Senate Bill sb2114c2
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
By the Committees on Health Care; and Banking and Insurance
587-2186-06
1 A bill to be entitled
2 An act relating to motor vehicle insurance;
3 reorganizing provisions pertaining to personal
4 injury protection benefits under the Florida
5 Motor Vehicle No-Fault Law for the purpose of
6 clarifying its meaning and intent and for the
7 purpose of better comprehension; amending s.
8 627.736, F.S.; providing that a self-employed
9 injured person or an injured person owning 25
10 percent or more interest in an employer offer
11 proof of income and lost wages to insurers as a
12 condition precedent for payment; providing for
13 a statement of earnings; requiring an insured
14 to notify an insurer in writing of election to
15 reserve benefits for lost wages; specifying
16 that such notification takes priority over
17 other claims, except specified hospital liens;
18 providing for Medicaid benefits; requiring the
19 Department of Health to determine by rule tests
20 deemed not to be medically necessary; providing
21 guidance as to criteria to be considered;
22 providing for required payment of benefits;
23 authorizing a parent or legal guardian of an
24 injured minor to complete application for
25 personal injury protection benefits; providing
26 for changes for treatment of injured persons;
27 providing requirements for compliance with
28 billing procedures; specifying the time period
29 within which a health care provider or other
30 specified provider must submit a statement of
31 charges; prohibiting providers from billing an
1
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 injured person under specified conditions for
2 emergency services and care; requiring insurers
3 to provide specified documents to insureds;
4 requiring that amounts repayable to an insurer
5 include the statutory interest penalty;
6 increasing the time period for an insurer to
7 respond to a demand letter; providing
8 requirements for the production and inspection
9 of an injured person's medical records from a
10 provider; providing that persons notifying
11 insurers of improper billing may obtain a
12 reward; restricting venue for any personal
13 injury protection claim to specified
14 jurisdictions and providing for costs of
15 transferring venue; amending s. 316.068, F.S.;
16 specifying information to be included in a
17 crash report; creating a rebuttable presumption
18 regarding the existence of passengers;
19 specifying conditions relating to reporting
20 passengers; amending s. 322.26, F.S.; providing
21 an additional circumstance relating to
22 insurance crimes for mandatory revocation of a
23 person's driver's license; amending s. 817.234,
24 F.S.; revising provisions specifying material
25 omission and insurance fraud; prohibiting
26 scheming to create documentation of a motor
27 vehicle crash that did not occur; providing a
28 criminal penalty; amending s. 817.2361, F.S.;
29 providing that creating, marketing, or
30 presenting fraudulent proof of motor vehicle
31 insurance is a felony of the third degree;
2
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 providing appropriations for law enforcement
2 and investigative personnel in the Division of
3 Insurance Fraud and for assistant state
4 attorney positions in specified circuits;
5 abrogating the repeal of provisions pertaining
6 to the Florida Motor Vehicle No-Fault Law;
7 providing an effective date.
8
9 Be It Enacted by the Legislature of the State of Florida:
10
11 Section 1. Section 627.736, Florida Statutes, is
12 amended to read:
13 627.736 Required personal injury protection benefits;
14 exclusions; priority; claims.--
15 (1) REQUIRED PERSONAL INJURY PROTECTION
16 BENEFITS.--Every insurance policy complying with the security
17 requirements of s. 627.733 shall provide personal injury
18 protection to the named insured, relatives residing in the
19 same household, persons operating the insured motor vehicle,
20 passengers in such motor vehicle, and other persons struck by
21 such motor vehicle and suffering bodily injury while not an
22 occupant of a self-propelled vehicle, subject to the
23 provisions of subsections (3) subsection (2) and (6) paragraph
24 (4)(d), to a limit of $10,000 for loss sustained by any such
25 person as a result of bodily injury, sickness, disease, or
26 death arising out of the ownership, maintenance, or use of a
27 motor vehicle as follows:
28 (a) Medical benefits.--Eighty percent of all
29 reasonable expenses for medically necessary medical, surgical,
30 X-ray, dental, and rehabilitative services, including
31 prosthetic devices, and medically necessary ambulance,
3
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 hospital, and nursing services. Such benefits shall also
2 include necessary remedial treatment and services recognized
3 and permitted under the laws of the state for an injured
4 person who relies upon spiritual means through prayer alone
5 for healing, in accordance with his or her religious beliefs;
6 however, this sentence does not affect the determination of
7 what other services or procedures are medically necessary.
8 (b) Disability benefits.--
9 1. Sixty percent of any loss of gross income and loss
10 of earning capacity per injured person individual from
11 inability to work proximately caused by the injury sustained
12 by the injured person, plus all expenses reasonably incurred
13 in obtaining from others ordinary and necessary services in
14 lieu of those that, but for the injury, the injured person
15 would have performed without income for the benefit of his or
16 her household. All disability benefits payable under this
17 provision shall be paid not less than every 2 weeks.
18 2. For an injured person who is self employed or an
19 injured person who owns over a 25-percent interest in his or
20 her employer, as a condition precedent to payment for lost
21 wages, the injured person must produce to the insurer
22 reasonable proof as to the injured person's income and loss of
23 earning capacity or additional expense, such that the insurer
24 may reasonably calculate the amount of the loss of income.
25 3. Every employer shall, if a request is made by an
26 insurer providing personal injury protection benefits under
27 ss. 627.730-627.7405 against whom a claim has been made,
28 furnish forthwith, in a form approved by the office, a sworn
29 statement of the earnings, since the time of the bodily injury
30 and for a 13-week time period before the injury, of the person
31 upon whose injury the claim is based.
4
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 4. If the insured elects to have disability benefits
2 reserved for lost wages, the insured shall notify the insurer
3 in writing, which shall be binding on the insurer. Receipt of
4 such notification shall take priority over all claims subject
5 to an assignment of benefits received after receipt of such
6 notice, except that receipt by the insurer of a properly
7 perfected hospital lien, prior to payment of the lost wage
8 claim, shall take priority over the insured's election to
9 reserve all benefits for lost wages.
10 (c) Death benefits.--The insurer shall pay death
11 benefits in the amount of $5,000 per individual. The insurer
12 may pay such benefits to the executor or administrator of the
13 deceased, to any of the deceased's relatives by blood or legal
14 adoption or connection by marriage, or to any person appearing
15 to the insurer to be equitably entitled thereto.
16 (d) Medicaid benefits.--When the Agency for Health
17 Care Administration provides, pays, or becomes liable for
18 medical assistance under the Medicaid program related to
19 injury, sickness, disease, or death arising out of the
20 ownership, maintenance, or use of a motor vehicle, benefits
21 under ss. 627.730-627.7405 shall be subject to the provisions
22 of the Medicaid program.
23 (2) AMOUNT OF PROPERTY DAMAGE COVERAGE.--
24 (a) Only insurers writing motor vehicle liability
25 insurance in this state may provide the required benefits of
26 this section, and no such insurer shall require the purchase
27 of any other motor vehicle coverage other than the purchase of
28 property damage liability coverage as required by s. 627.7275
29 as a condition for providing such required benefits.
30 (b) Insurers may not require that property damage
31 liability insurance in an amount greater than $10,000 be
5
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 purchased in conjunction with personal injury protection.
2 Such insurers shall make benefits and required property damage
3 liability insurance coverage available through normal
4 marketing channels. Any insurer writing motor vehicle
5 liability insurance in this state who fails to comply with
6 such availability requirement as a general business practice
7 shall be deemed to have violated part IX of chapter 626, and
8 such violation shall constitute an unfair method of
9 competition or an unfair or deceptive act or practice
10 involving the business of insurance; and any such insurer
11 committing such violation shall be subject to the penalties
12 afforded in such part, as well as those which may be afforded
13 elsewhere in the insurance code.
14 (3)(2) AUTHORIZED EXCLUSIONS.--Any insurer may exclude
15 benefits:
16 (a) For injury sustained by the named insured and
17 relatives residing in the same household while occupying
18 another motor vehicle owned by the named insured and not
19 insured under the policy or for injury sustained by any person
20 operating the insured motor vehicle without the express or
21 implied consent of the insured.
22 (b) To any injured person, if such person's conduct
23 contributed to his or her injury under any of the following
24 circumstances:
25 1. Causing injury to himself or herself intentionally;
26 or
27 2. Being injured while committing a felony.
28
29 Whenever an insured is charged with conduct as set forth in
30 subparagraph 2., the 30-day payment provision of subsection
31 (8) paragraph (4)(b) shall be held in abeyance, and the
6
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 insurer shall withhold payment of any personal injury
2 protection benefits pending the outcome of the case at the
3 trial level. If the charge is nolle prossed or dismissed or
4 the insured is acquitted, the 30-day payment provision shall
5 run from the date the insurer is notified of such action.
6 (4)(3) INSURED'S RIGHTS TO RECOVERY OF SPECIAL DAMAGES
7 IN TORT CLAIMS.--No insurer shall have a lien on any recovery
8 in tort by judgment, settlement, or otherwise for personal
9 injury protection benefits, whether suit has been filed or
10 settlement has been reached without suit. An injured person
11 party who is entitled to bring suit under the provisions of
12 ss. 627.730-627.7405, or his or her legal representative, has
13 shall have no right to recover any damages for which personal
14 injury protection benefits are paid or payable. The plaintiff
15 may prove all of his or her special damages notwithstanding
16 this limitation, but if special damages are introduced in
17 evidence, the trier of facts, whether judge or jury, shall not
18 award damages for personal injury protection benefits paid or
19 payable. In all cases in which a jury is required to fix
20 damages, the court shall instruct the jury that the plaintiff
21 shall not recover such special damages for personal injury
22 protection benefits paid or payable.
23 (5) NONREIMBURSABLE SERVICES.--The Department of
24 Health, in consultation with the appropriate professional
25 licensing boards, shall adopt, by rule, a list of diagnostic
26 tests deemed not to be medically necessary as defined in s.
27 627.732 for use in either the diagnosis or treatment of
28 persons sustaining bodily injury covered by personal injury
29 protection benefits under this section. The list shall be
30 revised from time to time as determined by the Department of
31 Health, in consultation with the appropriate professional
7
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 licensing boards. In determining whether a test is medically
2 necessary for purposes of this subsection, the department may
3 consider the degree of positive diagnostic or treatment
4 benefits in relation to costs; whether there is substantial
5 demonstrated medical value for the injured person; the
6 availability of alternative methods of treatment or diagnosis;
7 the immediacy or remoteness of likely benefit for the injured
8 person; whether there is evidence of overuse by providers
9 primarily for financial gain; whether there is acceptance of
10 the use of the tests for injured persons; and whether there
11 are reservations regarding such use as reported to the
12 department by the appropriate professional licensing boards.
13 The department shall give greater weight to the advice of the
14 appropriate licensing boards on whether a test is medically
15 unnecessary than to a degree of acceptance by some individuals
16 or groups within the relevant provider communities.
17 (6) REQUIRED PAYMENT OF BENEFITS.--The insurer of the
18 owner of a motor vehicle shall pay personal injury protection
19 benefits for:
20 (a) Accidental bodily injury sustained in this state
21 by the owner while occupying a motor vehicle, or while not an
22 occupant of a self-propelled vehicle if the injury is caused
23 by physical contact with a motor vehicle.
24 (b) Accidental bodily injury sustained outside this
25 state, but within the United States of America or its
26 territories or possessions or Canada, by the owner while
27 occupying the owner's motor vehicle.
28 (c) Accidental bodily injury sustained by a relative
29 of the owner residing in the same household, under the
30 circumstances described in paragraphs (a) and (b), provided
31 the relative at the time of the accident is domiciled in the
8
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 owner's household and is not himself or herself the owner of a
2 motor vehicle with respect to which security is required under
3 ss. 627.730-627.7405.
4 (d) Accidental bodily injury sustained in this state
5 by any other person while occupying the owner's motor vehicle
6 or, if a resident of this state, while not an occupant of a
7 self-propelled vehicle, if the injury is caused by physical
8 contact with such motor vehicle, provided the injured person
9 is not himself or herself:
10 1. The owner of a motor vehicle with respect to which
11 security is required under ss. 627.730-627.7405; or
12 2. Entitled to personal injury benefits from the
13 insurer of the owner or owners of such a motor vehicle.
14 (e) If two or more insurers are liable to pay personal
15 injury protection benefits for the same injury to any one
16 person, the maximum payable shall be as specified in
17 subsection (1), and any insurer paying the benefits shall be
18 entitled to recover from each of the other insurers an
19 equitable pro rata share of the benefits paid and expenses
20 incurred in processing the claim.
21 (7)(4) CLAIMS SUBMISSION BENEFITS; WHEN DUE.--Benefits
22 due from an insurer under ss. 627.730-627.7405 shall be
23 primary, except that benefits received under any workers'
24 compensation law shall be credited against the benefits
25 provided by subsection (1), and shall be due and payable as
26 loss accrues, upon receipt of reasonable proof of such loss
27 and the amount of expenses and loss incurred which are covered
28 by the policy issued under ss. 627.730-627.7405, subject to
29 the following:. When the Agency for Health Care Administration
30 provides, pays, or becomes liable for medical assistance under
31 the Medicaid program related to injury, sickness, disease, or
9
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 death arising out of the ownership, maintenance, or use of a
2 motor vehicle, benefits under ss. 627.730-627.7405 shall be
3 subject to the provisions of the Medicaid program.
4 (a) Medicaid reimbursement.--Medical benefits payable
5 under s. 627.736 shall reimburse fully any payment made by the
6 Medicaid program, up to the limits of coverage.
7 (b)(a) Personal injury protection application.--An
8 insurer may require written notice to be given as soon as
9 practicable after an accident involving a motor vehicle with
10 respect to which the policy affords the security required by
11 ss. 627.730-627.7405. If the injured person is a minor, the
12 parent or legal guardian of the minor, if requested by the
13 insurer, must accurately complete the personal injury
14 protection application.
15 (c) Charges for treatment of injured persons; billing
16 requirements.--
17 1. Any physician, hospital, clinic, or other person or
18 institution lawfully rendering treatment to an injured person
19 for a bodily injury covered by personal injury protection
20 insurance may charge the insurer and injured party only a
21 reasonable amount pursuant to this section for the services
22 and supplies rendered, and the insurer providing such coverage
23 may pay for such charges directly to such person or
24 institution lawfully rendering such treatment, if the insured
25 receiving such treatment or his or her guardian has
26 countersigned the properly completed invoice, bill, or claim
27 form approved by the office upon which such charges are to be
28 paid for as having actually been rendered, to the best
29 knowledge of the insured or his or her guardian. In no event,
30 however, may such a charge be in excess of the amount the
31 person or institution customarily charges for like services or
10
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 supplies. With respect to a determination of whether a charge
2 for a particular service, treatment, or otherwise is
3 reasonable, consideration may be given to evidence of usual
4 and customary charges and payments accepted by the provider
5 involved in the dispute, and reimbursement levels in the
6 community and various federal and state medical fee schedules
7 applicable to automobile and other insurance coverages, and
8 other information relevant to the reasonableness of the
9 reimbursement for the service, treatment, or supply.
10 2. All statements and bills for medical services
11 rendered by any physician, hospital, clinic, or other person
12 or institution shall be submitted to the insurer on a properly
13 completed Centers for Medicare and Medicaid Services (CMS)
14 1500 form or its successor or a UB 92 form or its successor.
15 3. All billings for such services, procedures, and
16 supplies submitted by health care providers and medical
17 suppliers shall comply with the Healthcare Correct Procedural
18 Coding System (HCPCS) and International Classification of
19 Diseases (ICD-9-CM) or their successors in effect at the time
20 of patient discharge, if applicable, or when the service was
21 rendered, if applicable, for the year in which services are
22 rendered.
23 4. All claims forms submitted by health care
24 providers, medical suppliers other than ambulance providers
25 licensed under part III of chapter 401, hospitals, and
26 physicians providing emergency care as defined in s. 395.002
27 shall include on the applicable claim form the signature and
28 professional license number of the provider who rendered
29 services in the line or space provided for "Signature of
30 Physician or Supplier, Including Degrees or Credentials" and
31 the date of the signature.
11
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 5. In determining compliance with applicable HCPCS and
2 ICD-9-CM coding, or their successors, guidance shall be
3 provided by the Healthcare Correct Procedural Coding System
4 (HCPCS) or its successor, International Classification of
5 Diseases (ICD-9-CM) or its successor, the Office of the
6 Inspector General (OIG), Physicians Compliance Guidelines,
7 rules of the Agency for Health Care Administration, the
8 Florida Health Information Management Association (FHIMA), and
9 other authoritative treatises.
10 6. Charges for medically necessary cephalic
11 thermograms, peripheral thermograms, spinal ultrasounds,
12 extremity ultrasounds, video fluoroscopy, and surface
13 electromyography shall not exceed the maximum reimbursement
14 allowance for such procedures as set forth in the applicable
15 fee schedule or other payment methodology established pursuant
16 to s. 440.13.
17 7. Allowable amounts that may be charged to a personal
18 injury protection insurance insurer and insured for medically
19 necessary nerve conduction testing when done in conjunction
20 with a needle electromyography procedure and both are
21 performed and billed solely by a physician licensed under
22 chapter 458, chapter 459, chapter 460, or chapter 461 who is
23 also certified by the American Board of Electrodiagnostic
24 Medicine or by a board recognized by the American Board of
25 Medical Specialties or the American Osteopathic Association or
26 who holds diplomate status with the American Chiropractic
27 Neurology Board or its predecessors shall not exceed 200
28 percent of the allowable amount under the participating
29 physician fee schedule of Medicare Part B for year 2001, for
30 the area in which the treatment was rendered, adjusted
31 annually on August 1 to reflect the prior calendar year's
12
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 changes in the annual Medical Care Item of the Consumer Price
2 Index for All Urban Consumers in the South Region as
3 determined by the Bureau of Labor Statistics of the United
4 States Department of Labor.
5 8. Allowable amounts that may be charged to a personal
6 injury protection insurance insurer and insured for medically
7 necessary nerve conduction testing that does not meet the
8 requirements of subparagraph 7. shall not exceed the
9 applicable fee schedule or other payment methodology
10 established pursuant to s. 440.13.
11 9. Allowable amounts that may be charged to a personal
12 injury protection insurance insurer and insured for magnetic
13 resonance imaging services shall not exceed 175 percent of the
14 allowable amount under the participating physician fee
15 schedule of Medicare Part B for year 2001, for the area in
16 which the treatment was rendered, adjusted annually on August
17 1 to reflect the prior calendar year's changes in the annual
18 Medical Care Item of the Consumer Price Index for All Urban
19 Consumers in the South Region as determined by the Bureau of
20 Labor Statistics of the United States Department of Labor for
21 the 12-month period ending June 30 of that year, except that
22 allowable amounts that may be charged to a personal injury
23 protection insurance insurer and insured for magnetic
24 resonance imaging services provided in facilities accredited
25 by the Accreditation Association for Ambulatory Health Care,
26 the American College of Radiology, or the Joint Commission on
27 Accreditation of Healthcare Organizations shall not exceed 200
28 percent of the allowable amount under the participating
29 physician fee schedule of Medicare Part B for year 2001, for
30 the area in which the treatment was rendered, adjusted
31 annually on August 1 to reflect the prior calendar year's
13
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 changes in the annual Medical Care Item of the Consumer Price
2 Index for All Urban Consumers in the South Region as
3 determined by the Bureau of Labor Statistics of the United
4 States Department of Labor for the 12-month period ending June
5 30 of that year. This paragraph does not apply to charges for
6 magnetic resonance imaging services and nerve conduction
7 testing for inpatients and emergency services and care as
8 defined in chapter 395 rendered by facilities licensed under
9 chapter 395.
10 10. A statement of medical services may not include
11 charges for medical services of a person or entity that
12 rendered such services without possessing all valid
13 qualifications and licenses required to lawfully provide and
14 bill for such services. However, a physician licensed under
15 chapter 458, chapter 459, chapter 460, or chapter 466 may
16 delegate diagnostic or treatment tasks to an employee to be
17 performed under the supervision of the physician in accordance
18 with the requirements and provisions of the applicable
19 licensing section.
20 11. For purposes of subsection (8), an insurer shall
21 not be considered to have been furnished with notice of the
22 amount of covered loss or medical bills due unless the
23 statements or bills comply with this paragraph, and unless the
24 statements or bills are properly completed in their entirety
25 as to all material provisions, with all required information
26 being provided therein.
27 12. An insurer may not systematically downcode with
28 the intent to deny reimbursement otherwise due. Such action
29 constitutes a material misrepresentation under s.
30 626.9541(1)(i)2.
31
14
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 (d) Direct billing an insurer for personal injury
2 protection benefits.--The insurer providing coverage may pay
3 for charges directly to the insured or the insured's assignee.
4 (e) Timely billing for nonemergency services.--With
5 respect to any treatment or service, other than medical
6 services billed by an ambulance provider licensed pursuant to
7 part III of chapter 401, a hospital or other provider for
8 emergency services as defined in s. 395.002, or inpatient
9 services rendered at a hospital-owned facility, the statement
10 of charges must be furnished to the insurer by the provider
11 and may not include, and the insurer is not required to pay,
12 charges for treatment or services rendered more than 35 days
13 before the postmark date of the statement, except for the
14 following:
15 1. Past due amounts previously billed on a timely
16 basis under this subsection.
17 2. If the provider submits to the insurer a notice of
18 initiation of treatment within 21 days after its first
19 examination or treatment of the claimant, the statement may
20 include charges for treatment or services rendered up to, but
21 not more than, 50 days before the postmark date of the
22 statement. The injured person is not liable for, and the
23 provider shall not bill the injured person for, charges that
24 are unpaid because of the provider's failure to comply with
25 this paragraph. Any agreement requiring the injured person or
26 insured to pay for such charges is unenforceable.
27 3. If the insured fails to furnish the provider with
28 the correct name and address of the insured's personal injury
29 protection insurer, the provider has 35 days from the date the
30 provider obtains the correct information to furnish the
31 insurer with a statement of the charges. The insurer is not
15
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 required to pay for such charges unless the provider includes
2 with the statement documentary evidence that was provided by
3 the insured during the 35-day period demonstrating that the
4 provider reasonably relied on erroneous information from the
5 insured and either:
6 a. A denial letter from the incorrect insurer; or
7 b. Proof of mailing, which may include an affidavit
8 under penalty of perjury, reflecting timely mailing to the
9 incorrect address or insurer.
10 (f) Timely billing for emergency services.--
11 1. For emergency services and care as defined in s.
12 395.002 rendered in a hospital emergency department or for
13 transport and treatment rendered by an ambulance provider
14 licensed pursuant to part III of chapter 401, the provider is
15 not required to furnish the statement of charges within the
16 time periods established by this subsection; however, such
17 charges must be submitted within 75 days after the date the
18 treatment was rendered, and the insurer shall not be
19 considered to have been furnished with notice of the amount of
20 covered loss for purposes of subsection (8) until it receives
21 a statement complying with subsection (7), or copy thereof,
22 which specifically identifies the place of service to be a
23 hospital emergency department or an ambulance.
24 2. If the insured fails to furnish the provider with
25 the correct name and address of the insured's personal injury
26 protection insurer, the provider has 75 days following the
27 date the provider obtains the correct information to furnish
28 the insurer with a statement of the charges. The insurer is
29 not required to pay for such charges unless the provider
30 includes with the statement:
31
16
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 a. Documentary evidence that was provided by the
2 insured during the 75-day period demonstrating that the
3 provider reasonably relied on erroneous information from the
4 insured;
5 b. A denial letter from the incorrect insurer; or
6 c. Proof of mailing, which may include an affidavit
7 under penalty of perjury, reflecting timely mailing to the
8 incorrect address or insurer.
9 (g) Billing notice and disclosures.--
10 1. Each notice of insured's rights under s. 627.7401
11 must include the following statement in type no smaller than
12 12-point font:
13
14 BILLING REQUIREMENTS.--Florida Statutes provide
15 that with respect to any treatment or services,
16 other than certain hospital and emergency
17 services, the statement of charges furnished to
18 the insurer by the provider may not include,
19 and the insurer and the injured person are not
20 required to pay, charges for treatment or
21 services rendered more than 35 days before the
22 postmark date of the statement, except for past
23 due amounts previously billed on a timely
24 basis, and except that, if the provider submits
25 to the insurer a notice of initiation of
26 treatment within 21 days after its first
27 examination or treatment of the claimant, the
28 statement may include charges for treatment or
29 services rendered up to, but not more than, 50
30 days before the postmark date of the statement.
31
17
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 2. Except for ambulance transport and treatment or
2 hospital and emergency services and care rendered pursuant to
3 s. 395.002, on each date services are rendered the health care
4 provider shall provide to the insured patient a written bill,
5 superbill, fee slip, or other similar document that
6 establishes in plain language a detailed description of the
7 service provided and the cost associated with the service. The
8 insured must sign the written bill, superbill, fee slip, or
9 other similar document immediately after having received
10 services. Copies of such disclosures shall be maintained as
11 part of the patient's medical records in accordance with
12 minimal record keeping standards. Health care providers or
13 service providers who do not render services in the presence
14 of the insured are not required to comply with this section.
15 (h) Upon request, the insured and his or her assigns
16 shall be sent a letter containing a payment log itemizing all
17 payments made, the applicable insurance declarations page, and
18 a copy of the insurance policy within 30 days after the
19 written request. Such request shall state that it is a
20 "request under s. 627.736(7)" and shall state with
21 specificity:
22 1. The name of the insured upon whom such benefits are
23 being sought, including a copy of the assignment giving rights
24 to the claimant if the claimant is not the insured.
25 2. The claim number or policy number upon which such
26 claim was originally submitted to the insurer.
27
28 Such request must be sent to the person and address specified
29 by the insurer for the purposes of receiving notices or
30 requests under this section.
31
18
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 (i) Benefits shall not be due or payable to or on the
2 behalf of an insured person if that person has committed, by a
3 material act or omission, any insurance fraud relating to
4 personal injury protection coverage under his or her policy,
5 if the fraud is admitted to in a sworn statement by the
6 insured or if it is established in a court of competent
7 jurisdiction. Any insurance fraud shall void all coverage
8 arising from the claim related to such fraud under the
9 personal injury protection coverage of the insured person who
10 committed the fraud, irrespective of whether a portion of the
11 insured person's claim may be legitimate, and any benefits
12 paid prior to the discovery of the insured person's insurance
13 fraud shall be recoverable by the insurer from the person who
14 committed insurance fraud in their entirety. The prevailing
15 party is entitled to its costs and attorney's fees in any
16 action in which it prevails in an insurer's action to enforce
17 its right of recovery under this paragraph.
18 (8) OVERDUE PERSONAL INJURY PROTECTION BENEFITS.--
19 (a)(b) Personal injury protection insurance benefits
20 paid pursuant to this section shall be overdue if not paid
21 within 30 days after the insurer is furnished written notice
22 of the amount fact of a covered loss, including a properly
23 completed CMS 1500 form or its successor or UB 92 form or its
24 successor, assignment of benefits, or, in the case of
25 disability benefits, proper written documentation of the claim
26 and of the amount of same. If such written notice is not
27 furnished to the insurer as to the entire claim, any partial
28 amount supported by written notice is overdue if not paid
29 within 30 days after such written notice is furnished to the
30 insurer. Any part or all of the remainder of the claim that
31 is subsequently supported by written notice is overdue if not
19
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 paid within 30 days after such written notice is furnished to
2 the insurer. When an insurer pays only a portion of a claim or
3 rejects a claim, the insurer shall provide at the time of the
4 partial payment or rejection an itemized specification of each
5 item that the insurer had reduced, omitted, or declined to pay
6 and any information that the insurer desires the claimant to
7 consider related to the medical necessity of the denied
8 treatment or to explain the reasonableness of the reduced
9 charge, provided that this shall not limit the introduction of
10 evidence at trial; and the insurer shall include the name and
11 address of the person to whom the claimant should respond and
12 a claim number to be referenced in future correspondence.
13 However, notwithstanding the fact that written notice has been
14 furnished to the insurer, any payment shall not be deemed
15 overdue when the insurer has reasonable proof to establish
16 that the insurer is not responsible for the payment. For the
17 purpose of calculating the extent to which any benefits are
18 overdue, payment shall be treated as being made on the date a
19 draft or other valid instrument which is equivalent to payment
20 was placed in the United States mail in a properly addressed,
21 postpaid envelope or, if not so posted, on the date of
22 delivery.
23 (b) Timely payment by an insurer This paragraph does
24 not preclude or limit the ability of the insurer to assert
25 that the claim was unrelated, was for services not lawfully
26 performed, was not medically necessary, or was unreasonable or
27 that the amount of the charge was in excess of that permitted
28 under, or in violation of, this section subsection (5). Such
29 assertion by the insurer may be made at any time, including
30 after payment of the claim or after the 30-day time period for
31 payment set forth in this subsection paragraph.
20
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 (c) All overdue payments shall bear simple interest at
2 the rate established under s. 55.03 or the rate established in
3 the insurance contract, whichever is greater, for the year in
4 which the payment became overdue, calculated from the date the
5 insurer was furnished with written notice of the amount of
6 covered loss. Interest shall be due at the time payment of the
7 overdue claim is made.
8 (d) The insurer of the owner of a motor vehicle shall
9 pay personal injury protection benefits for:
10 1. Accidental bodily injury sustained in this state by
11 the owner while occupying a motor vehicle, or while not an
12 occupant of a self-propelled vehicle if the injury is caused
13 by physical contact with a motor vehicle.
14 2. Accidental bodily injury sustained outside this
15 state, but within the United States of America or its
16 territories or possessions or Canada, by the owner while
17 occupying the owner's motor vehicle.
18 3. Accidental bodily injury sustained by a relative of
19 the owner residing in the same household, under the
20 circumstances described in subparagraph 1. or subparagraph 2.,
21 provided the relative at the time of the accident is domiciled
22 in the owner's household and is not himself or herself the
23 owner of a motor vehicle with respect to which security is
24 required under ss. 627.730-627.7405.
25 4. Accidental bodily injury sustained in this state by
26 any other person while occupying the owner's motor vehicle or,
27 if a resident of this state, while not an occupant of a
28 self-propelled vehicle, if the injury is caused by physical
29 contact with such motor vehicle, provided the injured person
30 is not himself or herself:
31
21
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 a. The owner of a motor vehicle with respect to which
2 security is required under ss. 627.730-627.7405; or
3 b. Entitled to personal injury benefits from the
4 insurer of the owner or owners of such a motor vehicle.
5 (e) If two or more insurers are liable to pay personal
6 injury protection benefits for the same injury to any one
7 person, the maximum payable shall be as specified in
8 subsection (1), and any insurer paying the benefits shall be
9 entitled to recover from each of the other insurers an
10 equitable pro rata share of the benefits paid and expenses
11 incurred in processing the claim.
12 (c)(f) It is a violation of the insurance code for an
13 insurer to fail to timely provide benefits as required by this
14 section with such frequency as to constitute a general
15 business practice.
16 (9) CALCULATION OF TIME OF PAYMENT.--For the purpose
17 of calculating the extent to which any benefits are overdue,
18 payment shall be treated as being made on the date a draft or
19 other valid instrument that is equivalent to payment was
20 placed in the United States mail in a properly addressed,
21 postpaid envelope or, if not so posted, on the date of
22 delivery.
23 (10) INTEREST ON OVERDUE PAYMENTS.--All overdue
24 payments shall bear simple interest at the rate established
25 under s. 55.03 or the rate established in the insurance
26 contract, whichever is greater, for the year in which the
27 payment became overdue, calculated from the date the insurer
28 was furnished with written notice of the amount of covered
29 loss. In the case of payment made by an insurer to the
30 insured, or insured's assignee, interest shall be due at the
31 time payment of the overdue claim is made. All amounts
22
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 repayable to the insurer shall bear simple interest at the
2 rate established under s. 55.03 for the year in which the
3 payment became repayable, calculated from the date the insurer
4 tendered payment.
5 (g) Benefits shall not be due or payable to or on the
6 behalf of an insured person if that person has committed, by a
7 material act or omission, any insurance fraud relating to
8 personal injury protection coverage under his or her policy,
9 if the fraud is admitted to in a sworn statement by the
10 insured or if it is established in a court of competent
11 jurisdiction. Any insurance fraud shall void all coverage
12 arising from the claim related to such fraud under the
13 personal injury protection coverage of the insured person who
14 committed the fraud, irrespective of whether a portion of the
15 insured person's claim may be legitimate, and any benefits
16 paid prior to the discovery of the insured person's insurance
17 fraud shall be recoverable by the insurer from the person who
18 committed insurance fraud in their entirety. The prevailing
19 party is entitled to its costs and attorney's fees in any
20 action in which it prevails in an insurer's action to enforce
21 its right of recovery under this paragraph.
22 (5) CHARGES FOR TREATMENT OF INJURED PERSONS.--
23 (a) Any physician, hospital, clinic, or other person
24 or institution lawfully rendering treatment to an injured
25 person for a bodily injury covered by personal injury
26 protection insurance may charge the insurer and injured party
27 only a reasonable amount pursuant to this section for the
28 services and supplies rendered, and the insurer providing such
29 coverage may pay for such charges directly to such person or
30 institution lawfully rendering such treatment, if the insured
31 receiving such treatment or his or her guardian has
23
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 countersigned the properly completed invoice, bill, or claim
2 form approved by the office upon which such charges are to be
3 paid for as having actually been rendered, to the best
4 knowledge of the insured or his or her guardian. In no event,
5 however, may such a charge be in excess of the amount the
6 person or institution customarily charges for like services or
7 supplies. With respect to a determination of whether a charge
8 for a particular service, treatment, or otherwise is
9 reasonable, consideration may be given to evidence of usual
10 and customary charges and payments accepted by the provider
11 involved in the dispute, and reimbursement levels in the
12 community and various federal and state medical fee schedules
13 applicable to automobile and other insurance coverages, and
14 other information relevant to the reasonableness of the
15 reimbursement for the service, treatment, or supply.
16 (11) CLAIMS NOT PROPERLY PAYABLE.--
17 (b)1. An insurer or insured is not required to pay a
18 claim or charges:
19 (a)a. Made by a broker or by a person making a claim
20 on behalf of a broker;
21 (b)b. For any service or treatment that was not lawful
22 at the time rendered;
23 (c)c. To any person who knowingly submits a false or
24 misleading statement relating to the claim or charges;
25 (d)d. With respect to a bill or statement that does
26 not substantially meet the applicable requirements of
27 paragraph (7)(b) (d);
28 (e)e. For any treatment or service that is upcoded, or
29 that is unbundled when such treatment or services should be
30 bundled, in accordance with subsection (7) paragraph (d). To
31 facilitate prompt payment of lawful services, an insurer may
24
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 change codes that it determines to have been improperly or
2 incorrectly upcoded or unbundled, and may make payment based
3 on the changed codes, without affecting the right of the
4 provider to dispute the change by the insurer, provided that
5 before doing so, the insurer must contact the health care
6 provider and discuss the reasons for the insurer's change and
7 the health care provider's reason for the coding, or make a
8 reasonable good faith effort to do so, as documented in the
9 insurer's file; and
10 (f)f. For medical services or treatment billed by a
11 physician and not provided in a hospital unless such services
12 are rendered by the physician or are incident to his or her
13 professional services and are included on the physician's
14 bill, including documentation verifying that the physician is
15 responsible for the medical services that were rendered and
16 billed.
17 2. Charges for medically necessary cephalic
18 thermograms, peripheral thermograms, spinal ultrasounds,
19 extremity ultrasounds, video fluoroscopy, and surface
20 electromyography shall not exceed the maximum reimbursement
21 allowance for such procedures as set forth in the applicable
22 fee schedule or other payment methodology established pursuant
23 to s. 440.13.
24 3. Allowable amounts that may be charged to a personal
25 injury protection insurance insurer and insured for medically
26 necessary nerve conduction testing when done in conjunction
27 with a needle electromyography procedure and both are
28 performed and billed solely by a physician licensed under
29 chapter 458, chapter 459, chapter 460, or chapter 461 who is
30 also certified by the American Board of Electrodiagnostic
31 Medicine or by a board recognized by the American Board of
25
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 Medical Specialties or the American Osteopathic Association or
2 who holds diplomate status with the American Chiropractic
3 Neurology Board or its predecessors shall not exceed 200
4 percent of the allowable amount under the participating
5 physician fee schedule of Medicare Part B for year 2001, for
6 the area in which the treatment was rendered, adjusted
7 annually on August 1 to reflect the prior calendar year's
8 changes in the annual Medical Care Item of the Consumer Price
9 Index for All Urban Consumers in the South Region as
10 determined by the Bureau of Labor Statistics of the United
11 States Department of Labor.
12 4. Allowable amounts that may be charged to a personal
13 injury protection insurance insurer and insured for medically
14 necessary nerve conduction testing that does not meet the
15 requirements of subparagraph 3. shall not exceed the
16 applicable fee schedule or other payment methodology
17 established pursuant to s. 440.13.
18 5. Allowable amounts that may be charged to a personal
19 injury protection insurance insurer and insured for magnetic
20 resonance imaging services shall not exceed 175 percent of the
21 allowable amount under the participating physician fee
22 schedule of Medicare Part B for year 2001, for the area in
23 which the treatment was rendered, adjusted annually on August
24 1 to reflect the prior calendar year's changes in the annual
25 Medical Care Item of the Consumer Price Index for All Urban
26 Consumers in the South Region as determined by the Bureau of
27 Labor Statistics of the United States Department of Labor for
28 the 12-month period ending June 30 of that year, except that
29 allowable amounts that may be charged to a personal injury
30 protection insurance insurer and insured for magnetic
31 resonance imaging services provided in facilities accredited
26
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 by the Accreditation Association for Ambulatory Health Care,
2 the American College of Radiology, or the Joint Commission on
3 Accreditation of Healthcare Organizations shall not exceed 200
4 percent of the allowable amount under the participating
5 physician fee schedule of Medicare Part B for year 2001, for
6 the area in which the treatment was rendered, adjusted
7 annually on August 1 to reflect the prior calendar year's
8 changes in the annual Medical Care Item of the Consumer Price
9 Index for All Urban Consumers in the South Region as
10 determined by the Bureau of Labor Statistics of the United
11 States Department of Labor for the 12-month period ending June
12 30 of that year. This paragraph does not apply to charges for
13 magnetic resonance imaging services and nerve conduction
14 testing for inpatients and emergency services and care as
15 defined in chapter 395 rendered by facilities licensed under
16 chapter 395.
17 6. The Department of Health, in consultation with the
18 appropriate professional licensing boards, shall adopt, by
19 rule, a list of diagnostic tests deemed not to be medically
20 necessary for use in the treatment of persons sustaining
21 bodily injury covered by personal injury protection benefits
22 under this section. The initial list shall be adopted by
23 January 1, 2004, and shall be revised from time to time as
24 determined by the Department of Health, in consultation with
25 the respective professional licensing boards. Inclusion of a
26 test on the list of invalid diagnostic tests shall be based on
27 lack of demonstrated medical value and a level of general
28 acceptance by the relevant provider community and shall not be
29 dependent for results entirely upon subjective patient
30 response. Notwithstanding its inclusion on a fee schedule in
31 this subsection, an insurer or insured is not required to pay
27
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 any charges or reimburse claims for any invalid diagnostic
2 test as determined by the Department of Health.
3 (c)1. With respect to any treatment or service, other
4 than medical services billed by a hospital or other provider
5 for emergency services as defined in s. 395.002 or inpatient
6 services rendered at a hospital-owned facility, the statement
7 of charges must be furnished to the insurer by the provider
8 and may not include, and the insurer is not required to pay,
9 charges for treatment or services rendered more than 35 days
10 before the postmark date of the statement, except for past due
11 amounts previously billed on a timely basis under this
12 paragraph, and except that, if the provider submits to the
13 insurer a notice of initiation of treatment within 21 days
14 after its first examination or treatment of the claimant, the
15 statement may include charges for treatment or services
16 rendered up to, but not more than, 75 days before the postmark
17 date of the statement. The injured party is not liable for,
18 and the provider shall not bill the injured party for, charges
19 that are unpaid because of the provider's failure to comply
20 with this paragraph. Any agreement requiring the injured
21 person or insured to pay for such charges is unenforceable.
22 2. If, however, the insured fails to furnish the
23 provider with the correct name and address of the insured's
24 personal injury protection insurer, the provider has 35 days
25 from the date the provider obtains the correct information to
26 furnish the insurer with a statement of the charges. The
27 insurer is not required to pay for such charges unless the
28 provider includes with the statement documentary evidence that
29 was provided by the insured during the 35-day period
30 demonstrating that the provider reasonably relied on erroneous
31 information from the insured and either:
28
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 a. A denial letter from the incorrect insurer; or
2 b. Proof of mailing, which may include an affidavit
3 under penalty of perjury, reflecting timely mailing to the
4 incorrect address or insurer.
5 3. For emergency services and care as defined in s.
6 395.002 rendered in a hospital emergency department or for
7 transport and treatment rendered by an ambulance provider
8 licensed pursuant to part III of chapter 401, the provider is
9 not required to furnish the statement of charges within the
10 time periods established by this paragraph; and the insurer
11 shall not be considered to have been furnished with notice of
12 the amount of covered loss for purposes of paragraph (4)(b)
13 until it receives a statement complying with paragraph (d), or
14 copy thereof, which specifically identifies the place of
15 service to be a hospital emergency department or an ambulance
16 in accordance with billing standards recognized by the Health
17 Care Finance Administration.
18 4. Each notice of insured's rights under s. 627.7401
19 must include the following statement in type no smaller than
20 12 points:
21
22 BILLING REQUIREMENTS.--Florida Statutes provide
23 that with respect to any treatment or services,
24 other than certain hospital and emergency
25 services, the statement of charges furnished to
26 the insurer by the provider may not include,
27 and the insurer and the injured party are not
28 required to pay, charges for treatment or
29 services rendered more than 35 days before the
30 postmark date of the statement, except for past
31 due amounts previously billed on a timely
29
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 basis, and except that, if the provider submits
2 to the insurer a notice of initiation of
3 treatment within 21 days after its first
4 examination or treatment of the claimant, the
5 statement may include charges for treatment or
6 services rendered up to, but not more than, 75
7 days before the postmark date of the statement.
8
9 (d) All statements and bills for medical services
10 rendered by any physician, hospital, clinic, or other person
11 or institution shall be submitted to the insurer on a properly
12 completed Centers for Medicare and Medicaid Services (CMS)
13 1500 form, UB 92 forms, or any other standard form approved by
14 the office or adopted by the commission for purposes of this
15 paragraph. All billings for such services rendered by
16 providers shall, to the extent applicable, follow the
17 Physicians' Current Procedural Terminology (CPT) or Healthcare
18 Correct Procedural Coding System (HCPCS), or ICD-9 in effect
19 for the year in which services are rendered and comply with
20 the Centers for Medicare and Medicaid Services (CMS) 1500 form
21 instructions and the American Medical Association Current
22 Procedural Terminology (CPT) Editorial Panel and Healthcare
23 Correct Procedural Coding System (HCPCS). All providers other
24 than hospitals shall include on the applicable claim form the
25 professional license number of the provider in the line or
26 space provided for "Signature of Physician or Supplier,
27 Including Degrees or Credentials." In determining compliance
28 with applicable CPT and HCPCS coding, guidance shall be
29 provided by the Physicians' Current Procedural Terminology
30 (CPT) or the Healthcare Correct Procedural Coding System
31 (HCPCS) in effect for the year in which services were
30
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 rendered, the Office of the Inspector General (OIG),
2 Physicians Compliance Guidelines, and other authoritative
3 treatises designated by rule by the Agency for Health Care
4 Administration. No statement of medical services may include
5 charges for medical services of a person or entity that
6 performed such services without possessing the valid licenses
7 required to perform such services. For purposes of paragraph
8 (4)(b), an insurer shall not be considered to have been
9 furnished with notice of the amount of covered loss or medical
10 bills due unless the statements or bills comply with this
11 paragraph, and unless the statements or bills are properly
12 completed in their entirety as to all material provisions,
13 with all relevant information being provided therein.
14 (12) DEMAND LETTER.--
15 (a) As a condition precedent to filing any action for
16 benefits under this section, the insurer must be provided with
17 written notice of an intent to initiate litigation. Such
18 notice may not be sent until the claim is overdue, including
19 any additional time the insurer has to pay the claim pursuant
20 to subsection (8).
21 (b) The notice required shall state that it is a
22 "demand letter under s. 627.736(14)" and shall state with
23 specificity:
24 1. The name of the insured upon whom such benefits are
25 being sought, including a copy of the assignment giving rights
26 to the claimant if the claimant is not the insured.
27 2. The claim number or policy number upon which such
28 claim was originally submitted to the insurer.
29 3. To the extent applicable, the name of any medical
30 provider who rendered to an insured the treatment, services,
31 accommodations, or supplies that form the basis of such claim;
31
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 and an itemized statement specifying each exact amount, the
2 date of treatment, service, or accommodation, and the type of
3 benefit claimed to be due. A completed form satisfying the
4 requirements of subsection (7) or the lost-wage statement
5 previously submitted may be used as the itemized statement. To
6 the extent that the demand involves an insurer's withdrawal of
7 payment under subsection (15) for future treatment not yet
8 rendered, the claimant shall attach a copy of the insurer's
9 notice withdrawing such payment and an itemized statement of
10 the type, frequency, and duration of future treatment claimed
11 to be reasonable and medically necessary.
12 (c) Each notice required by this subsection must be
13 delivered to the insurer by United States certified or
14 registered mail, return receipt requested. Such postal costs
15 shall be reimbursed by the insurer if so requested by the
16 claimant in the notice, when the insurer pays the claim. Such
17 notice must be sent to the person and address specified by the
18 insurer for the purposes of receiving notices under this
19 subsection. Each licensed insurer, whether domestic, foreign,
20 or alien, shall file with the office designation of the name
21 and address of the person to whom notices pursuant to this
22 subsection shall be sent which the office shall make available
23 on its Internet website. The name and address on file with the
24 office pursuant to s. 624.422 shall be deemed the authorized
25 representative to accept notice pursuant to this subsection in
26 the event no other designation has been made.
27 (d) If, within 21 days after receipt of notice by the
28 insurer, the overdue claim specified in the notice is paid by
29 the insurer together with applicable interest and a penalty of
30 10 percent of the overdue amount paid by the insurer, subject
31 to a maximum penalty of $250, no action may be brought against
32
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 the insurer. If the demand involves an insurer's withdrawal of
2 payment under subsection (15) for future treatment not yet
3 rendered, no action may be brought against the insurer if,
4 within 21 days after its receipt of the notice, the insurer
5 mails to the person filing the notice a written statement of
6 the insurer's agreement to pay for such treatment in
7 accordance with the notice and to pay a penalty of 10 percent,
8 subject to a maximum penalty of $250, when it pays for such
9 future treatment in accordance with the requirements of this
10 section. To the extent the insurer determines not to pay any
11 amount demanded, the penalty shall not be payable in any
12 subsequent action. For purposes of this subsection, payment or
13 the insurer's agreement shall be treated as being made on the
14 date a draft or other valid instrument that is equivalent to
15 payment, or the insurer's written statement of agreement, is
16 placed in the United States mail in a properly addressed,
17 postpaid envelope, or if not so posted, on the date of
18 delivery. The insurer is not obligated to pay any attorney's
19 fees if the insurer pays the claim or mails its agreement to
20 pay for future treatment within the time prescribed by this
21 subsection.
22 (e) The applicable statute of limitation for an action
23 under this section shall be tolled for a period of 21 business
24 days by the mailing of the notice required by this subsection.
25 (f) Any insurer making a general business practice of
26 not paying valid claims until receipt of the notice required
27 by this subsection is engaging in an unfair trade practice
28 under the insurance code.
29 (13) DISCLOSURE AND ACKNOWLEDGEMENT FORM.--
30 (a)(e)1. At the initial treatment or service provided,
31 each physician, other licensed professional, clinic, or other
33
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 medical institution providing medical services upon which a
2 claim for personal injury protection benefits is based shall
3 require an insured person, or his or her guardian, to execute
4 a disclosure and acknowledgment form, which reflects at a
5 minimum that:
6 1.a. The insured, or his or her guardian, must
7 countersign the form attesting to the fact that the services
8 set forth therein were actually rendered;
9 2.b. The insured, or his or her guardian, has both the
10 right and affirmative duty to confirm that the services were
11 actually rendered;
12 3.c. The insured, or his or her guardian, was not
13 solicited by any person to seek any services from the medical
14 provider;
15 4.d. That the physician, other licensed professional,
16 clinic, or other medical institution rendering services for
17 which payment is being claimed explained the services to the
18 insured or his or her guardian; and
19 5.e. If the insured notifies the insurer in writing of
20 a billing error, the insured may be entitled to a certain
21 percentage of a reduction in the amounts paid by the insured's
22 motor vehicle insurer.
23 (b)2. The physician, other licensed professional,
24 clinic, or other medical institution rendering services for
25 which payment is being claimed has the affirmative duty to
26 explain the services rendered to the insured, or his or her
27 guardian, so that the insured, or his or her guardian,
28 countersigns the form with informed consent.
29 (c)3. Countersignature by the insured, or his or her
30 guardian, is not required for the reading of diagnostic tests
31
34
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
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 (d)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 subsection
6 paragraph.
7 (e)5. The original completed disclosure and
8 acknowledgment form shall be furnished to the insurer pursuant
9 to subsection (8) paragraph (4)(b) and may not be
10 electronically furnished.
11 (f)6. This disclosure and acknowledgment form is not
12 required for services billed by a provider for emergency
13 services as defined in s. 395.002, for emergency services and
14 care as defined in s. 395.002 rendered in a hospital emergency
15 department, or for transport and treatment rendered by an
16 ambulance provider licensed pursuant to part III of chapter
17 401.
18 (g)7. The Financial Services Commission shall adopt,
19 by rule, a standard disclosure and acknowledgment form that
20 shall be used to fulfill the requirements of this subsection
21 paragraph, effective 90 days after such form is adopted and
22 becomes final. The commission shall adopt a proposed rule by
23 October 1, 2003. Until the rule is final, the provider may use
24 a form of its own which otherwise complies with the
25 requirements of this paragraph.
26 (h)8. As used in this subsection paragraph,
27 "countersigned" means a second or verifying signature, as on a
28 previously signed document, and is not satisfied by the
29 statement "signature on file" or any similar statement.
30 (i)9. The requirements of This subsection applies
31 paragraph apply only with respect to the initial treatment or
35
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 service of the insured by a provider. For subsequent
2 treatments or service, the provider must maintain a patient
3 log signed by the patient, in chronological order by date of
4 service, that is consistent with the services being rendered
5 to the patient as claimed. The requirements of this paragraph
6 subparagraph for maintaining a patient log signed by the
7 patient may be met by a hospital that maintains medical
8 records as required by s. 395.3025 and applicable rules and
9 makes such records available to the insurer upon request.
10 (f) Upon written notification by any person, an
11 insurer shall investigate any claim of improper billing by a
12 physician or other medical provider. The insurer shall
13 determine if the insured was properly billed for only those
14 services and treatments that the insured actually received. If
15 the insurer determines that the insured has been improperly
16 billed, the insurer shall notify the insured, the person
17 making the written notification and the provider of its
18 findings and shall reduce the amount of payment to the
19 provider by the amount determined to be improperly billed. If
20 a reduction is made due to such written notification by any
21 person, the insurer shall pay to the person 20 percent of the
22 amount of the reduction, up to $500. If the provider is
23 arrested due to the improper billing, then the insurer shall
24 pay to the person 40 percent of the amount of the reduction,
25 up to $500.
26 (g) An insurer may not systematically downcode with
27 the intent to deny reimbursement otherwise due. Such action
28 constitutes a material misrepresentation under s.
29 626.9541(1)(i)2.
30 (6) DISCOVERY OF FACTS ABOUT AN INJURED PERSON;
31 DISPUTES.--
36
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 (a) Every employer shall, if a request is made by an
2 insurer providing personal injury protection benefits under
3 ss. 627.730-627.7405 against whom a claim has been made,
4 furnish forthwith, in a form approved by the office, a sworn
5 statement of the earnings, since the time of the bodily injury
6 and for a reasonable period before the injury, of the person
7 upon whose injury the claim is based.
8 (14) DISCOVERY OF FACTS ABOUT AN INJURED PERSON;
9 DISPUTES.--
10 (a)(b) Every physician, hospital, clinic, or other
11 medical institution providing, before or after bodily injury
12 upon which a claim for personal injury protection insurance
13 benefits is based, any products, services, or accommodations
14 in relation to that or any other injury, or in relation to a
15 condition claimed to be connected with that or any other
16 injury, shall, if requested to do so by the insurer against
17 whom the claim has been made:,
18 1. Furnish forthwith a written report of the history,
19 condition, treatment, dates, and costs of such treatment of
20 the injured person and why the items identified by the insurer
21 were reasonable in amount and medically necessary.,
22 2. Provide together with a sworn statement that the
23 treatment or services rendered were reasonable and necessary
24 with respect to the bodily injury sustained. Such sworn
25 statement shall read as follows: "Under penalty of perjury, I
26 declare that I have read the foregoing, and the facts alleged
27 are true, to the best of my knowledge and belief."
28 3. Identify and identifying which portion of the
29 expenses for such treatment or services was incurred as a
30 result of such bodily injury.,
31
37
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 4. and Produce forthwith, and permit the inspection
2 and copying of, his or her or its records regarding such
3 history, condition, treatment, dates, and costs of treatment;
4 provided that this shall not limit the introduction of
5 evidence at trial. Such sworn statement shall read as follows:
6 "Under penalty of perjury, I declare that I have read the
7 foregoing, and the facts alleged are true, to the best of my
8 knowledge and belief."
9 (b) However, if the records are maintained at an
10 alternative location, the requested records shall be made
11 available at the principal place of business within 25 working
12 days after the request. If the requested records are not made
13 available within this time period and such records are later
14 admitted into evidence or otherwise used to support a claim by
15 the health care provider against the insurer, the court shall
16 not award attorney's fees to the provider pursuant to this
17 section or s. 627.428. At the time of the records inspection,
18 the health care provider shall allow the insurer to inspect
19 records and photograph the equipment and associated documents
20 associated with the insured's treatment, services, or
21 supplies.
22 (c) A No cause of action for violation of the
23 physician-patient privilege or invasion of the right of
24 privacy is not shall be permitted against any physician,
25 hospital, clinic, or other medical institution complying with
26 the provisions of this section.
27 (d) The person requesting such records and such sworn
28 statement shall pay all reasonable costs connected therewith.
29 (e) If an insurer makes a written request for
30 documentation or information under this paragraph within 30
31 days after having received notice of the amount of a covered
38
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 loss under subsection (7) paragraph (4)(a), the amount or the
2 partial amount that which is the subject of the insurer's
3 inquiry shall become overdue if the insurer does not pay in
4 accordance with subsection (8) paragraph (4)(b) or within 15
5 10 days after the insurer's receipt of the requested
6 documentation or information, whichever occurs later. For
7 purposes of this paragraph, the term "receipt" includes, but
8 is not limited to, inspection and copying pursuant to this
9 subsection paragraph.
10 (f) Any insurer that requests documentation or
11 information pertaining to reasonableness of charges or medical
12 necessity under this subsection paragraph without a reasonable
13 basis for such requests as a general business practice is
14 engaging in an unfair trade practice under the insurance code.
15 (g)(c) In the event of any dispute regarding an
16 insurer's right to discovery of facts under this section, the
17 insurer may petition a court of competent jurisdiction to
18 enter an order permitting such discovery. The order may be
19 made only on motion for good cause shown and upon notice to
20 all persons having an interest, and it shall specify the time,
21 place, manner, conditions, and scope of the discovery. Such
22 court may, in order to protect against annoyance,
23 embarrassment, or oppression, as justice requires, enter an
24 order refusing discovery or specifying conditions of discovery
25 and may order payments of costs and expenses of the
26 proceeding, including reasonable fees for the appearance of
27 attorneys at the proceedings, as justice requires.
28 (h)(d) The injured person shall be furnished, upon
29 request, a copy of all information obtained by the insurer
30 under the provisions of this section, and shall pay a
31 reasonable charge, if required by the insurer.
39
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 (i)(e) Notice to an insurer of the existence of a
2 claim shall not be unreasonably withheld by an insured.
3 (15)(7) MENTAL AND PHYSICAL EXAMINATION OF INJURED
4 PERSON; REPORTS.--
5 (a) Whenever the mental or physical condition of an
6 injured person covered by personal injury protection is
7 material to any claim that has been or may be made for past or
8 future personal injury protection insurance benefits, such
9 person shall, upon the request of an insurer, submit to mental
10 or physical examination by a physician or physicians.
11 (b) The costs of any examinations requested by an
12 insurer shall be borne entirely by the insurer.
13 (c) Such examination shall be conducted within the
14 municipality where the insured is receiving treatment, or in a
15 location reasonably accessible to the insured, which, for
16 purposes of this paragraph, means any location within the
17 municipality in which the insured resides, or any location
18 within 10 miles by road of the insured's residence, provided
19 such location is within the county in which the insured
20 resides.
21 (d) If the examination is to be conducted in a
22 location reasonably accessible to the insured, and if there is
23 no qualified physician to conduct the examination in a
24 location reasonably accessible to the insured, then such
25 examination shall be conducted in an area of the closest
26 proximity to the insured's residence.
27 (e) Personal protection Insurers are authorized to
28 include reasonable provisions in personal injury protection
29 insurance policies for mental and physical examination of
30 those claiming personal injury protection insurance benefits.
31
40
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 (f) An insurer may not withdraw payment of a treating
2 physician without the consent of the injured person covered by
3 the personal injury protection, unless the insurer first
4 obtains a valid report by a Florida physician licensed under
5 the same chapter as the treating physician whose treatment
6 authorization is sought to be withdrawn, stating that
7 treatment was not reasonable, related, or necessary.
8 (g) A valid report is one that is prepared and signed
9 by the physician examining the injured person or reviewing the
10 treatment records of the injured person and is factually
11 supported by the examination and treatment records if reviewed
12 and that has not been modified by anyone other than the
13 physician.
14 (h) The physician preparing the report must be in
15 active practice, unless the physician is physically disabled.
16 Active practice means that during the 3 years immediately
17 preceding the date of the physical examination or review of
18 the treatment records the physician must have devoted
19 professional time to the active clinical practice of
20 evaluation, diagnosis, or treatment of medical conditions or
21 to the instruction of students in an accredited health
22 professional school or accredited residency program or a
23 clinical research program that is affiliated with an
24 accredited health professional school or teaching hospital or
25 accredited residency program.
26 (i) The physician preparing a report at the request of
27 an insurer and physicians rendering expert opinions on behalf
28 of persons claiming medical benefits for personal injury
29 protection, or on behalf of an insured through an attorney or
30 another entity, shall maintain, for at least 3 years, copies
31 of all examination reports as medical records and shall
41
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 maintain, for at least 3 years, records of all payments for
2 the examinations and reports.
3 (j) Neither an insurer nor any person acting at the
4 direction of or on behalf of an insurer may materially change
5 an opinion in a report prepared under this subsection
6 paragraph or direct the physician preparing the report to
7 change such opinion. The denial of a payment as the result of
8 such a changed opinion constitutes a material
9 misrepresentation under s. 626.9541(1)(i)2.; however, this
10 provision does not preclude the insurer from calling to the
11 attention of the physician errors of fact in the report based
12 upon information in the claim file.
13 (k)(b) If requested by the person examined, a party
14 causing an examination to be made shall deliver to him or her
15 a copy of every written report concerning the examination
16 rendered by an examining physician, at least one of which
17 reports must set out the examining physician's findings and
18 conclusions in detail. After such request and delivery, the
19 party causing the examination to be made is entitled, upon
20 request, to receive from the person examined every written
21 report available to him or her or his or her representative
22 concerning any examination, previously or thereafter made, of
23 the same mental or physical condition. By requesting and
24 obtaining a report of the examination so ordered, or by taking
25 the deposition of the examiner, the person examined waives any
26 privilege he or she may have, in relation to the claim for
27 benefits, regarding the testimony of every other person who
28 has examined, or may thereafter examine, him or her in respect
29 to the same mental or physical condition. If a person
30 unreasonably refuses to submit to an examination, the personal
31
42
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 injury protection carrier is no longer liable for subsequent
2 personal injury protection benefits.
3 (8) APPLICABILITY OF PROVISION REGULATING ATTORNEY'S
4 FEES.--With respect to any dispute under the provisions of ss.
5 627.730-627.7405 between the insured and the insurer, or
6 between an assignee of an insured's rights and the insurer,
7 the provisions of s. 627.428 shall apply, except as provided
8 in subsection (11).
9 (16)(9) CANCELLATION OR NONRENEWAL.--
10 (a) Each insurer that which has issued a policy
11 providing personal injury protection benefits shall report the
12 renewal, cancellation, or nonrenewal thereof to the Department
13 of Highway Safety and Motor Vehicles within 45 days from the
14 effective date of the renewal, cancellation, or nonrenewal.
15 (b) Upon the issuance of a policy providing personal
16 injury protection benefits to a named insured not previously
17 insured by the insurer thereof during that calendar year, the
18 insurer shall report the issuance of the new policy to the
19 Department of Highway Safety and Motor Vehicles within 30
20 days. The report shall be in such form and format and contain
21 such information as is may be required by the Department of
22 Highway Safety and Motor Vehicles which shall include a format
23 compatible with the data processing capabilities of such said
24 department, and the Department of Highway Safety and Motor
25 Vehicles is authorized to adopt rules necessary with respect
26 thereto. Failure by an insurer to file proper reports with the
27 Department of Highway Safety and Motor Vehicles as required by
28 this subsection or rules adopted with respect to the
29 requirements of this subsection constitutes a violation of the
30 Florida Insurance Code.
31
43
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 (c) Reports of cancellations and policy renewals and
2 reports of the issuance of new policies received by the
3 Department of Highway Safety and Motor Vehicles are
4 confidential and exempt from the provisions of s. 119.07(1).
5 (d) These records are to be used for enforcement and
6 regulatory purposes only, including the generation by the
7 department of data regarding compliance by owners of motor
8 vehicles with financial responsibility coverage requirements.
9 In addition, the Department of Highway Safety and Motor
10 Vehicles shall release, upon a written request by a person
11 involved in a motor vehicle accident, by the person's
12 attorney, or by a representative of the person's motor vehicle
13 insurer, the name of the insurance company and the policy
14 number for the policy covering the vehicle named by the
15 requesting party. The written request must include a copy of
16 the appropriate accident form as provided in s. 316.065, s.
17 316.066, or s. 316.068.
18 (e)(b) Every insurer with respect to each insurance
19 policy providing personal injury protection benefits shall
20 notify the named insured or in the case of a commercial fleet
21 policy, the first named insured in writing that any
22 cancellation or nonrenewal of the policy will be reported by
23 the insurer to the Department of Highway Safety and Motor
24 Vehicles. The notice shall also inform the named insured that
25 failure to maintain personal injury protection and property
26 damage liability insurance on a motor vehicle when required by
27 law may result in the loss of registration and driving
28 privileges in this state, and the notice shall inform the
29 named insured of the amount of the reinstatement fees required
30 by s. 627.733(7). This notice is for informational purposes
31
44
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 only, and no civil liability shall attach to an insurer due to
2 failure to provide this notice.
3 (17)(10) PREFERRED PROVIDERS.--An insurer may
4 negotiate and enter into contracts with licensed health care
5 providers for the benefits described in this section, referred
6 to in this section as "preferred providers," which shall
7 include health care providers licensed under chapters 458,
8 459, 460, 461, and 463. The insurer may provide an option to
9 an insured to use a preferred provider at the time of purchase
10 of the policy for personal injury protection benefits, if the
11 requirements of this subsection are met. If the insured
12 elects to use a provider who is not a preferred provider,
13 whether the insured purchased a preferred provider policy or a
14 nonpreferred provider policy, the medical benefits provided by
15 the insurer shall be as required by this section. If the
16 insured elects to use a provider who is a preferred provider,
17 the insurer may pay medical benefits in excess of the benefits
18 required by this section and may waive or lower the amount of
19 any deductible that applies to such medical benefits. If the
20 insurer offers a preferred provider policy to a policyholder
21 or applicant, it must also offer a nonpreferred provider
22 policy. The insurer shall provide each policyholder with a
23 current roster of preferred providers in the county in which
24 the insured resides at the time of purchase of such policy,
25 and shall make such list available for public inspection
26 during regular business hours at the principal office of the
27 insurer within the state.
28 (11) DEMAND LETTER.--
29 (a) As a condition precedent to filing any action for
30 benefits under this section, the insurer must be provided with
31 written notice of an intent to initiate litigation. Such
45
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 notice may not be sent until the claim is overdue, including
2 any additional time the insurer has to pay the claim pursuant
3 to paragraph (4)(b).
4 (b) The notice required shall state that it is a
5 "demand letter under s. 627.736(11)" and shall state with
6 specificity:
7 1. The name of the insured upon which such benefits
8 are being sought, including a copy of the assignment giving
9 rights to the claimant if the claimant is not the insured.
10 2. The claim number or policy number upon which such
11 claim was originally submitted to the insurer.
12 3. To the extent applicable, the name of any medical
13 provider who rendered to an insured the treatment, services,
14 accommodations, or supplies that form the basis of such claim;
15 and an itemized statement specifying each exact amount, the
16 date of treatment, service, or accommodation, and the type of
17 benefit claimed to be due. A completed form satisfying the
18 requirements of paragraph (5)(d) or the lost-wage statement
19 previously submitted may be used as the itemized statement. To
20 the extent that the demand involves an insurer's withdrawal of
21 payment under paragraph (7)(a) for future treatment not yet
22 rendered, the claimant shall attach a copy of the insurer's
23 notice withdrawing such payment and an itemized statement of
24 the type, frequency, and duration of future treatment claimed
25 to be reasonable and medically necessary.
26 (c) Each notice required by this subsection must be
27 delivered to the insurer by United States certified or
28 registered mail, return receipt requested. Such postal costs
29 shall be reimbursed by the insurer if so requested by the
30 claimant in the notice, when the insurer pays the claim. Such
31 notice must be sent to the person and address specified by the
46
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 insurer for the purposes of receiving notices under this
2 subsection. Each licensed insurer, whether domestic, foreign,
3 or alien, shall file with the office designation of the name
4 and address of the person to whom notices pursuant to this
5 subsection shall be sent which the office shall make available
6 on its Internet website. The name and address on file with the
7 office pursuant to s. 624.422 shall be deemed the authorized
8 representative to accept notice pursuant to this subsection in
9 the event no other designation has been made.
10 (d) If, within 15 days after receipt of notice by the
11 insurer, the overdue claim specified in the notice is paid by
12 the insurer together with applicable interest and a penalty of
13 10 percent of the overdue amount paid by the insurer, subject
14 to a maximum penalty of $250, no action may be brought against
15 the insurer. If the demand involves an insurer's withdrawal of
16 payment under paragraph (7)(a) for future treatment not yet
17 rendered, no action may be brought against the insurer if,
18 within 15 days after its receipt of the notice, the insurer
19 mails to the person filing the notice a written statement of
20 the insurer's agreement to pay for such treatment in
21 accordance with the notice and to pay a penalty of 10 percent,
22 subject to a maximum penalty of $250, when it pays for such
23 future treatment in accordance with the requirements of this
24 section. To the extent the insurer determines not to pay any
25 amount demanded, the penalty shall not be payable in any
26 subsequent action. For purposes of this subsection, payment or
27 the insurer's agreement shall be treated as being made on the
28 date a draft or other valid instrument that is equivalent to
29 payment, or the insurer's written statement of agreement, is
30 placed in the United States mail in a properly addressed,
31 postpaid envelope, or if not so posted, on the date of
47
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 delivery. The insurer shall not be obligated to pay any
2 attorney's fees if the insurer pays the claim or mails its
3 agreement to pay for future treatment within the time
4 prescribed by this subsection.
5 (e) The applicable statute of limitation for an action
6 under this section shall be tolled for a period of 15 business
7 days by the mailing of the notice required by this subsection.
8 (f) Any insurer making a general business practice of
9 not paying valid claims until receipt of the notice required
10 by this subsection is engaging in an unfair trade practice
11 under the insurance code.
12 (18)(12) CIVIL ACTION FOR INSURANCE FRAUD.--An insurer
13 shall have a cause of action against any person convicted of,
14 or who, regardless of adjudication of guilt, pleads guilty or
15 nolo contendere to insurance fraud under s. 817.234, patient
16 brokering under s. 817.505, or kickbacks under s. 456.054,
17 associated with a claim for personal injury protection
18 benefits in accordance with this section. An insurer
19 prevailing in an action brought under this subsection may
20 recover compensatory, consequential, and punitive damages
21 subject to the requirements and limitations of part II of
22 chapter 768, and attorney's fees and costs incurred in
23 litigating a cause of action against any person convicted of,
24 or who, regardless of adjudication of guilt, pleads guilty or
25 nolo contendere to insurance fraud under s. 817.234, patient
26 brokering under s. 817.505, or kickbacks under s. 456.054,
27 associated with a claim for personal injury protection
28 benefits in accordance with this section.
29 (19)(13) MINIMUM BENEFIT COVERAGE.--If the Financial
30 Services Commission determines that the cost savings under
31 personal injury protection insurance benefits paid by insurers
48
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 have been realized due to the provisions of this act, prior
2 legislative reforms, or other factors, the commission may
3 increase the minimum $10,000 benefit coverage requirement. In
4 establishing the amount of such increase, the commission must
5 determine that the additional premium for such coverage is
6 approximately equal to the premium cost savings that have been
7 realized for the personal injury protection coverage with
8 limits of $10,000.
9 (20) REWARD.--Upon written notification by any person,
10 an insurer shall investigate any claim of improper billing by
11 a physician or other medical provider. The insurer shall
12 determine if the insured was properly billed for only those
13 services and treatments that the insured actually received. If
14 the insurer determines that the insured has been improperly
15 billed, the insurer shall notify the insured, the person
16 making the written notification and the provider of its
17 findings and shall reduce the amount of payment to the
18 provider by the amount determined to be improperly billed. If
19 a reduction is made due to such written notification by any
20 person, the insurer shall pay to the person 20 percent of the
21 amount of the reduction up to $500. If the provider is
22 arrested due to the improper billing, the insurer shall pay to
23 the person 40 percent of the amount of the reduction up to
24 $500.
25 (21) VENUE.--Venue for any personal injury protection
26 claim, in the case of an assignment of benefits, shall be in
27 the jurisdiction where the insured resides, where the accident
28 occurs, or where the disputed health care services were
29 performed. Venue may be raised at any time. The cost of
30 transferring venue shall be borne by the plaintiff, and such
31 costs shall not be recoverable as plaintiff's damages.
49
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 Section 2. Subsection (2) of section 316.068, Florida
2 Statutes, is amended to read:
3 316.068 Crash report forms.--
4 (2) Every crash report required to be made in writing
5 must be made on the appropriate form approved by the
6 department and must contain all the information required
7 therein to include:
8 (a) The date, time, and location of the crash;
9 (b) A description of the vehicles involved;
10 (c) The names and addresses of the parties involved;
11 (d) The names and addresses of all drivers and
12 passengers in the vehicles involved;
13 (e) The names and addresses of witnesses;
14 (f) The name, badge number, and law enforcement agency
15 of the officer investigating the crash; and
16 (g) The names of the insurance companies for the
17 respective parties involved in the crash unless not available.
18
19 The absence of information in such written crash reports
20 regarding the existence of passengers in the vehicles involved
21 in the crash constitutes a rebuttable presumption that no such
22 passengers were involved in the reported crash.
23 Notwithstanding any other provisions of this section, a crash
24 report produced electronically by a law enforcement officer
25 must, at a minimum, contain the same information as is called
26 for on those forms approved by the department.
27 Section 3. Subsection (9) is added to section 322.26,
28 Florida Statutes, to read:
29 322.26 Mandatory revocation of license by
30 department.--The department shall forthwith revoke the license
31
50
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 or driving privilege of any person upon receiving a record of
2 such person's conviction of any of the following offenses:
3 (9) Conviction in any court having jurisdiction over
4 offenses committed under s. 817.234(8) or (9) or s. 817.505.
5 Section 4. Paragraph (a) of subsection (7) and
6 subsection (9) of section 817.234, Florida Statutes, are
7 amended to read:
8 817.234 False and fraudulent insurance claims.--
9 (7)(a) It shall constitute a material omission and
10 insurance fraud, punishable as provided in subsection (11),
11 for any service physician or other provider, other than a
12 hospital, to engage in a general business practice of billing
13 amounts as its usual and customary charge, if such provider
14 has agreed with the insured patient or intends to waive
15 deductibles or copayments, or does not for any other reason
16 intend to collect the total amount of such charge. With
17 respect to a determination as to whether a service physician
18 or other provider has engaged in such general business
19 practice, consideration shall be given to evidence of whether
20 the physician or other provider made a good faith attempt to
21 collect such deductible or copayment. This paragraph does not
22 apply to physicians or other providers who waive deductibles
23 or copayments or reduce their bills as part of a bodily injury
24 settlement or verdict.
25 (9) A person may not organize, plan, or knowingly
26 participate in an intentional motor vehicle crash or a scheme
27 to create documentation of a motor vehicle crash that did not
28 occur for the purpose of making motor vehicle tort claims or
29 claims for personal injury protection benefits as required by
30 s. 627.736. Any person who violates this subsection commits a
31 felony of the second degree, punishable as provided in s.
51
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 775.082, s. 775.083, or s. 775.084. A person who is convicted
2 of a violation of this subsection shall be sentenced to a
3 minimum term of imprisonment of 2 years.
4 Section 5. Section 817.2361, Florida Statutes, is
5 amended to read:
6 817.2361 False or fraudulent proof of motor vehicle
7 insurance card.--Any person who, with intent to deceive any
8 other person, creates, markets, or presents a false or
9 fraudulent proof of motor vehicle insurance card commits a
10 felony of the third degree, punishable as provided in s.
11 775.082, s. 775.083, or s. 775.084.
12 Section 6. For the 2006-2007 fiscal year, the sum of
13 $1,533,296 million is appropriated on a recurring basis and an
14 associated salary rate of 1,220,000 is authorized from the
15 Insurance Regulatory Trust Fund to the Division of Insurance
16 Fraud within the Department of Financial Services for the
17 purpose of providing a competitive pay adjustment of $10,000
18 plus benefits for each of the existing sworn law enforcement
19 officer positions in the division in order to achieve relative
20 parity with sworn law enforcement investigators who have
21 similar responsibilities at other state agencies. This
22 appropriation is for the purposes provided in s. 626.989,
23 Florida Statutes.
24 Section 7. For the 2006-2007 fiscal year, the sums of
25 $510,276 in recurring funds and $111,455 in nonrecurring funds
26 are appropriated from the Insurance Regulatory Trust Fund of
27 the Department of Financial Services to the Division of
28 Insurance Fraud within the department for the purpose of
29 providing a new fraud unit within the division consisting of
30 six sworn law enforcement officers, one non-sworn
31 investigator, one crime analyst, and one clerical position. A
52
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 total of nine full-time equivalent positions and associated
2 salary rate of 381,500 are authorized. This appropriation is
3 for the purposes provided in s. 626.989, Florida Statutes.
4 Section 8. For the 2006-2007 fiscal year, the sums of
5 $415,291 in recurring funds and $52,430 in nonrecurring funds
6 are appropriated from the Insurance Regulatory Trust Fund of
7 the Department of Financial Services to the Division of
8 Insurance Fraud within the department and 10 full-time
9 equivalent positions and associated salary rate of 342,500 are
10 authorized. This appropriation is for the purposes provided in
11 s. 626.989, Florida Statutes.
12 Section 9. For the 2006-2007 fiscal year, the sum of
13 $750,000 in recurring funds is appropriated from the Insurance
14 Regulatory Trust Fund in equal amounts to the State Attorneys
15 for the 4th, 6th, 9th, 13th, 15th, and 17th Circuits to
16 establish and fund an additional assistant state attorney
17 position in each circuit for the purpose of prosecuting cases
18 of insurance fraud.
19 Section 10. Effective January 1, 2009, sections
20 627.730, 627.731, 627.732, 627.733, 627.734, 627.736, 627.737,
21 627.739, 627.7401, 627.7403, and 627.7405, Florida Statutes,
22 constituting the Florida Motor Vehicle No-Fault Law, are
23 repealed, unless reviewed and reenacted by the Legislature
24 before that date.
25 Section 11. Section 19 of chapter 2003-411, Laws of
26 Florida, is repealed.
27 Section 12. This act shall take effect October 1,
28 2006.
29
30
31
53
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 CS for CS for SB 2114
587-2186-06
1 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
2 CS for Senate Bill 2114
3
4 The committee substitute requires Medicaid to be fully
reimbursed for any benefits covered by personal injury
5 protection (PIP) insurance; exempts ambulance providers,
hospitals and physicians providing emergency services from
6 certain claim form requirements; clarifies that a claim may
not include charges for services by a provider that does not
7 possess all valid qualifications and licenses required to
lawfully provide such services, however, a physician licensed
8 under chapter 458, 459, 460, or 466, F.S., may delegate
diagnostic or treatment tasks to an employee to be performed
9 under the supervision of the physician and still charge for
such services; requires that if an insured fails to furnish
10 the provider with correct PIP insurer information, that the
provider has 75 days following the date the provider obtains
11 the correct information to furnish the appropriate PIP insurer
with a statement of the charges; deletes the requirement that
12 a provider submit a written bill at the time of treatment
which the patient must sign; and deletes language that
13 prohibits the contingency risk multiplier as applied to
attorney fee awards in no-fault cases.
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
54
CODING: Words stricken are deletions; words underlined are additions.