for which
26 payment is being claimed has the affirmative duty to explain
27 the services rendered to the insured, or his or her guardian,
28 so that the insured, or his or her guardian, countersigns the
29 form with informed consent.
30 3. Countersignature by the insured, or his or her
31 guardian, is not required for the reading of diagnostic tests
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1 or other services that are of such a nature that they are not
2 required to be performed in the presence of the insured.
3 4. The licensed medical professional rendering
4 treatment for which payment is being claimed must sign, by his
5 or her own hand, the form complying with this paragraph.
6 5. The original completed disclosure and
7 acknowledgement form shall be furnished to the insurer
8 pursuant to paragraph (4)(b) and may not be electronically
9 furnished.
10 6. This disclosure and acknowledgement form is not
11 required for services billed by a hospital or billed by
12 another provider for emergency services as defined in s.
13 395.002, for inpatient services rendered at a hospital-owned
14 facility, for emergency services and care as defined in s.
15 395.002 rendered in a hospital emergency department, or for
16 transport and treatment rendered by an ambulance provider
17 licensed pursuant to part III of chapter 401.
18 7. The Financial Services Commission shall adopt, by
19 rule, a standard disclosure and acknowledgment form that shall
20 be used to fulfill the requirements of this paragraph,
21 effective 90 days after such form is adopted and becomes
22 final. The commission shall adopt a proposed rule by October
23 1, 2003. Until the rule is final, the provider may use a form
24 of its own which otherwise complies with the requirements of
25 this paragraph.
26 (g) Upon written notification by any person, an
27 insurer shall investigate any claim of improper billing by a
28 physician or other medical provider. The insurer shall
29 determine if the insured was properly billed for only those
30 services and treatments that the insured actually received. If
31 the insurer determines that the insured has been improperly
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1 billed, the insurer shall notify the insured, the person
2 making the written notification and the provider of its
3 findings and shall reduce the amount of payment to the
4 provider by the amount determined to be improperly billed. If
5 a reduction is made due to such written notification by any
6 person, the insurer shall pay to the person 20 percent of the
7 amount of the reduction, up to $500. If the provider is
8 arrested due to the improper billing, then the insurer shall
9 pay to the person 40 percent of the amount of the reduction,
10 up to $500.
11 (h) An insurer may not systematically downcode with
12 the intent to deny reimbursement otherwise due. Such action
13 constitutes a material misrepresentation under s.
14 626.9541(1)(i)2.
15 (6) DISCOVERY OF FACTS ABOUT AN INJURED PERSON;
16 DISPUTES.--
17 (a) Every employer shall, if a request is made by an
18 insurer providing personal injury protection benefits under
19 ss. 627.730-627.7405 against whom a claim has been made,
20 furnish forthwith, in a form approved by the department, a
21 sworn statement of the earnings, since the time of the bodily
22 injury and for a reasonable period before the injury, of the
23 person upon whose injury the claim is based.
24 (b) Every physician, hospital, clinic, or other
25 medical institution providing, before or after bodily injury
26 upon which a claim for personal injury protection insurance
27 benefits is based, any products, services, or accommodations
28 in relation to that or any other injury, or in relation to a
29 condition claimed to be connected with that or any other
30 injury, shall, if requested to do so by the insurer against
31 whom the claim has been made, furnish forthwith a written
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1 report of the history, condition, treatment, dates, and costs
2 of such treatment of the injured person and why the items
3 identified by the insurer were reasonable in amount and
4 medically necessary, together with a sworn statement that the
5 treatment or services rendered were reasonable and necessary
6 with respect to the bodily injury sustained and identifying
7 which portion of the expenses for such treatment or services
8 was incurred as a result of such bodily injury, and produce
9 forthwith, and permit the inspection and copying of, his or
10 her or its records regarding such history, condition,
11 treatment, dates, and costs of treatment; provided that this
12 shall not limit the introduction of evidence at trial. Such
13 sworn statement shall read as follows: "Under penalty of
14 perjury, I declare that I have read the foregoing, and the
15 facts alleged are true, to the best of my knowledge and
16 belief." No cause of action for violation of the
17 physician-patient privilege or invasion of the right of
18 privacy shall be permitted against any physician, hospital,
19 clinic, or other medical institution complying with the
20 provisions of this section. The person requesting such records
21 and such sworn statement shall pay all reasonable costs
22 connected therewith. If an insurer makes a written request for
23 documentation or information under this paragraph within 30
24 days after having received notice of the amount of a covered
25 loss under paragraph (4)(a), the amount or the partial amount
26 which is the subject of the insurer's inquiry shall become
27 overdue if the insurer does not pay in accordance with
28 paragraph (4)(b) or within 10 days after the insurer's receipt
29 of the requested documentation or information, whichever
30 occurs later. For purposes of this paragraph, the term
31 "receipt" includes, but is not limited to, inspection and
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1 copying pursuant to this paragraph. Any insurer that requests
2 documentation or information pertaining to reasonableness of
3 charges or medical necessity under this paragraph without a
4 reasonable basis for such requests as a general business
5 practice is engaging in an unfair trade practice under the
6 insurance code.
7 (c) In the event of any dispute regarding an insurer's
8 right to discovery of facts under this section about an
9 injured person's earnings or about his or her history,
10 condition, or treatment, or the dates and costs of such
11 treatment, the insurer may petition a court of competent
12 jurisdiction to enter an order permitting such discovery. The
13 order may be made only on motion for good cause shown and upon
14 notice to all persons having an interest, and it shall specify
15 the time, place, manner, conditions, and scope of the
16 discovery. Such court may, in order to protect against
17 annoyance, embarrassment, or oppression, as justice requires,
18 enter an order refusing discovery or specifying conditions of
19 discovery and may order payments of costs and expenses of the
20 proceeding, including reasonable fees for the appearance of
21 attorneys at the proceedings, as justice requires.
22 (d) The injured person shall be furnished, upon
23 request, a copy of all information obtained by the insurer
24 under the provisions of this section, and shall pay a
25 reasonable charge, if required by the insurer.
26 (e) Notice to an insurer of the existence of a claim
27 shall not be unreasonably withheld by an insured.
28 (7) MENTAL AND PHYSICAL EXAMINATION OF INJURED PERSON;
29 REPORTS.--
30 (a) Whenever the mental or physical condition of an
31 injured person covered by personal injury protection is
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1 material to any claim that has been or may be made for past or
2 future personal injury protection insurance benefits, such
3 person shall, upon the request of an insurer, submit to mental
4 or physical examination by a physician or physicians. The
5 costs of any examinations requested by an insurer shall be
6 borne entirely by the insurer. Such examination shall be
7 conducted within the municipality where the insured is
8 receiving treatment, or in a location reasonably accessible to
9 the insured, which, for purposes of this paragraph, means any
10 location within the municipality in which the insured resides,
11 or any location within 10 miles by road of the insured's
12 residence, provided such location is within the county in
13 which the insured resides. If the examination is to be
14 conducted in a location reasonably accessible to the insured,
15 and if there is no qualified physician to conduct the
16 examination in a location reasonably accessible to the
17 insured, then such examination shall be conducted in an area
18 of the closest proximity to the insured's residence. Personal
19 protection insurers are authorized to include reasonable
20 provisions in personal injury protection insurance policies
21 for mental and physical examination of those claiming personal
22 injury protection insurance benefits. An insurer may not
23 withdraw payment of a treating physician without the consent
24 of the injured person covered by the personal injury
25 protection, unless the insurer first obtains a valid report by
26 a physician licensed under the same chapter as the treating
27 physician whose treatment authorization is sought to be
28 withdrawn, stating that treatment was not reasonable, related,
29 or necessary. A valid report is one that is prepared and
30 signed by the physician examining the injured person or
31 reviewing the treatment records of the injured person and is
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1 factually supported by the examination and treatment records
2 if reviewed and that has not been modified by anyone other
3 than the physician. The physician preparing the report must be
4 in active practice, unless the physician is physically
5 disabled. Active practice means that during the 3 years
6 immediately preceding the date of the physical examination or
7 review of the treatment records the physician must have
8 devoted professional time to the active clinical practice of
9 evaluation, diagnosis, or treatment of medical conditions or
10 to the instruction of students in an accredited health
11 professional school or accredited residency program or a
12 clinical research program that is affiliated with an
13 accredited health professional school or teaching hospital or
14 accredited residency program. The physician preparing a report
15 at the request of an insurer, or on behalf of an insurer
16 through an attorney or another entity, shall maintain, for at
17 least 3 years, copies of all examination reports as medical
18 records and shall maintain, for at least 3 years, records of
19 all payments for the examinations and reports. Neither an
20 insurer nor any person acting at the direction of or on behalf
21 of an insurer may materially change an opinion in a report
22 prepared under this paragraph or direct the physician
23 preparing the report to change such opinion. The denial of a
24 payment as the result of such a changed opinion constitutes a
25 material misrepresentation under s. 626.9541(1)(i)2.; however,
26 this provision does not preclude the insurer from calling to
27 the attention of the physician errors of fact in the report
28 based upon information in the claim file.
29 (b) If requested by the person examined, a party
30 causing an examination to be made shall deliver to him or her
31 a copy of every written report concerning the examination
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1 rendered by an examining physician, at least one of which
2 reports must set out the examining physician's findings and
3 conclusions in detail. After such request and delivery, the
4 party causing the examination to be made is entitled, upon
5 request, to receive from the person examined every written
6 report available to him or her or his or her representative
7 concerning any examination, previously or thereafter made, of
8 the same mental or physical condition. By requesting and
9 obtaining a report of the examination so ordered, or by taking
10 the deposition of the examiner, the person examined waives any
11 privilege he or she may have, in relation to the claim for
12 benefits, regarding the testimony of every other person who
13 has examined, or may thereafter examine, him or her in respect
14 to the same mental or physical condition. If a person
15 unreasonably refuses to submit to an examination, the personal
16 injury protection carrier is no longer liable for subsequent
17 personal injury protection benefits.
18 (8) APPLICABILITY OF PROVISION REGULATING ATTORNEY'S
19 FEES.--With respect to any dispute under the provisions of ss.
20 627.730-627.7405 between the insured and the insurer, or
21 between an assignee of an insured's rights and the insurer,
22 the provisions of s. 627.428 shall apply, except as provided
23 in subsections subsection (11), (12), and (13).
24 (10)(a) An insurer may negotiate and enter into
25 contracts with licensed health care providers for the benefits
26 described in this section, referred to in this section as
27 "preferred providers," which shall include health care
28 providers licensed under chapters 458, 459, 460, 461, and 463.
29 The insurer may provide an option to an insured to use a
30 preferred provider at the time of purchase of the policy for
31 personal injury protection benefits, if the requirements of
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1 this subsection are met. If the insured elects to use a
2 provider who is not a preferred provider, whether the insured
3 purchased a preferred provider policy or a nonpreferred
4 provider policy, the medical benefits provided by the insurer
5 shall be as required by this section. If the insured elects to
6 use a provider who is a preferred provider, the insurer may
7 pay medical benefits in excess of the benefits required by
8 this section and may waive or lower the amount of any
9 deductible that applies to such medical benefits. If the
10 insurer offers a preferred provider policy to a policyholder
11 or applicant, it must also offer a nonpreferred provider
12 policy. The insurer shall provide each policyholder with a
13 current roster of preferred providers in the county in which
14 the insured resides at the time of purchase of such policy,
15 and shall make such list available for public inspection
16 during regular business hours at the principal office of the
17 insurer within the state.
18 (b) Paragraph (a) does not prohibit an insurer that
19 chooses not to offer a preferred provider policy from
20 providing the benefits described in subsection (1) pursuant to
21 a contract entered into directly or indirectly with a licensed
22 health care provider or hospital that establishes agreed
23 amounts to be charged by such health care provider or hospital
24 for services rendered to persons entitled to such benefits.
25 Such agreement shall establish the reasonable amount for such
26 services in accord with subsection (1).
27 (11) DEMAND LETTER.--
28 (a) As a condition precedent to filing any action for
29 an overdue claim for benefits under this section paragraph
30 (4)(b), the insurer must be provided with written notice of an
31 intent to initiate litigation; provided, however, that, except
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1 with regard to a claim or amended claim or judgment for
2 interest only which was not paid or was incorrectly
3 calculated, such notice is not required for an overdue claim
4 that the insurer has denied or reduced, nor is such notice
5 required if the insurer has been provided documentation or
6 information at the insurer's request pursuant to subsection
7 (6). Such notice may not be sent until the claim is overdue,
8 including any additional time the insurer has to pay the claim
9 pursuant to paragraph (4)(b).
10 (b) The notice required shall state that it is a
11 "demand letter under s. 627.736(11)" and shall state with
12 specificity:
13 1. The name of the insured upon which such benefits
14 are being sought, including a copy of the assignment giving
15 rights to the claimant if the claimant is not the insured.
16 2. The claim number or policy number upon which such
17 claim was originally submitted to the insurer.
18 3. To the extent applicable, the name of any medical
19 provider who rendered to an insured the treatment, services,
20 accommodations, or supplies that form the basis of such claim;
21 and an itemized statement specifying each exact amount, the
22 date of treatment, service, or accommodation, and the type of
23 benefit claimed to be due. A completed form satisfying the
24 requirements of paragraph (5)(e) or the lost-wage statement
25 previously submitted Health Care Finance Administration 1500
26 form, UB 92, or successor forms approved by the Secretary of
27 the United States Department of Health and Human Services may
28 be used as the itemized statement. To the extent that the
29 demand involves an insurer's withdrawal of payment under
30 paragraph (7)(a) for future treatment not yet rendered, the
31 claimant shall attach a copy of the insurer's notice
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1 withdrawing such payment and an itemized statement of the
2 type, frequency, and duration of future treatment claimed to
3 be reasonable and medically necessary.
4 (c) Each notice required by this subsection section
5 must be delivered to the insurer by United States certified or
6 registered mail, return receipt requested. Such postal costs
7 shall be reimbursed by the insurer if so requested by the
8 claimant provider in the notice, when the insurer pays the
9 overdue claim. Such notice must be sent to the person and
10 address specified by the insurer for the purposes of receiving
11 notices under this subsection section, on the document denying
12 or reducing the amount asserted by the filer to be overdue.
13 Each licensed insurer, whether domestic, foreign, or alien,
14 shall may file with the office department designation of the
15 name and address of the person to whom notices pursuant to
16 this subsection section shall be sent which the office shall
17 make available on its Internet website when such document does
18 not specify the name and address to whom the notices under
19 this section are to be sent or when there is no such document.
20 The name and address on file with the office department
21 pursuant to s. 624.422 shall be deemed the authorized
22 representative to accept notice pursuant to this subsection
23 section in the event no other designation has been made.
24 (d) If, within 15 7 business days after receipt of
25 notice by the insurer, the overdue claim specified in the
26 notice is paid by the insurer together with applicable
27 interest and a penalty of 10 percent of the overdue amount
28 paid by the insurer, subject to a maximum penalty of $250, no
29 action for nonpayment or late payment may be brought against
30 the insurer. If the demand involves an insurer's withdrawal of
31 payment under paragraph (7)(a) for future treatment not yet
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1 rendered, no action may be brought against the insurer if,
2 within 15 days after its receipt of the notice, the insurer
3 mails to the person filing the notice a written statement of
4 the insurer's agreement to pay for such treatment in
5 accordance with the notice and to pay a penalty of 10 percent,
6 subject to a maximum penalty of $250, when it pays for such
7 future treatment in accordance with the requirements of this
8 section. To the extent the insurer determines not to pay any
9 the overdue amount demanded, the penalty shall not be payable
10 in any subsequent action for nonpayment or late payment. For
11 purposes of this subsection, payment or the insurer's
12 agreement shall be treated as being made on the date a draft
13 or other valid instrument that is equivalent to payment, or
14 the insurer's written statement of agreement, is placed in the
15 United States mail in a properly addressed, postpaid envelope,
16 or if not so posted, on the date of delivery. The insurer
17 shall not be obligated to pay any attorney's fees if the
18 insurer pays the claim or mails its agreement to pay for
19 future treatment within the time prescribed by this
20 subsection.
21 (e) The applicable statute of limitation for an action
22 under this section shall be tolled for a period of 15 business
23 days by the mailing of the notice required by this subsection.
24 (f) Any insurer making a general business practice of
25 not paying valid claims until receipt of the notice required
26 by this subsection section is engaging in an unfair trade
27 practice under the insurance code.
28 (12) MEDICAL PEER REVIEW.--
29 (a) Applicability.--This subsection applies to all
30 medical benefits payable under paragraph (1)(a); however, this
31 subsection is limited to disputes of whether a service,
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1 treatment, or otherwise is medically necessary, reasonable in
2 the amount charged, correctly coded, and related to the injury
3 covered by the policy under s. 627.736. The applicability of
4 this subsection shall be broadly construed to favor inclusion
5 of disputes. The parties voluntarily may include other issues
6 related to the items and issues in dispute.
7 (b) Definitions.--As used in this subsection, the
8 term:
9 1. "Agency" means the Agency for Health Care
10 Administration.
11 2. "Claimant" means the insured injured person or the
12 medical provider involved in a dispute under this subsection.
13 3. "Initiating party" means the party filing a notice.
14 4. "Notice means the notice initiating peer review.
15 5. "Peer reviewer" means the health care practitioner
16 defined in s. 456.001(4) or other person who is employed by
17 or, under contract with, a peer review organization, to whom a
18 particular medical dispute has been referred by the peer
19 review organization, and who from other work derives less than
20 25 percent of his or her income from insurers of any kind. For
21 issues of medical necessity, the health care organization must
22 use a health care practitioner who is licensed under the same
23 chapter as the health care practitioner involved in this
24 dispute. A health care practitioner must have an active
25 patient practice of at least 8 hours per week.
26 6. "Peer review organization" means one or more
27 qualified entities selected by and contracted with the agency
28 that employs or contracts with peer reviewers.
29 7. "Respondent" means the party upon whom a notice is
30 filed.
31
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1 (c) Program implementation.--The agency shall
2 establish a program by October 1, 2003, to provide assistance
3 to medical providers, insurers, and insured injured persons
4 for the expedited resolution of disputed medical claims for
5 personal injury protection benefits under this section. The
6 agency shall contract with one or more peer review
7 organizations for the performance of peer review of medical
8 issues. Contracted peer review organizations shall be fully
9 accredited by URAC, also known as the American Accreditation
10 HealthCare Commission, Inc., or another comparable nationally
11 recognized organization if approved by the agency, shall
12 maintain an office in this state, be subject to the
13 jurisdiction of this state, and shall be responsible for
14 properly credentialing and educating peer reviewers and
15 ensuring compliance with the provisions of this subsection.
16 The agency shall take reasonable measures to ensure that the
17 peer review organization and peer reviewers are not biased
18 toward the insurer or claimant, that the reports required in
19 paragraph (g) are timely, and that the insurer and claimant
20 timely submit the documentation required in paragraph (f).
21 (d) Immunity.--Peer review organizations and peer
22 reviewers are immune from liability in the execution of their
23 peer review functions to the extent provided in s. 766.101.
24 (e) Notice initiating review.--If the insurer does not
25 pay the amount demanded within 15 days after its receipt of
26 the demand letter referenced under subsection (11), peer
27 review may be initiated under this subsection by the delivery
28 of a notice under this paragraph. To facilitate faster
29 resolution of claims, a claimant may simultaneously and
30 together deliver the demand letter and a notice under this
31 section to the insurer and the peer review organization, in
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1 which case the insurer shall have 10 additional days to
2 provide the explanation and supporting documentation provided
3 for in paragraph (f) and to make the written offer provided
4 for in paragraph (i). The initiating party shall deliver a
5 notice to the peer review organization which shall state that
6 it is a "notice initiating peer review under section
7 627.736(12), Florida Statutes," and shall also provide the
8 same information required under subsection (11) as to any item
9 or issue still in dispute. To facilitate cost-efficient
10 resolution of disputes, the petitioner shall aggregate in its
11 notice all matters that are in dispute and subject to this
12 subsection. The initiating party, if the claimant, shall
13 deliver a copy of the notice to the person and address for
14 demand letters under paragraph (11)(c) and, if the insurer,
15 shall deliver a copy of the notice to the person or entity
16 that filed the demand letter under subsection (11). Each
17 notice must be delivered by United States certified or
18 registered mail, return receipt requested. Notice shall be
19 treated as being delivered on the date notice is placed in the
20 United States mail in a properly addressed, postpaid envelope,
21 or if not so posted, on the date of delivery.
22 (f) Supporting documentation.--As to matters in
23 dispute, the initiating party shall submit to the peer review
24 organization and the respondent an explanation of its position
25 and supporting documentation within 10 days after it gives its
26 notice, and the respondent shall submit to the peer review
27 organization and the initiating party an explanation of its
28 position and supporting documentation within 10 days after its
29 receipt of the notice. The peer review organization may
30 require the parties to submit additional documentation.
31
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1 (g) Review process.--The peer reviewer shall issue a
2 written report within 10 days after its receipt of all written
3 documentation. The report must include a statement of the
4 issues posed and, as applicable, an itemized statement of the
5 items determined to be medically necessary, reasonable, and
6 related to the injury, and the type, frequency, and duration
7 of future treatment determined to be reasonable and medically
8 necessary. Issues shall be decided in a summary manner by the
9 peer reviewer from the records and pleadings submitted by the
10 claimant and insurer. The peer review process is dependent
11 upon the initiating party and respondent each explaining in
12 writing the nature of the dispute and upon providing
13 sufficient documentation for resolution of the issue or claim.
14 The peer reviewer may consider any documents submitted by
15 either party subject only to the requirements of this
16 subsection. The peer reviewer shall not examine the claimant
17 or insurer. The peer reviewer may, in its discretion, schedule
18 a telephone conference with the insurer and claimant to
19 facilitate the dispute resolution in a cost-effective,
20 efficient manner. The provisions of chapter 90 governing the
21 rules of evidence shall not apply to proceedings before the
22 peer reviewer. Applying the standards of care, applicable
23 practice parameters, including those related to utilization,
24 and relevant provisions of this section, the peer reviewer
25 shall make a recommendation, pursuant to its contract with the
26 peer review organization, of the medical merits of the
27 dispute.
28 (h) Dispute costs.--The agency shall approve a review
29 cost fee schedule and a late payment fee schedule for use by
30 the peer review organization. The rules adopted by the agency
31 shall reflect procedures that minimize the costs of a review
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1 and specify the circumstances under which review costs are not
2 incurred, including when the insurer pays the amount demanded
3 so as to resolve a dispute without submission of supporting
4 documentation to the review organization or a party declines
5 to participate in the peer review. The initiating party and
6 respondent shall each pay 50 percent of all review costs.
7 However, if the amount recommended by the peer reviewer is
8 greater than the amount offered in writing to the claimant by
9 the insurer within 15 days after the initiation of the review,
10 the insurer shall pay all of the review costs up to the first
11 $500, and the remainder shall be divided equally between the
12 insurer and the claimant. Neither party nor the review
13 organization shall reveal the amount of the insurer's offer to
14 the peer reviewer.
15 (i) Payment by insurer.--As to any item in dispute, if
16 the insurer pays the item recommended by the peer review
17 organization within 10 business days after its receipt of the
18 written recommendation of the peer reviewer, or if at any time
19 prior to or during the pendency of a dispute under this
20 subsection the insurer pays the item demanded by the claimant,
21 together with applicable interest under paragraph (4)(c), a
22 penalty of 10 percent of the overdue amount paid by the
23 insurer, subject to a maximum penalty of $250, then as to the
24 disputed items so paid the insurer is not liable in any action
25 for attorney's fees otherwise required by provisions of the
26 insurance code or for damages under s. 624.155. If the dispute
27 involves an insurer's withdrawal of payment under paragraph
28 (7)(a) for future treatment not yet rendered, the insurer is
29 not liable in any action for attorney's fees otherwise
30 required by the insurance code or for damages under s. 624.155
31 if, within 10 business days after its receipt of the written
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1 recommendation of the peer reviewer, or at any time prior to
2 or during the pendency of a dispute under this subsection, the
3 insurer mails to the claimant a written statement of its
4 agreement to pay for such treatment in accordance with the
5 claimant's demand or peer reviewer's recommendation and to pay
6 a penalty of 10 percent, subject to a maximum penalty of $250,
7 when it pays for such future treatment in accordance with this
8 section. For purposes of this subsection, payment or the
9 insurer's agreement shall be treated as being made on the date
10 a draft or other valid instrument that is equivalent to
11 payment, or the insurer's written statement of agreement, is
12 placed in the United States mail in a properly addressed,
13 postpaid envelope, or if not so posted, on the date of
14 delivery.
15 (j) Access to court.--Peer review under this
16 subsection is a condition precedent to the filing of any
17 action based on a dispute subject to this subsection. A party
18 may not file an action related to a disputed amount subject to
19 this section while a dispute is pending under this subsection.
20 The respondent may decline to participate as to the entirety
21 or any item in dispute. To the extent that the insurer
22 declines to participate or declines to pay the items
23 recommended, the insurer remains potentially liable for
24 reasonable attorney's fees otherwise required by the insurance
25 code and for damages under s. 624.155. To the extent that the
26 claimant declines to participate or declines to accept payment
27 from the insurer tendered in accordance with paragraph (i),
28 the insurer is not liable for attorney's fees otherwise
29 required by the insurance code or for damages under s.
30 624.155. The decision of the peer reviewer is not binding on
31 any party and the parties retain access to courts in
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1 accordance with this subsection. A party may seek judicial
2 review of the recommendation of the peer reviewer to determine
3 whether the recommendation was reasonable. A recommendation is
4 reasonable unless it was procured by corruption, fraud, or
5 other undue means; there was evident partiality by the peer
6 reviewer or misconduct prejudicing the rights of any party; or
7 the peer reviewer exceeded the authority and power granted by
8 this subsection. If the court declares the peer review
9 recommendation to be not reasonable, the peer review
10 recommendation shall be vacated, the peer review organization
11 shall provide a different peer reviewer to review the dispute
12 and issued a recommendation, and the peer review process shall
13 proceed as if no action had been filed.
14 (k) Evidence in litigation.--The notice of dispute and
15 all documents submitted by the health care practitioner and
16 the insurer, together with the notice of resolution and the
17 resolution of any appeal, may be introduced into evidence in
18 any civil action if such documents are admissible pursuant to
19 the Florida Evidence Code.
20 (l) Rules.--The agency shall adopt rules to administer
21 this subsection.
22 (13) ALTERNATIVE DISPUTE RESOLUTION.--
23 (a) This subsection applies to disputes and claims
24 that are not subject to peer review under subsection (12). For
25 purposes of this subsection, the term "mediation" means the
26 alternative dispute resolution provided for in this
27 subsection, and the term "mediator" means the person
28 attempting to resolve the dispute or claim under this
29 subsection. As to any such dispute or claim to which this
30 subsection applies, if the insurer does not pay the amount
31 demanded within 15 days after its receipt of the demand letter
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1 referenced under subsection (1), either party may request
2 mediation of the claim; except that to facilitate faster
3 resolution of claims, a claimant may simultaneously and
4 together deliver both the demand letter and a request under
5 this subsection to the insurer and the department. As to any
6 item that is subject both to peer review under subsection (12)
7 and to this subsection because there is an issue to which
8 subsection (12) does not apply, a party may not request
9 mediation until the peer review process is concluded, absent
10 consent of the other party. The insurer may file a request for
11 mediation only on or before the 15th day after receipt of the
12 demand letter. Mediation is optional and either party may
13 decline to participate.
14 (b) A request for mediation shall be filed with the
15 department on a form approved by the department. The request
16 for mediation must state the reason for the request for
17 mediation and must include and state all the issues in dispute
18 at the time of the request which are to be mediated. The
19 filing of a request for mediation tolls the applicable time
20 requirements for filing suit for a period of 60 days following
21 the conclusion of the mediation process or the time prescribed
22 in s. 95.11, whichever is later.
23 (c) The mediation shall be conducted as an informal
24 process in which formal rules of evidence and procedure need
25 not be observed. The party to the mediation is not required to
26 attend the mediation if each representative of the party
27 participating in a mediation has the authority to make a
28 binding decision. All parties must mediate in good faith.
29 (d) The department shall randomly select mediators.
30 Each party may once reject the mediator selected, either
31
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1 originally or after the opposing side has exercised its option
2 to reject a mediator.
3 (e) If the insurer requests mediation, the costs of
4 mediation shall be paid by the insurer. Otherwise, the costs
5 shall be paid equally by both parties, except as provided in
6 paragraph (p).
7 (f) Only one mediation may be requested for all issues
8 that are, or with due diligence of the requesting party could
9 have been, addressed with such mediation, unless all parties
10 agree to further mediation.
11 (g) Upon receipt of a request for mediation, the
12 department shall refer the request to a mediator. The mediator
13 shall notify the applicant and all interested parties, as
14 identified by the applicant, and any other parties the
15 mediator believes may have an interest in the mediation, of
16 the date, time, and place of the mediation conference. The
17 conference may be held by telephone, if feasible. The
18 mediation conference shall be held within 45 days after the
19 request for mediation.
20 (h) The department shall approve mediators to conduct
21 mediations pursuant to this section. All mediators must file
22 an application under oath for approval as a mediator.
23 (i) To qualify for approval as a mediator, a person
24 must meet the following qualifications:
25 1. Possess a masters or doctorate degree in
26 psychology, counseling, business, accounting, or economics; be
27 a member of The Florida Bar; be licensed as a certified public
28 accountant; or demonstrate that the applicant for approval has
29 been actively engaged as a qualified mediator for at least 4
30 years prior to July 1, 1990.
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1 2. Within 4 years immediately preceding the date the
2 application for approval is filed with the department, have
3 completed a minimum of a 40-hour training program approved by
4 the department and successfully passed a final examination
5 included in the training program and approved by the
6 department. The training program shall include and address all
7 of the following:
8 a. Mediation theory.
9 b. Mediation process and techniques.
10 c. Standards of conduct for mediators.
11 d. Conflict management and intervention skills.
12 e. Insurance nomenclature.
13 f. The provisions of this section and additional
14 training if required as to any person not trained concerning
15 applicable principles of law.
16 (j) The Financial Services Commission must adopt rules
17 of procedure for claims mediation, taking into consideration a
18 system that is consistent with this section and that:
19 1. Is fair.
20 2. Promotes settlement.
21 3. Avoids delay.
22 4. Is nonadversarial.
23 5. Used a framework for modern mediating technique.
24 6. Controls costs and expenses of mediation.
25 7. Provides that, as to persons not represented by an
26 attorney, consumer affairs specialists of the department shall
27 be available for consultation to the extent that they may
28 lawfully do so, and that the mediator shall diligently inquire
29 and ascertain all facts necessary to formulate a fair and
30 informed recommendation pursuant to paragraph (m).
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1 (k) Disclosures and information divulged in the
2 mediation process are not admissible in any subsequent action
3 or proceeding relating to the claim or to the cause of action
4 giving rise to the claim, except as provided in paragraph (m).
5 (l) A person demanding mediation under this section
6 may not demand or request mediation after a suit is filed
7 relating to the same issues already mediated.
8 (m) For matters that are not resolved by the parties
9 at the conclusion of the mediation, the mediator shall prepare
10 a report recommending whether any amount is due and, if so,
11 the amount deemed to be owed on an itemized basis. Such report
12 shall be sent to all parties in attendance at the mediation
13 and to the department. This recommendation is not binding on
14 any party and the parties retain access to courts. The
15 mediator's written recommendation is admissible in any
16 subsequent action or proceeding relating to the claim or to
17 the cause of action giving rise to the claim only for purposes
18 of determining the award of attorney's fees.
19 (n) If the insurer declines to participate in
20 mediation or declines to pay the amount recommended in a
21 mediator's report, the insurer remains potentially liable for
22 reasonable attorney's fees pursuant to law. In such cases,
23 contingency risk multipliers apply only if the court
24 determines and states explicitly the particular legal or
25 factual issue involved and provides reasons supporting its
26 determination. The contingency risk multiplier shall be 2.5 if
27 the court determines that the issue is of such great public
28 importance that the public interest requires the determination
29 of that issue.
30 (o) If the claimant declines to mediate or declines to
31 settle the matter in accordance with the recommendation of the
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1 mediator pursuant to this section, the insurer is not liable
2 for attorney's fees otherwise required by provisions of the
3 insurance code or for damages under s. 624.155.
4 (p) The insurer is not liable for attorney's fees
5 otherwise required by provisions of the insurance code or for
6 damages under s. 624.155 if the insurer tenders payment of the
7 amount demanded in the demand letter at any time prior to the
8 insurer's receipt of the mediator's written recommendation, or
9 tenders the amount recommended within 10 days after the
10 insurer's receipt of the mediator's written recommendation,
11 together with the mediator's fee if any has accrued,
12 applicable interest, and a penalty of 10 percent of the
13 overdue amount paid by the insurer, subject to a maximum
14 penalty of $250. If the dispute involves an insurer's
15 withdrawal of payment under paragraph (7)(a) for future
16 treatment not yet rendered, the insurer is not liable in any
17 action for attorney's fees otherwise required by the insurance
18 code or for damages under s. 624.155 if within 10 business
19 days after its receipt of the written recommendation of the
20 peer reviewer, or at any time prior to or during the pendency
21 of a dispute under this subsection, the insurer tenders the
22 mediator's fee if any has accrued, and mails to the claimant a
23 written statement of its agreement to pay for such treatment
24 in accordance with the claimant's demand or mediator's
25 recommendation and to pay a penalty of 10 percent, subject to
26 a maximum penalty of $250, when it pays for such future
27 treatment in accordance with this section. However, if the
28 mediator recommends an amount that is in excess of the amount
29 that the insurer has paid, the insurer is liable for
30 reasonable attorney's fees of the claimant of up to $1,000, as
31 determined by the mediator. For purposes of this subsection,
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1 payment or the insurer's agreement shall be treated as being
2 made on the date a draft or other valid instrument that is
3 equivalent to payment or tender of payment, or the insurer's
4 written statement of agreement, is placed in the United States
5 mail in a properly addressed, postpaid envelope, or if not so
6 posted, on the date of delivery.
7 (q) An action may not be brought against an insurer
8 without attaching a copy of the notice required by this
9 subsection and a copy of the proof of delivery of the notice
10 required by this section.
11 (r) A party may seek judicial review of the
12 recommendation of the mediator to determine whether the
13 recommendation was reasonable. A recommendation is reasonable
14 unless it was procured by corruption, fraud, or other undue
15 means; there was evident partiality by the peer reviewer or
16 misconduct prejudicing the rights of any party; or the
17 mediator exceeded the authority and power granted by this
18 subsection. If the court declares the recommendation to be not
19 reasonable, the mediation recommendation shall be vacated, the
20 department shall provide a different mediator to review the
21 dispute and issue a recommendation, and the mediation process
22 shall proceed as if no action had been filed.
23 (14)(12) CIVIL ACTION FOR INSURANCE FRAUD.--
24 (a) An insurer shall have a cause of action against
25 any person convicted of, or who, regardless of adjudication of
26 guilt, pleads guilty or nolo contendere to insurance fraud
27 under s. 817.234, patient brokering under s. 817.505, or
28 kickbacks under s. 456.054, associated with a claim for
29 personal injury protection benefits in accordance with this
30 section. An insurer prevailing in an action brought under
31 this subsection may recover compensatory, consequential, and
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1 punitive damages subject to the requirements and limitations
2 of part II of chapter 768, and attorney's fees and costs
3 incurred in litigating a cause of action against any person
4 convicted of, or who, regardless of adjudication of guilt,
5 pleads guilty or nolo contendere to insurance fraud under s.
6 817.234, patient brokering under s. 817.505, or kickbacks
7 under s. 456.054, associated with a claim for personal injury
8 protection benefits in accordance with this section.
9 (b) Notwithstanding its payment, an insurer and
10 insured shall not be precluded from maintaining a civil cause
11 of action against any person or business entity to recover
12 payments for services later determined to have been unlawfully
13 rendered or otherwise in violation of any provision of this
14 section.
15 (15) If the Financial Services Commission determines
16 that the cost savings under personal injury protection
17 insurance benefits paid by insurers have been realized due to
18 the provisions of this act, prior legislative reforms, or
19 other factors, the commission may increase the minimum $10,000
20 benefit coverage requirement. In establishing the amount of
21 such increase, the commission must determine that the
22 additional premium for such coverage is approximately equal to
23 the premium cost savings that have been realized for the
24 personal injury protection coverage with limits of $10,000.
25 Section 10. Subsection (2) of section 627.739, Florida
26 Statutes, is amended to read:
27 627.739 Personal injury protection; optional
28 limitations; deductibles.--
29 (2) Insurers shall offer to each applicant and to each
30 policyholder, upon the renewal of an existing policy,
31 deductibles, in amounts of $250, $500, $1,000, and $2,000. The
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1 deductible amount must be applied to 100 percent of the
2 expenses and losses described in s. 627.736. After the
3 deductible is met, each insured is eligible to receive up to
4 $10,000 in total benefits described in s. 627.736(1)., such
5 amount to be deducted from the benefits otherwise due each
6 person subject to the deduction. However, this subsection
7 shall not be applied to reduce the amount of any benefits
8 received in accordance with s. 627.736(1)(c).
9 Section 11. Subsection (9) is added to section 768.79,
10 Florida Statutes, to read:
11 768.79 Offer of judgment and demand for judgment.--
12 (9) This section is applicable to any civil action
13 filed which applies to s. 627.736, in any court in this state.
14 A filing in compliance with this section does not constitute
15 an admission of coverage, and an insurer may not be estopped
16 from denying coverage, denying liability, or defending against
17 any claim on its merits.
18 Section 12. Subsections (7), (8), and (9) of section
19 817.234, Florida Statutes, are amended to read:
20 817.234 False and fraudulent insurance claims.--
21 (7)(a) It shall constitute a material omission and
22 insurance fraud for any physician or other provider, other
23 than a hospital, to engage in a general business practice of
24 billing amounts as its usual and customary charge, if such
25 provider has agreed with the patient or intends to waive
26 deductibles or copayments, or does not for any other reason
27 intend to collect the total amount of such charge.
28 (b) The provisions of this section shall also apply as
29 to any insurer or adjusting firm or its agents or
30 representatives who, with intent, injure, defraud, or deceive
31 any claimant with regard to any claim. The claimant shall
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1 have the right to recover the damages provided in this
2 section.
3 (c) An insurer, or any person acting at the direction
4 of or on behalf of an insurer, may not change an opinion in a
5 mental or physical report prepared under s. 627.736(7) or
6 direct the physician preparing the report to change such
7 opinion; however, this provision does not preclude the insurer
8 from calling to the attention of the physician errors of fact
9 in the report based upon information in the claim file. Any
10 person who violates this paragraph commits a felony of the
11 third degree, punishable as provided in s. 775.082, s.
12 775.083, or s. 775.084.
13 (8)(a) A It is unlawful for any person may not, in his
14 or her individual capacity or in his or her capacity as a
15 public or private employee, or for any firm, corporation,
16 partnership, or association, to solicit or cause to be
17 solicited any business from a person involved in a motor
18 vehicle accident with the intent of defrauding any other
19 person, by any means of communication other than advertising
20 directed to the public for the purpose of making motor vehicle
21 tort claims or claims for personal injury protection benefits
22 required by s. 627.736. Charges for any services rendered by
23 a health care provider or attorney who violates this
24 subsection in regard to the person for whom such services were
25 rendered are noncompensable and unenforceable as a matter of
26 law. Any person who violates the provisions of this paragraph
27 subsection commits a felony of the second third degree,
28 punishable as provided in s. 775.082, s. 775.083, or s.
29 775.084. A person who is convicted of a violation of this
30 subsection shall be sentenced to a minimum term of
31 imprisonment of 2 years.
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1 (b) A person may not solicit or cause to be solicited
2 any business from a person involved in a motor vehicle
3 accident by any means of communication other than advertising
4 directed to the public for the purpose of making motor vehicle
5 tort claims or claims for personal injury protection benefits
6 required by s. 627.736, within 60 days after the occurrence of
7 the motor vehicle accident. Any person who violates this
8 paragraph commits a felony of the third degree, punishable as
9 provided in s. 775.082, s. 775.083, or s. 775.084.
10 (c) A lawyer, health care practitioner as defined in
11 s. 456.001, or owner or medical director of a clinic required
12 to be licensed pursuant to s. 400.903 may not, at any time
13 after 60 days have elapsed from the occurrence of a motor
14 vehicle accident, solicit or cause to be solicited any
15 business from a person involved in a motor vehicle accident by
16 means of in-person or telephone contact at the person's
17 residence, for the purpose of making motor vehicle tort claims
18 or claims for personal injury protection benefits required by
19 s. 627.736. Any person who violates this paragraph commits a
20 felony of the third degree, punishable as provided in s.
21 775.082, s. 775.083, or s. 775.084.
22 (d) Charges for any services rendered by any person
23 who violates this subsection in regard to the person for whom
24 such services were rendered are noncompensable and
25 unenforceable as a matter of law.
26 (9) A person may not organize, plan, or knowingly
27 participate in an intentional motor vehicle crash for the
28 purpose of making motor vehicle tort claims or claims for
29 personal injury protection benefits as required by s. 627.736.
30 It is unlawful for any attorney to solicit any business
31 relating to the representation of a person involved in a motor
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1 vehicle accident for the purpose of filing a motor vehicle
2 tort claim or a claim for personal injury protection benefits
3 required by s. 627.736. The solicitation by advertising of
4 any business by an attorney relating to the representation of
5 a person injured in a specific motor vehicle accident is
6 prohibited by this section. Any person attorney who violates
7 the provisions of this paragraph subsection commits a felony
8 of the second third degree, punishable as provided in s.
9 775.082, s. 775.083, or s. 775.084. A person who is convicted
10 of a violation of this subsection shall be sentenced to a
11 minimum term of imprisonment of 2 years. Whenever any circuit
12 or special grievance committee acting under the jurisdiction
13 of the Supreme Court finds probable cause to believe that an
14 attorney is guilty of a violation of this section, such
15 committee shall forward to the appropriate state attorney a
16 copy of the finding of probable cause and the report being
17 filed in the matter. This section shall not be interpreted to
18 prohibit advertising by attorneys which does not entail a
19 solicitation as described in this subsection and which is
20 permitted by the rules regulating The Florida Bar as
21 promulgated by the Florida Supreme Court.
22 Section 13. Section 817.236, Florida Statutes, is
23 amended to read:
24 817.236 False and fraudulent motor vehicle insurance
25 application.--Any person who, with intent to injure, defraud,
26 or deceive any motor vehicle insurer, including any
27 statutorily created underwriting association or pool of motor
28 vehicle insurers, presents or causes to be presented any
29 written application, or written statement in support thereof,
30 for motor vehicle insurance knowing that the application or
31 statement contains any false, incomplete, or misleading
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1 information concerning any fact or matter material to the
2 application commits a felony misdemeanor of the third first
3 degree, punishable as provided in s. 775.082, or s. 775.083,
4 or s. 775.084.
5 Section 14. Section 817.2361, Florida Statutes, is
6 created to read:
7 817.2361 False or fraudulent motor vehicle insurance
8 card.--Any person who, with intent to deceive any other
9 person, creates, markets, or presents a false or fraudulent
10 motor vehicle insurance card commits a felony of the third
11 degree, punishable as provided in s. 775.082, s. 775.083, or
12 s. 775.084.
13 Section 15. Effective October 1, 2003, paragraphs (c)
14 and (g) of subsection (3) of section 921.0022, Florida
15 Statutes, are amended to read:
16 921.0022 Criminal Punishment Code; offense severity
17 ranking chart.--
18 (3) OFFENSE SEVERITY RANKING CHART
19
20 Florida Felony
21 Statute Degree Description
22
23
24 (c) LEVEL 3
25 119.10(3) 3rd Unlawful use of confidential
26 information from police reports.
27 316.066(3)(d)-(f) 3rd Unlawfully obtaining or using
28 confidential crash reports.
29 316.193(2)(b) 3rd Felony DUI, 3rd conviction.
30
31
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1 316.1935(2) 3rd Fleeing or attempting to elude
2 law enforcement officer in marked
3 patrol vehicle with siren and
4 lights activated.
5 319.30(4) 3rd Possession by junkyard of motor
6 vehicle with identification
7 number plate removed.
8 319.33(1)(a) 3rd Alter or forge any certificate of
9 title to a motor vehicle or
10 mobile home.
11 319.33(1)(c) 3rd Procure or pass title on stolen
12 vehicle.
13 319.33(4) 3rd With intent to defraud, possess,
14 sell, etc., a blank, forged, or
15 unlawfully obtained title or
16 registration.
17 327.35(2)(b) 3rd Felony BUI.
18 328.05(2) 3rd Possess, sell, or counterfeit
19 fictitious, stolen, or fraudulent
20 titles or bills of sale of
21 vessels.
22 328.07(4) 3rd Manufacture, exchange, or possess
23 vessel with counterfeit or wrong
24 ID number.
25 376.302(5) 3rd Fraud related to reimbursement
26 for cleanup expenses under the
27 Inland Protection Trust Fund.
28 400.903(3) 3rd Operating a clinic without a
29 license or filing false license
30 application or other required
31 information.
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1 501.001(2)(b) 2nd Tampers with a consumer product
2 or the container using materially
3 false/misleading information.
4 697.08 3rd Equity skimming.
5 790.15(3) 3rd Person directs another to
6 discharge firearm from a vehicle.
7 796.05(1) 3rd Live on earnings of a prostitute.
8 806.10(1) 3rd Maliciously injure, destroy, or
9 interfere with vehicles or
10 equipment used in firefighting.
11 806.10(2) 3rd Interferes with or assaults
12 firefighter in performance of
13 duty.
14 810.09(2)(c) 3rd Trespass on property other than
15 structure or conveyance armed
16 with firearm or dangerous weapon.
17 812.014(2)(c)2. 3rd Grand theft; $5,000 or more but
18 less than $10,000.
19 812.0145(2)(c) 3rd Theft from person 65 years of age
20 or older; $300 or more but less
21 than $10,000.
22 815.04(4)(b) 2nd Computer offense devised to
23 defraud or obtain property.
24 817.034(4)(a)3. 3rd Engages in scheme to defraud
25 (Florida Communications Fraud
26 Act), property valued at less
27 than $20,000.
28 817.233 3rd Burning to defraud insurer.
29
30
31
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1 817.234(8)
2 (b)-(c)&(9) 3rd Unlawful solicitation of persons
3 involved in motor vehicle
4 accidents.
5 817.234(11)(a) 3rd Insurance fraud; property value
6 less than $20,000.
7 817.236 3rd Filing a false motor vehicle
8 insurance application.
9 817.2361 3rd Creating, marketing, or
10 presenting a false or fraudulent
11 motor vehicle insurance card.
12 817.505(4) 3rd Patient brokering.
13 828.12(2) 3rd Tortures any animal with intent
14 to inflict intense pain, serious
15 physical injury, or death.
16 831.28(2)(a) 3rd Counterfeiting a payment
17 instrument with intent to defraud
18 or possessing a counterfeit
19 payment instrument.
20 831.29 2nd Possession of instruments for
21 counterfeiting drivers' licenses
22 or identification cards.
23 838.021(3)(b) 3rd Threatens unlawful harm to public
24 servant.
25 843.19 3rd Injure, disable, or kill police
26 dog or horse.
27 870.01(2) 3rd Riot; inciting or encouraging.
28
29
30
31
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1 893.13(1)(a)2. 3rd Sell, manufacture, or deliver
2 cannabis (or other s.
3 893.03(1)(c), (2)(c)1., (2)(c)2.,
4 (2)(c)3., (2)(c)5., (2)(c)6.,
5 (2)(c)7., (2)(c)8., (2)(c)9.,
6 (3), or (4) drugs).
7 893.13(1)(d)2. 2nd Sell, manufacture, or deliver s.
8 893.03(1)(c), (2)(c)1., (2)(c)2.,
9 (2)(c)3., (2)(c)5., (2)(c)6.,
10 (2)(c)7., (2)(c)8., (2)(c)9.,
11 (3), or (4) drugs within 200 feet
12 of university or public park.
13 893.13(1)(f)2. 2nd Sell, manufacture, or deliver s.
14 893.03(1)(c), (2)(c)1., (2)(c)2.,
15 (2)(c)3., (2)(c)5., (2)(c)6.,
16 (2)(c)7., (2)(c)8., (2)(c)9.,
17 (3), or (4) drugs within 200 feet
18 of public housing facility.
19 893.13(6)(a) 3rd Possession of any controlled
20 substance other than felony
21 possession of cannabis.
22 893.13(7)(a)8. 3rd Withhold information from
23 practitioner regarding previous
24 receipt of or prescription for a
25 controlled substance.
26 893.13(7)(a)9. 3rd Obtain or attempt to obtain
27 controlled substance by fraud,
28 forgery, misrepresentation, etc.
29 893.13(7)(a)10. 3rd Affix false or forged label to
30 package of controlled substance.
31
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1 893.13(7)(a)11. 3rd Furnish false or fraudulent
2 material information on any
3 document or record required by
4 chapter 893.
5 893.13(8)(a)1. 3rd Knowingly assist a patient, other
6 person, or owner of an animal in
7 obtaining a controlled substance
8 through deceptive, untrue, or
9 fraudulent representations in or
10 related to the practitioner's
11 practice.
12 893.13(8)(a)2. 3rd Employ a trick or scheme in the
13 practitioner's practice to assist
14 a patient, other person, or owner
15 of an animal in obtaining a
16 controlled substance.
17 893.13(8)(a)3. 3rd Knowingly write a prescription
18 for a controlled substance for a
19 fictitious person.
20 893.13(8)(a)4. 3rd Write a prescription for a
21 controlled substance for a
22 patient, other person, or an
23 animal if the sole purpose of
24 writing the prescription is a
25 monetary benefit for the
26 practitioner.
27 918.13(1)(a) 3rd Alter, destroy, or conceal
28 investigation evidence.
29 944.47
30 (1)(a)1.-2. 3rd Introduce contraband to
31 correctional facility.
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1 944.47(1)(c) 2nd Possess contraband while upon the
2 grounds of a correctional
3 institution.
4 985.3141 3rd Escapes from a juvenile facility
5 (secure detention or residential
6 commitment facility).
7 (g) LEVEL 7
8 316.193(3)(c)2. 3rd DUI resulting in serious bodily
9 injury.
10 327.35(3)(c)2. 3rd Vessel BUI resulting in serious
11 bodily injury.
12 402.319(2) 2nd Misrepresentation and negligence
13 or intentional act resulting in
14 great bodily harm, permanent
15 disfiguration, permanent
16 disability, or death.
17 409.920(2) 3rd Medicaid provider fraud.
18 456.065(2) 3rd Practicing a health care
19 profession without a license.
20 456.065(2) 2nd Practicing a health care
21 profession without a license
22 which results in serious bodily
23 injury.
24 458.327(1) 3rd Practicing medicine without a
25 license.
26 459.013(1) 3rd Practicing osteopathic medicine
27 without a license.
28 460.411(1) 3rd Practicing chiropractic medicine
29 without a license.
30 461.012(1) 3rd Practicing podiatric medicine
31 without a license.
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1 462.17 3rd Practicing naturopathy without a
2 license.
3 463.015(1) 3rd Practicing optometry without a
4 license.
5 464.016(1) 3rd Practicing nursing without a
6 license.
7 465.015(2) 3rd Practicing pharmacy without a
8 license.
9 466.026(1) 3rd Practicing dentistry or dental
10 hygiene without a license.
11 467.201 3rd Practicing midwifery without a
12 license.
13 468.366 3rd Delivering respiratory care
14 services without a license.
15 483.828(1) 3rd Practicing as clinical laboratory
16 personnel without a license.
17 483.901(9) 3rd Practicing medical physics
18 without a license.
19 484.013(1)(c) 3rd Preparing or dispensing optical
20 devices without a prescription.
21 484.053 3rd Dispensing hearing aids without a
22 license.
23 494.0018(2) 1st Conviction of any violation of
24 ss. 494.001-494.0077 in which the
25 total money and property
26 unlawfully obtained exceeded
27 $50,000 and there were five or
28 more victims.
29
30
31
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1 560.123(8)(b)1. 3rd Failure to report currency or
2 payment instruments exceeding
3 $300 but less than $20,000 by
4 money transmitter.
5 560.125(5)(a) 3rd Money transmitter business by
6 unauthorized person, currency or
7 payment instruments exceeding
8 $300 but less than $20,000.
9 655.50(10)(b)1. 3rd Failure to report financial
10 transactions exceeding $300 but
11 less than $20,000 by financial
12 institution.
13 782.051(3) 2nd Attempted felony murder of a
14 person by a person other than the
15 perpetrator or the perpetrator of
16 an attempted felony.
17 782.07(1) 2nd Killing of a human being by the
18 act, procurement, or culpable
19 negligence of another
20 (manslaughter).
21 782.071 2nd Killing of human being or viable
22 fetus by the operation of a motor
23 vehicle in a reckless manner
24 (vehicular homicide).
25 782.072 2nd Killing of a human being by the
26 operation of a vessel in a
27 reckless manner (vessel
28 homicide).
29 784.045(1)(a)1. 2nd Aggravated battery; intentionally
30 causing great bodily harm or
31 disfigurement.
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1 784.045(1)(a)2. 2nd Aggravated battery; using deadly
2 weapon.
3 784.045(1)(b) 2nd Aggravated battery; perpetrator
4 aware victim pregnant.
5 784.048(4) 3rd Aggravated stalking; violation of
6 injunction or court order.
7 784.07(2)(d) 1st Aggravated battery on law
8 enforcement officer.
9 784.074(1)(a) 1st Aggravated battery on sexually
10 violent predators facility staff.
11 784.08(2)(a) 1st Aggravated battery on a person 65
12 years of age or older.
13 784.081(1) 1st Aggravated battery on specified
14 official or employee.
15 784.082(1) 1st Aggravated battery by detained
16 person on visitor or other
17 detainee.
18 784.083(1) 1st Aggravated battery on code
19 inspector.
20 790.07(4) 1st Specified weapons violation
21 subsequent to previous conviction
22 of s. 790.07(1) or (2).
23 790.16(1) 1st Discharge of a machine gun under
24 specified circumstances.
25 790.165(2) 2nd Manufacture, sell, possess, or
26 deliver hoax bomb.
27 790.165(3) 2nd Possessing, displaying, or
28 threatening to use any hoax bomb
29 while committing or attempting to
30 commit a felony.
31
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1 790.166(3) 2nd Possessing, selling, using, or
2 attempting to use a hoax weapon
3 of mass destruction.
4 790.166(4) 2nd Possessing, displaying, or
5 threatening to use a hoax weapon
6 of mass destruction while
7 committing or attempting to
8 commit a felony.
9 796.03 2nd Procuring any person under 16
10 years for prostitution.
11 800.04(5)(c)1. 2nd Lewd or lascivious molestation;
12 victim less than 12 years of age;
13 offender less than 18 years.
14 800.04(5)(c)2. 2nd Lewd or lascivious molestation;
15 victim 12 years of age or older
16 but less than 16 years; offender
17 18 years or older.
18 806.01(2) 2nd Maliciously damage structure by
19 fire or explosive.
20 810.02(3)(a) 2nd Burglary of occupied dwelling;
21 unarmed; no assault or battery.
22 810.02(3)(b) 2nd Burglary of unoccupied dwelling;
23 unarmed; no assault or battery.
24 810.02(3)(d) 2nd Burglary of occupied conveyance;
25 unarmed; no assault or battery.
26 812.014(2)(a) 1st Property stolen, valued at
27 $100,000 or more; cargo stolen
28 valued at $50,000 or more;
29 property stolen while causing
30 other property damage; 1st degree
31 grand theft.
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1 812.014(2)(b)3. 2nd Property stolen, emergency
2 medical equipment; 2nd degree
3 grand theft.
4 812.0145(2)(a) 1st Theft from person 65 years of age
5 or older; $50,000 or more.
6 812.019(2) 1st Stolen property; initiates,
7 organizes, plans, etc., the theft
8 of property and traffics in
9 stolen property.
10 812.131(2)(a) 2nd Robbery by sudden snatching.
11 812.133(2)(b) 1st Carjacking; no firearm, deadly
12 weapon, or other weapon.
13 817.234(8)(a) 2nd Solicitation of motor vehicle
14 accident victims with intent to
15 defraud.
16 817.234(9) 2nd Organizing, planning, or
17 participating in an intentional
18 motor vehicle collision.
19 817.234(11)(c) 1st Insurance fraud; property value
20 $100,000 or more.
21 825.102(3)(b) 2nd Neglecting an elderly person or
22 disabled adult causing great
23 bodily harm, disability, or
24 disfigurement.
25 825.103(2)(b) 2nd Exploiting an elderly person or
26 disabled adult and property is
27 valued at $20,000 or more, but
28 less than $100,000.
29 827.03(3)(b) 2nd Neglect of a child causing great
30 bodily harm, disability, or
31 disfigurement.
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1 827.04(3) 3rd Impregnation of a child under 16
2 years of age by person 21 years
3 of age or older.
4 837.05(2) 3rd Giving false information about
5 alleged capital felony to a law
6 enforcement officer.
7 872.06 2nd Abuse of a dead human body.
8 893.13(1)(c)1. 1st Sell, manufacture, or deliver
9 cocaine (or other drug prohibited
10 under s. 893.03(1)(a), (1)(b),
11 (1)(d), (2)(a), (2)(b), or
12 (2)(c)4.) within 1,000 feet of a
13 child care facility or school.
14 893.13(1)(e)1. 1st Sell, manufacture, or deliver
15 cocaine or other drug prohibited
16 under s. 893.03(1)(a), (1)(b),
17 (1)(d), (2)(a), (2)(b), or
18 (2)(c)4., within 1,000 feet of
19 property used for religious
20 services or a specified business
21 site.
22 893.13(4)(a) 1st Deliver to minor cocaine (or
23 other s. 893.03(1)(a), (1)(b),
24 (1)(d), (2)(a), (2)(b), or
25 (2)(c)4. drugs).
26 893.135(1)(a)1. 1st Trafficking in cannabis, more
27 than 25 lbs., less than 2,000
28 lbs.
29 893.135
30 (1)(b)1.a. 1st Trafficking in cocaine, more than
31 28 grams, less than 200 grams.
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1 893.135
2 (1)(c)1.a. 1st Trafficking in illegal drugs,
3 more than 4 grams, less than 14
4 grams.
5 893.135
6 (1)(d)1. 1st Trafficking in phencyclidine,
7 more than 28 grams, less than 200
8 grams.
9 893.135(1)(e)1. 1st Trafficking in methaqualone, more
10 than 200 grams, less than 5
11 kilograms.
12 893.135(1)(f)1. 1st Trafficking in amphetamine, more
13 than 14 grams, less than 28
14 grams.
15 893.135
16 (1)(g)1.a. 1st Trafficking in flunitrazepam, 4
17 grams or more, less than 14
18 grams.
19 893.135
20 (1)(h)1.a. 1st Trafficking in
21 gamma-hydroxybutyric acid (GHB),
22 1 kilogram or more, less than 5
23 kilograms.
24 893.135
25 (1)(j)1.a. 1st Trafficking in 1,4-Butanediol, 1
26 kilogram or more, less than 5
27 kilograms.
28 893.135
29 (1)(k)2.a. 1st Trafficking in Phenethylamines,
30 10 grams or more, less than 200
31 grams.
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1 896.101(5)(a) 3rd Money laundering, financial
2 transactions exceeding $300 but
3 less than $20,000.
4 896.104(4)(a)1. 3rd Structuring transactions to evade
5 reporting or registration
6 requirements, financial
7 transactions exceeding $300 but
8 less than $20,000.
9 Section 16. The amendments made by this act to
10 sections 456.0375(1)(b) and 627.736(5)(b)3. and 6., Florida
11 Statutes, are intended to clarify the legislative intent of
12 those provisions as they existed at the time those provisions
13 initially took effect. Accordingly, sections 456.0375(1)(b)
14 and 627.736(5)(b)3., Florida Statutes, as amended by this act
15 shall operate retroactively to October 1, 2001; and section
16 627.736(5)(b)6., as amended by this act, shall operate
17 retroactively to June 19, 2001.
18 Section 17. Effective March 1, 2004, section 456.0375,
19 Florida Statutes, is repealed.
20 Section 18. (1) On or before January 1, 2004, every
21 insurer writing with a managing general agent and having a
22 per-policy fee in its rate filing shall make a rate filing
23 under section 627.0651, Florida Statutes, to conform its
24 per-policy fee to the requirements of this act.
25 (2) Any increase in benefits approved by the Financial
26 Services Commission under subsection (14) of section 627.736,
27 Florida Statutes, as added by this act, shall apply to new and
28 renewal policies that are effective 120 days after the order
29 issued by the commission becomes final. Subsection (2) of
30 section 627.739, Florida Statutes, as amended by this act,
31
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1 shall apply to new and renewal policies issued on or after
2 October 1, 2003.
3 (3) Subject to any specific effective dates in this
4 act, paragraphs (4)(b), (5)(b), (5)(c), (5)(e), (5)(f),
5 (5)(g), and (5)(h) of section 627.736, Florida Statutes, as
6 amended by this act, shall apply to treatment and services
7 occurring on or after October 1, 2003.
8 (4) Subsection (11) of section 627.736, Florida
9 Statutes, as amended by this act, shall apply to actions filed
10 on and after the effective date of this act. Subsections (12)
11 and (13) of section 627.736, Florida Statutes, as amended by
12 this act, shall apply to new and renewal policies issued on
13 and after October 1, 2003.
14 (5) Paragraph (7)(a) of section 627.736, Florida
15 Statutes, as amended by this act, and paragraph (7)(c) of
16 section 817.234, Florida Statutes, as amended by this act,
17 shall apply to examinations conducted on and after October 1,
18 2003.
19 Section 19. By December 31, 2004, the Department of
20 Financial Services, the Department of Health, and the Agency
21 for Health Care Administration each shall submit a report on
22 the implementation of this act and recommendations, if any, to
23 further improve the automobile insurance market, reduce
24 automobile insurance costs, and reduce automobile insurance
25 fraud and abuse to the President of the Senate and the Speaker
26 of the House of Representatives.
27 Section 20. There is appropriated $2.5 million from
28 the Health Care Trust Fund, and 51 full-time equivalent
29 positions are authorized, for the Agency for Health Care
30 Administration to implement the provisions of this act.
31
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1 Section 21. Except as otherwise expressly provided in
2 this act, this act shall take effect July 1, 2003.
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1 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
2 Senate Bill CS/SB 1202
3
4 The committee substitute establishes an expedited peer review
procedure to resolve personal injury protection (PIP) disputes
5 involving medical and other related issues between claimants,
providers and insurers. Provides definitions; qualifications
6 for peer reviewers; notice provisions; review procedures;
costs; and attorney's fees. The Agency for Health Care
7 Administration (AHCA) will administer the peer review program.
8 Designates mediation as the alternative dispute resolution
process and restricts its application to non-medical issues.
9
Provides that third-party vendors approved by the Division of
10 Insurance Fraud within the Department of Financial Services
may furnish crash reports solely to insurers for adjustment
11 and claims' investigation purposes. Provides that such vendors
are subject to criminal penalties.
12
Provides exceptions to the definition of a "clinic" relating
13 to continuing care facilities, community college and
university clinics, and clinical facilities affiliated with
14 medical schools.
15 Provides for a six-month extension for a magnetic resonance
imaging (MRI) facility to become accredited by specified
16 accreditation organizations. Prohibits certain entities formed
for the purpose of avoiding compliance with the accreditation
17 requirements from being licensed as clinics.
18 Provides for the definition of an independent diagnostic
testing facility to include both the technical testing
19 component and professional service component and that the
lawful billing by such a facility does not violate the
20 upcoding restriction.
21 Narrows the definition of what services are "incident" to a
physician's services.
22
Reduces the amount of insurance policy fees provided to
23 specified entities for the investigation and prosecution of
motor vehicle insurance fraud.
24
Specifies that certain tests and services, including MRI
25 services, are subject to 200 percent of the Medicare Part B
Participating Physician fee schedule and that other specified
26 tests are subject to the workers' compensation fee schedule.
Provides for the Financial Services Commission to at least
27 annually review changes to the Medicare fee schedule and adopt
such changes for PIP, if warranted to maintain availability
28 and affordability of services.
29 Clarifies that the disclosure and acknowledgement form
pertains to the provision of services instead of charges and
30 exempts specified emergency services.
31 Removes the authority for the Department of Health to
promulgate utilization guidelines.
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1 Provides an appropriation of $2.5 million from the Health Care
Trust Fund and 51 FTE's for the Agency for Health Care
2 Administration to implement the provisions of the act.
3 Provides for effective dates.
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