HB 0631

1	A bill to be entitled
2	An act relating to the provision of health care services;
3	amending s. 627.6131, F.S.; prohibiting a health insurer
4	from demanding repayment of an overpayment made due to
5	error of the health insurer; reducing a period of time for
6	a claim for overpayment; requiring a health insurer to
7	pay, and prohibiting denial of, a claim for treatment
8	under certain circumstances; providing exceptions;
9	authorizing certain aggrieved persons to bring certain
10	actions for certain violations; providing for recovery of
11	amounts, interest, attorney's fees, and court costs;
12	providing limits; requiring attorneys to submit affidavits
13	for fees; providing for awards of fees or costs to become
14	a part of the judgment and subject to execution; providing
15	for application; amending s. 641.19, F.S.; clarifying a
16	definition; amending s. 641.31, F.S.; prohibiting health
17	maintenance contracts from prohibiting or restricting
18	subscribers from assigning plan benefits to noncontract
19	physicians for certain services; requiring recognition of
20	the assignment and payment of services; providing
21	requirements for certain physicians accepting such
22	assignments; amending s. 641.315, F.S.; revising required
23	contract termination provisions; amending s. 641.3155,
24	F.S.; prohibiting a health maintenance organization from
25	demanding repayment of an overpayment made due to error of
26	the health maintenance organization; reducing a period of
27	time for a claim for overpayment; authorizing certain
28	aggrieved persons to bring certain actions for certain
29	violations; providing for recovery of amounts, interest,
30	attorney's fees, and court costs; providing limits;
31	requiring attorneys to submit affidavits for fees;
32	providing for awards of fees or costs to become a part of
33	the judgment and subject to execution; providing for
34	application; amending s. 641.3156, F.S.; requiring a
35	health maintenance organization to pay, and prohibiting
36	denial of, a claim for treatment under certain
37	circumstances; providing exceptions; amending s. 641.513,
38	F.S.; revising provisions for reimbursement of noncontract
39	providers; providing an effective date.
40
41	Be It Enacted by the Legislature of the State of Florida:
42
43	Section 1.  Subsection (6) of section 627.6131, Florida
44	Statutes, is amended, and subsections (18) and (19) are added to
45	said section, to read:
46	627.6131  Payment of claims.--
47	(6)  If a health insurer determines that it has made an
48	overpayment to a provider for services rendered to an insured,
49	the health insurer must make a claim for such overpayment to the
50	provider's designated location. A health insurer may not demand
51	repayment from the provider in any instance in which the
52	overpayment is attributable to error of the health insurer. A
53	health insurer that makes a claim for overpayment to a provider
54	under this section shall give the provider a written or
55	electronic statement specifying the basis for the retroactive
56	denial or payment adjustment. The insurer must identify the
57	claim or claims, or overpayment claim portion thereof, for which
58	a claim for overpayment is submitted.
59	(a)  If an overpayment determination is the result of
60	retroactive review or audit of coverage decisions or payment
61	levels not related to fraud, a health insurer shall adhere to
62	the following procedures:
63	1.  All claims for overpayment must be submitted to a
64	provider within 12 30 months after the health insurer's payment
65	of the claim. A provider must pay, deny, or contest the health
66	insurer's claim for overpayment within 40 days after the receipt
67	of the claim. All contested claims for overpayment must be paid
68	or denied within 120 days after receipt of the claim. Failure to
69	pay or deny overpayment and claim within 140 days after receipt
70	creates an uncontestable obligation to pay the claim.
71	2.  A provider that denies or contests a health insurer's
72	claim for overpayment or any portion of a claim shall notify the
73	health insurer, in writing, within 35 days after the provider
74	receives the claim that the claim for overpayment is contested
75	or denied. The notice that the claim for overpayment is denied
76	or contested must identify the contested portion of the claim
77	and the specific reason for contesting or denying the claim and,
78	if contested, must include a request for additional information.
79	If the health insurer submits additional information, the health
80	insurer must, within 35 days after receipt of the request, mail
81	or electronically transfer the information to the provider. The
82	provider shall pay or deny the claim for overpayment within 45
83	days after receipt of the information. The notice is considered
84	made on the date the notice is mailed or electronically
85	transferred by the provider.
86	3.  The health insurer may not reduce payment to the
87	provider for other services unless the provider agrees to the
88	reduction in writing or fails to respond to the health insurer's
89	overpayment claim as required by this paragraph.
90	4.  Payment of an overpayment claim is considered made on
91	the date the payment was mailed or electronically transferred.
92	An overdue payment of a claim bears simple interest at the rate
93	of 12 percent per year. Interest on an overdue payment for a
94	claim for an overpayment begins to accrue when the claim should
95	have been paid, denied, or contested.
96	(b)  A claim for overpayment shall not be permitted beyond
97	12 30 months after the health insurer's payment of a claim,
98	except that claims for overpayment may be sought beyond that
99	time from providers convicted of fraud pursuant to s. 817.234.
100	(18)  A claim for treatment must be paid by a health
101	insurer and may not be denied if a provider, whether or not
102	under contract with the health insurer, follows the insurer's
103	authorization procedures and receives authorization for a
104	covered service for an eligible subscriber, unless the provider
105	provided information to the health insurer with willful intent
106	to misinform the health insurer. Emergency services are subject
107	to the provisions of ss. 395.1041 and 401.45 and are not subject
108	to the provisions of this subsection.
109	(19)(a)  Without regard to any other remedy or relief to
110	which a person is entitled, or obligated to under contract,
111	anyone aggrieved by a violation of this section may bring an
112	action for damages or to obtain a declaratory judgment that an
113	act or practice violates this section and to enjoin a person who
114	has violated, is violating, or is otherwise likely to violate
115	this section.
116	(b)  In any action brought by a person who has suffered
117	damages as a result of a violation of this section, such person
118	may recover any amounts due the person, including accrued
119	interest, plus attorney's fees and court costs as provided in
120	paragraphs (c) and (d).
121	(c)1.  In any civil action brought pursuant to this
122	subsection, the prevailing party, after judgment in the trial
123	court and after exhausting all appeals, if any, shall receive
124	his or her attorney's fees and costs from the nonprevailing
125	party.
126	2.  If the provider is the prevailing party, such fees
127	shall not exceed three times the amount in controversy or
128	$10,000, whichever is greater.
129	3.  If the health insurer is the prevailing party on any
130	claim or defense for which the court finds that the insured or
131	the insured's assignee knew or should have known that the claim
132	or defense was not supported by the material facts necessary to
133	establish the claim or defense, or would not be supported by the
134	application of then-existing law as to those material facts,
135	such fees shall not exceed two times the amount in controversy
136	or $5,000, whichever is greater.
137	(d)1.  In any civil action brought by a health insurer
138	pursuant to this subsection, the prevailing party, after
139	judgment in the trial court and after exhausting all appeals, if
140	any, shall receive his or her attorney's fees and costs from the
141	nonprevailing party.
142	2.  If the health insurer is the prevailing party on any
143	claim or defense for which the court finds that the insured or
144	the insured's assignee knew or should have known that the claim
145	or defense was not supported by the material facts necessary to
146	establish the claim or defense, or would not be supported by the
147	application of then-existing law as to those material facts,
148	such fees shall not exceed two times the amount in controversy
149	or $5,000, whichever is greater.
150	3.  If the insured or the insured's assignee is the
151	prevailing party, such fees shall not exceed three times the
152	amount in controversy or $10,000, whichever is greater.
153	(e)  The attorney for the prevailing party shall submit to
154	the trial judge who presided over the civil case a sworn
155	affidavit of his or her time spent on the case and his or her
156	costs incurred for all the motions, hearings, and appeals.
157	(f)  Any award of attorney's fees or court costs shall
158	become a part of the judgment and subject to execution as
159	provided by law.
160	(g)  This subsection shall apply in any proceeding in which
161	the provider alleges that the health insurer has failed to
162	comply with its contractual obligations.
163	Section 2.  Subsection (16) of section 641.19, Florida
164	Statutes, is amended to read:
165	641.19  Definitions.--As used in this part, the term:
166	(16)  "Schedule of reimbursements" means a schedule of fees
167	to be paid by a health maintenance organization to a physician
168	provider for reimbursement for specific services pursuant to the
169	terms of a contract. The physician provider's net reimbursement
170	may vary after consideration of other factors, including, but
171	not limited to, bundling codes together into another code,
172	modifiers used, and member cost-sharing responsibility, as long
173	as these factors are disclosed and included in the terms of the
174	contract between the health maintenance organization and
175	provider. The reimbursement schedule may be stated as:
176	(a)  A percentage of the current Medicare fee schedule and
177	rules for specific relative-value services;
178	(b)  A listing of the reimbursements to be paid by Current
179	Procedural Terminology codes for physicians that pertain to each
180	physician's practice; or
181	(c)  Any other method agreed upon by the parties.
182
183	Specific nonrelative-value services shall be stated separately
184	from relative-value services, and reimbursement for unclassified
185	services shall be on a reasonable basis.
186	Section 3.  Subsection (41) is added to section 641.31,
187	Florida Statutes, to read:
188	641.31  Health maintenance contracts.--
189	(41)(a)  A health maintenance organization contract may not
190	prohibit or restrict a subscriber from assigning plan benefits
191	to physicians not under contract with the organization for
192	covered health care services rendered by the physician to the
193	subscriber.
194	(b)  Any assignment by a subscriber of plan benefits that
195	designates that the subscriber has been accepted by a physician
196	not under contract with the organization must be recognized by
197	the organization and paid pursuant to s. 641.3155.
198	(c)  Except for physicians providing services pursuant to
199	s. 641.513, any physician who accepts an assignment pursuant to
200	this subsection agrees, by submitting the claim to the health
201	maintenance organization, to accept the amount paid by the
202	health maintenance organization as payment in full for the
203	health care services provided and to not collect any balance
204	from the subscriber.
205	Section 4.  Subsections (1) and (2) of section 641.315,
206	Florida Statutes, are amended to read:
207	641.315  Provider contracts.--
208	(1)  Each contract between a health maintenance
209	organization and a provider of health care services must be in
210	writing and must contain a provision that, except as otherwise
211	provided, the subscriber is not liable to the provider for any
212	services for which the health maintenance organization is liable
213	as specified in s. 641.3154.
214	(2)(a)  Each contract between a health maintenance
215	organization and a provider of health care services For all
216	provider contracts executed after October 1, 1991, and within
217	180 days after October 1, 1991, for contracts in existence as of
218	October 1, 1991:
219	1.  The contracts must provide that require the provider
220	may terminate the contract, without cause, by giving 90 to give
221	60 days' advance written notice to the health maintenance
222	organization and the office. before canceling the contract with
223	the health maintenance organization for any reason; and
224	2.  The contract must also provide that nonpayment for
225	goods or services rendered by the provider to the health
226	maintenance organization is not a valid reason for avoiding the
227	90-day 60-day advance notice of cancellation.
228	(b)  Each contract between a health maintenance
229	organization and a provider of health care services All provider
230	contracts must contain a provision providing provide that the
231	health maintenance organization may terminate the contract,
232	without cause, by giving 90 will provide 60 days' advance
233	written notice to the provider and the office before canceling,
234	without cause, the contract with the provider, except in a case
235	in which a patient's health is subject to imminent danger or a
236	physician's ability to practice medicine is effectively impaired
237	by an action by the Board of Medicine or other governmental
238	agency.
239	Section 5.  Subsection (5) of section 641.3155, Florida
240	Statutes, is amended, and subsection (16) is added to said
241	section, to read:
242	641.3155  Prompt payment of claims.--
243	(5)  If a health maintenance organization determines that
244	it has made an overpayment to a provider for services rendered
245	to a subscriber, the health maintenance organization must make a
246	claim for such overpayment to the provider's designated
247	location. The health maintenance organization may not demand
248	repayment from the provider in any instance in which the
249	overpayment is attributable to error of the health maintenance
250	organization. A health maintenance organization that makes a
251	claim for overpayment to a provider under this section shall
252	give the provider a written or electronic statement specifying
253	the basis for the retroactive denial or payment adjustment. The
254	health maintenance organization must identify the claim or
255	claims, or overpayment claim portion thereof, for which a claim
256	for overpayment is submitted.
257	(a)  If an overpayment determination is the result of
258	retroactive review or audit of coverage decisions or payment
259	levels not related to fraud, a health maintenance organization
260	shall adhere to the following procedures:
261	1.  All claims for overpayment must be submitted to a
262	provider within 12 30 months after the health maintenance
263	organization's payment of the claim. A provider must pay, deny,
264	or contest the health maintenance organization's claim for
265	overpayment within 40 days after the receipt of the claim. All
266	contested claims for overpayment must be paid or denied within
267	120 days after receipt of the claim. Failure to pay or deny
268	overpayment and claim within 140 days after receipt creates an
269	uncontestable obligation to pay the claim.
270	2.  A provider that denies or contests a health maintenance
271	organization's claim for overpayment or any portion of a claim
272	shall notify the organization, in writing, within 35 days after
273	the provider receives the claim that the claim for overpayment
274	is contested or denied. The notice that the claim for
275	overpayment is denied or contested must identify the contested
276	portion of the claim and the specific reason for contesting or
277	denying the claim and, if contested, must include a request for
278	additional information. If the organization submits additional
279	information, the organization must, within 35 days after receipt
280	of the request, mail or electronically transfer the information
281	to the provider. The provider shall pay or deny the claim for
282	overpayment within 45 days after receipt of the information. The
283	notice is considered made on the date the notice is mailed or
284	electronically transferred by the provider.
285	3.  The health maintenance organization may not reduce
286	payment to the provider for other services unless the provider
287	agrees to the reduction in writing or fails to respond to the
288	health maintenance organization's overpayment claim as required
289	by this paragraph.
290	4.  Payment of an overpayment claim is considered made on
291	the date the payment was mailed or electronically transferred.
292	An overdue payment of a claim bears simple interest at the rate
293	of 12 percent per year. Interest on an overdue payment for a
294	claim for an overpayment payment begins to accrue when the claim
295	should have been paid, denied, or contested.
296	(b)  A claim for overpayment shall not be permitted beyond
297	12 30 months after the health maintenance organization's payment
298	of a claim, except that claims for overpayment may be sought
299	beyond that time from providers convicted of fraud pursuant to
300	s. 817.234.
301	(16)(a)  Without regard to any other remedy or relief to
302	which a person is entitled, or obligated to under contract,
303	anyone aggrieved by a violation of this section, s. 641.3156, or
304	s. 641.513 may bring an action for damages or to obtain a
305	declaratory judgment that an act or practice violates this
306	section, s. 641.3156, or s. 641.513 and to enjoin a person who
307	has violated, is violating, or is otherwise likely to violate
308	this section.
309	(b)  In any action brought by a person who has suffered
310	damages as a result of a violation of this section, s. 641.3156,
311	or s. 641.513, such person may recover any amounts due the
312	person, including accrued interest, plus attorney's fees and
313	court costs as provided in paragraphs (c) and (d).
314	(c)1.  In any civil action brought pursuant to this
315	subsection, the prevailing party, after judgment in the trial
316	court and after exhausting all appeals, if any, shall receive
317	his or her attorney's fees and costs from the nonprevailing
318	party.
319	2.  If the provider is the prevailing party, such fees
320	shall not exceed three times the amount in controversy or
321	$10,000, whichever is greater.
322	3.  If the health maintenance organization is the
323	prevailing party on any claim or defense for which the court
324	finds that the provider knew or should have known that the claim
325	or defense was not supported by the material facts necessary to
326	establish the claim or defense, or would not be supported by the
327	application of then-existing law as to those material facts,
328	such fees shall not exceed two times the amount in controversy
329	or $5,000, whichever is greater.
330	(d)1.  In any civil action brought by a health maintenance
331	organization pursuant to this subsection, the prevailing party,
332	after judgment in the trial court and after exhausting all
333	appeals, if any, shall receive his or her attorney's fees and
334	costs from the nonprevailing party.
335	2.  If the health maintenance organization is the
336	prevailing party on any claim or defense for which the court
337	finds that the provider knew or should have known that the claim
338	or defense was not supported by the material facts necessary to
339	establish the claim or defense, or would not be supported by the
340	application of then-existing law as to those material facts,
341	such fees shall not exceed two times the amount in controversy
342	or $5,000, whichever is greater.
343	3.  If the provider is the prevailing party, such fees
344	shall not exceed three times the amount in controversy or
345	$10,000, whichever is greater.
346	(e)  The attorney for the prevailing party shall submit to
347	the trial judge who presided over the civil case a sworn
348	affidavit of his or her time spent on the case and his or her
349	costs incurred for all the motions, hearings, and appeals.
350	(f)  Any award of attorney's fees or costs shall become a
351	part of the judgment and subject to execution as provided by
352	law.
353	(g)  This subsection shall apply in any proceeding in which
354	the provider alleges that the health maintenance organization
355	has failed to comply with its contractual obligations.
356	Section 6.  Subsection (2) of section 641.3156, Florida
357	Statutes, is amended to read:
358	641.3156  Treatment authorization; payment of claims.--
359	(2)  A claim for treatment must be paid by a health
360	maintenance organization and may not be denied if a provider,
361	whether or not under contract with a health maintenance
362	organization, follows the health maintenance organization's
363	authorization procedures and receives authorization for a
364	covered service for an eligible subscriber, unless the provider
365	provided information to the health maintenance organization with
366	the willful intention to misinform the health maintenance
367	organization. Emergency services are subject to the provisions
368	of ss. 395.1041 and 401.45 and are not subject to the provisions
369	of this subsection.
370	Section 7.  Subsection (5) of section 641.513, Florida
371	Statutes, is amended to read:
372	641.513  Requirements for providing emergency services and
373	care.--
374	(5)  Reimbursement for services pursuant to this section by
375	a provider who does not have a contract with the health
376	maintenance organization, or provided to subscribers who are not
377	Medicaid recipients by a provider for whom no contract exists
378	between the provider and the health maintenance organization,
379	shall be the lesser of:
380	(a)  The provider's charges;
381	(b)  The usual and customary provider charges for similar
382	services in the community where the services were provided. For
383	physicians only, the usual and customary charge shall be the
384	average gross charge for that service in the county where the
385	service is provided; or
386	(c)  The charge mutually agreed to by the health
387	maintenance organization and the provider within 30 60 days
388	after of the submittal of the claim.
389
390	Such reimbursement shall be net of any applicable copayment
391	authorized pursuant to subsection (4).
392	Section 8.  Subsection (5) of section 641.513, Florida
393	Statutes, as created by section 9 of chapter 96-223, Laws of
394	Florida, is amended to read:
395	641.513  Requirements for providing emergency services and
396	care.--
397	(5)  Reimbursement for services pursuant to under this
398	section by a provider who does not have a contract with the
399	health maintenance organization, or provided to subscribers who
400	are not Medicaid recipients by a provider for whom no contract
401	exists between the provider and the health maintenance
402	organization, shall be the lesser of:
403	(a)  The provider's charges;
404	(b)  The usual and customary provider charges for similar
405	services in the community where the services were provided. For
406	physicians only, the usual and customary charge shall be the
407	average gross charge for that service in the county where the
408	service is provided; or
409	(c)  The charge mutually agreed to by the health
410	maintenance organization and the provider within 30 60 days
411	after the submittal of the claim.
412
413	Such reimbursement shall be net of any applicable copayment
414	authorized pursuant to subsection (4).
415	Section 9.  This act shall take effect October 1, 2005.

CODING: Words stricken are deletions; words underlined are additions.