Senate Bill sb7094pb
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
FOR CONSIDERATION By the Committee on Banking and Insurance
597-1265D-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.
8 627.732, F.S.; defining the terms "services,"
9 "contracted services," and "rendered"; amending
10 s. 627.736, F.S.; providing that a
11 self-employed injured person or an injured
12 person owning 25 percent or more interest in an
13 employer offer proof of income and lost wages
14 to insurers as a condition precedent for
15 payment; requiring an insured to notify an
16 insurer in writing of election to reserve
17 benefits for lost wages; specifying that such
18 notification takes priority over other claims,
19 except specified hospital liens; clarifying
20 that personal injury protection benefits are
21 primary, except for workers' compensation
22 benefits; authorizing a parent or legal
23 guardian of an injured minor to complete
24 application for personal injury protection
25 benefits; providing requirements for compliance
26 with billing procedures; providing that charges
27 for medical services and supplies shall not
28 exceed the allowance under the Medicare fee
29 schedule; providing that specified charges are
30 noncompensable; specifying the time period
31 within which a health care provider or other
1
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 specified provider must submit a statement of
2 charges; prohibiting providers from billing an
3 injured person under specified conditions for
4 emergency services and care; requiring a
5 provider to submit a written bill at the time
6 of treatment which the injured patient must
7 sign; requiring insurers to provide specified
8 documents to insureds; providing for a valid,
9 binding assignment of benefits and for priority
10 of payment under multiple assignments of
11 benefits; requiring that amounts repayable to
12 an insurer include the statutory interest
13 penalty; deleting provisions relating to
14 charges for personal injury protection
15 benefits; increasing the time period for an
16 insurer to respond to a demand letter;
17 providing requirements for the production and
18 inspection of an injured person's medical
19 records from a provider; specifying persons
20 subject to an examination under oath and
21 providing for compensation; providing that, if
22 requested, an examination under oath is a
23 condition precedent to filing a suit; requiring
24 an insured to provide notice of a claim within
25 1 year after incident; providing that an
26 insurer may contract for a notice to be less
27 than 1 year; providing requirements relating to
28 a mental or physical examination; eliminating
29 the application of a contingency risk
30 multiplier as to attorney-fee awards in
31 specified disputes; creating provisions
2
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 allowing an insurer to bring a civil action to
2 recover amounts paid and expenses incurred
3 against persons presenting claims that a court
4 determines meet specified criteria; deleting
5 specified civil actions; removing the monetary
6 limit on the amount that may be provided to
7 persons notifying insurers of improper billing;
8 restricting venue for any personal injury
9 protection claim to specified jurisdictions and
10 providing for costs of transferring venue;
11 providing that this section not be deemed to
12 preempt or supersede any causes of action that
13 are otherwise available; abrogating the repeal
14 of provisions pertaining to the Florida Motor
15 Vehicle No-Fault Law; providing an effective
16 date.
17
18 Be It Enacted by the Legislature of the State of Florida:
19
20 Section 1. Subsections (16), (17) and (18) are added
21 to section 627.732, Florida Statutes, to read:
22 627.732 Definitions.--As used in ss. 627.730-627.7405,
23 the term:
24 (16) "Services" includes treatment, procedures,
25 supplies, and equipment.
26 (17) "Contracted services" means goods or services
27 provided or performed by anyone other than a statutory
28 employee of the supplier or provider.
29 (18) "Rendered" means actually performed a treatment
30 or a service.
31
3
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 Section 2. Section 627.736, Florida Statutes, is
2 amended to read:
3 627.736 Required personal injury protection benefits;
4 exclusions; priority; claims.--
5 (1) REQUIRED PERSONAL INJURY PROTECTION
6 BENEFITS.--Every insurance policy complying with the security
7 requirements of s. 627.733 shall provide personal injury
8 protection to the named insured, relatives residing in the
9 same household, persons operating the insured motor vehicle,
10 passengers in such motor vehicle, and other persons struck by
11 such motor vehicle and suffering bodily injury while not an
12 occupant of a self-propelled vehicle, subject to the
13 provisions of subsections (3) subsection (2) and (6) paragraph
14 (4)(d), to a limit of $10,000 for loss sustained by any such
15 person as a result of bodily injury, sickness, disease, or
16 death arising out of the ownership, maintenance, or use of a
17 motor vehicle as follows:
18 (a) Medical benefits.--Eighty percent of all
19 reasonable expenses for medically necessary medical, surgical,
20 X-ray, dental, and rehabilitative services, including
21 prosthetic devices, and medically necessary ambulance,
22 hospital, and nursing services. Such benefits shall also
23 include necessary remedial treatment and services recognized
24 and permitted under the laws of the state for an injured
25 person who relies upon spiritual means through prayer alone
26 for healing, in accordance with his or her religious beliefs;
27 however, this sentence does not affect the determination of
28 what other services or procedures are medically necessary.
29 (b) Disability benefits.--
30 1. Sixty percent of any loss of gross income and loss
31 of earning capacity per injured person individual from
4
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 inability to work proximately caused by the injury sustained
2 by the injured person, plus all expenses reasonably incurred
3 in obtaining from others ordinary and necessary services in
4 lieu of those that, but for the injury, the injured person
5 would have performed without income for the benefit of his or
6 her household. All disability benefits payable under this
7 provision shall be paid not less than every 2 weeks.
8 2. For an injured person who is self employed or an
9 injured person who owns over a 25-percent interest in his or
10 her employer, as a condition precedent to payment for lost
11 wages, the injured person must produce to the insurer
12 reasonable proof as to the injured person's net income and
13 loss of earning capacity or additional expense, such that the
14 insurer may reasonably calculate the amount of the loss of
15 income.
16 3. Every employer shall, if a request is made by an
17 insurer providing personal injury protection benefits under
18 ss. 627.730-627.7405 against whom a claim has been made,
19 furnish forthwith, in a form approved by the office, a sworn
20 statement of the earnings, since the time of the bodily injury
21 and for a reasonable period before the injury, of the person
22 upon whose injury the claim is based.
23 4. If the insured elects to have disability benefits
24 reserved for lost wages, the insured shall notify the insurer
25 in writing. Receipt of such notification shall take priority
26 over all claims subject to an assignment of benefits received
27 after receipt of such notice, except that a properly perfected
28 hospital lien shall take priority over the insured's election
29 to reserve all benefits for lost wages.
30 (c) Death benefits.--The insurer shall pay death
31 benefits in the amount of $5,000 per individual. The insurer
5
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 may pay such benefits to the executor or administrator of the
2 deceased, to any of the deceased's relatives by blood or legal
3 adoption or connection by marriage, or to any person appearing
4 to the insurer to be equitably entitled thereto.
5 (d) Medicaid benefits.--When the Agency for Health
6 Care Administration provides, pays, or becomes liable for
7 medical assistance under the Medicaid program related to
8 injury, sickness, disease, or death arising out of the
9 ownership, maintenance, or use of a motor vehicle, benefits
10 under ss. 627.730-627.7405 shall be subject to the provisions
11 of the Medicaid program.
12 (2) AMOUNT OF PROPERTY DAMAGE COVERAGE.--
13 (a) Only insurers writing motor vehicle liability
14 insurance in this state may provide the required benefits of
15 this section, and no such insurer shall require the purchase
16 of any other motor vehicle coverage other than the purchase of
17 property damage liability coverage as required by s. 627.7275
18 as a condition for providing such required benefits.
19 (b) Insurers may not require that property damage
20 liability insurance in an amount greater than $10,000 be
21 purchased in conjunction with personal injury protection.
22 Such insurers shall make benefits and required property damage
23 liability insurance coverage available through normal
24 marketing channels. Any insurer writing motor vehicle
25 liability insurance in this state who fails to comply with
26 such availability requirement as a general business practice
27 shall be deemed to have violated part IX of chapter 626, and
28 such violation shall constitute an unfair method of
29 competition or an unfair or deceptive act or practice
30 involving the business of insurance; and any such insurer
31 committing such violation shall be subject to the penalties
6
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 afforded in such part, as well as those which may be afforded
2 elsewhere in the insurance code.
3 (3)(2) AUTHORIZED EXCLUSIONS.--Any insurer may exclude
4 benefits:
5 (a) For injury sustained by the named insured and
6 relatives residing in the same household while occupying
7 another motor vehicle owned by the named insured and not
8 insured under the policy or for injury sustained by any person
9 operating the insured motor vehicle without the express or
10 implied consent of the insured.
11 (b) To any injured person, if such person's conduct
12 contributed to his or her injury under any of the following
13 circumstances:
14 1. Causing injury to himself or herself intentionally;
15 or
16 2. Being injured while committing a felony.
17
18 Whenever an insured is charged with conduct as set forth in
19 subparagraph 2., the 30-day payment provision of paragraph
20 (9)(a) (4)(b) shall be held in abeyance, and the insurer shall
21 withhold payment of any personal injury protection benefits
22 pending the outcome of the case at the trial level. If the
23 charge is nolle prossed or dismissed or the insured is
24 acquitted, the 30-day payment provision shall run from the
25 date the insurer is notified of such action.
26 (4)(3) INSURED'S RIGHTS TO RECOVERY OF SPECIAL DAMAGES
27 IN TORT CLAIMS.--No insurer shall have a lien on any recovery
28 in tort by judgment, settlement, or otherwise for personal
29 injury protection benefits, whether suit has been filed or
30 settlement has been reached without suit. An injured person
31 party who is entitled to bring suit under the provisions of
7
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 ss. 627.730-627.7405, or his or her legal representative, has
2 shall have no right to recover any damages for which personal
3 injury protection benefits are paid, or payable, or otherwise
4 available. The plaintiff may prove all of his or her special
5 damages notwithstanding this limitation, but if special
6 damages are introduced in evidence, the trier of facts,
7 whether judge or jury, shall not award damages for personal
8 injury protection benefits paid, or payable, or otherwise
9 available. In all cases in which a jury is required to fix
10 damages, the court shall instruct the jury that the plaintiff
11 shall not recover such special damages for personal injury
12 protection benefits paid, or payable, or otherwise available.
13 (5) NONREIMBURSABLE SERVICES.--The Department of
14 Health, in consultation with the appropriate professional
15 licensing boards, shall adopt, by rule, a list of diagnostic
16 tests deemed not to be medically necessary for use in the
17 treatment of persons sustaining bodily injury covered by
18 personal injury protection benefits under this section. The
19 list shall be revised from time to time as determined by the
20 Department of Health, in consultation with the respective
21 professional licensing boards. Inclusion of a test on the list
22 of invalid diagnostic tests shall be based on lack of
23 demonstrated medical value and a level of general acceptance
24 by the relevant provider community and shall not be dependent
25 for results entirely upon subjective patient response.
26 Notwithstanding its inclusion on a fee schedule in this
27 section, an insurer or insured is not required to pay any
28 charges or reimburse claims for any invalid diagnostic test as
29 determined by the Department of Health.
30
31
8
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 (6) REQUIRED PAYMENT OF BENEFITS.--The insurer of the
2 owner of a motor vehicle shall pay personal injury protection
3 benefits for:
4 (a) Accidental bodily injury sustained in this state
5 by the owner while occupying a motor vehicle, or while not an
6 occupant of a self-propelled vehicle if the injury is caused
7 by physical contact with a motor vehicle.
8 (b) Accidental bodily injury sustained outside this
9 state, but within the United States of America or its
10 territories or possessions or Canada, by the owner while
11 occupying the owner's motor vehicle.
12 (c) Accidental bodily injury sustained by a relative
13 of the owner residing in the same household, under the
14 circumstances described in paragraphs (a) and (b), provided
15 the relative at the time of the accident is domiciled in the
16 owner's household and is not himself or herself the owner of a
17 motor vehicle with respect to which security is required under
18 ss. 627.730-627.7405.
19 (d) Accidental bodily injury sustained in this state
20 by any other person while occupying the owner's motor vehicle
21 or, if a resident of this state, while not an occupant of a
22 self-propelled vehicle, if the injury is caused by physical
23 contact with such motor vehicle, provided the injured person
24 is not himself or herself:
25 1. The owner of a motor vehicle with respect to which
26 security is required under ss. 627.730-627.7405; or
27 2. Entitled to personal injury benefits from the
28 insurer of the owner or owners of such a motor vehicle.
29 (e) If two or more insurers are liable to pay personal
30 injury protection benefits for the same injury to any one
31 person, the maximum payable shall be as specified in
9
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 subsection (1), and any insurer paying the benefits shall be
2 entitled to recover from each of the other insurers an
3 equitable pro rata share of the benefits paid and expenses
4 incurred in processing the claim.
5 (7) CLAIMS SUBMISSION (4) BENEFITS; WHEN
6 DUE.--Benefits due from an insurer under ss. 627.730-627.7405
7 shall be primary, except for that benefits received under any
8 workers' compensation benefits that are primary over personal
9 injury protection benefits, law shall be credited against the
10 benefits provided by subsection (1), and shall be due and
11 payable as loss accrues, upon receipt of reasonable proof of
12 such loss and the amount of expenses and loss incurred which
13 are covered by the policy issued under ss. 627.730-627.7405,
14 subject to the following:. When the Agency for Health Care
15 Administration provides, pays, or becomes liable for medical
16 assistance under the Medicaid program related to injury,
17 sickness, disease, or death arising out of the ownership,
18 maintenance, or use of a motor vehicle, benefits under ss.
19 627.730-627.7405 shall be subject to the provisions of the
20 Medicaid program.
21 (a) Personal injury protection application.--An
22 insurer may require written notice to be given as soon as
23 practicable after an accident involving a motor vehicle with
24 respect to which the policy affords the security required by
25 ss. 627.730-627.7405. If the injured person is a minor, the
26 parent or legal guardian of the minor, if requested by the
27 insurer, must accurately complete the personal injury
28 protection application.
29 (b) Billing requirements.--
30 1. All statements and bills for medical services
31 rendered by any physician, hospital, clinic, or other person
10
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 or institution shall be submitted to the insurer on a properly
2 completed Centers for Medicare and Medicaid Services (CMS)
3 1500 form or a UB 92 form.
4 2. All billings for such services, procedures, and
5 supplies submitted by health care providers and medical
6 suppliers shall comply with the Healthcare Correct Procedural
7 Coding System (HCPCS) and International Classification of
8 Diseases (ICD-9-CM) in effect for the year in which services
9 are rendered.
10 3. All claims forms submitted by health care providers
11 and medical suppliers other than hospitals shall include on
12 the applicable claim form the signature and professional
13 license number of the provider in the line or space provided
14 for "Signature of Physician or Supplier, Including Degrees or
15 Credentials" and the date of the signature.
16 4. In determining compliance with applicable HCPCS and
17 ICD-9-CM coding, guidance shall be provided by the Healthcare
18 Correct Procedural Coding System (HCPCS), International
19 Classification of Diseases (ICD-9-CM), National Correct Coding
20 Initiative, the Office of the Inspector General (OIG),
21 Physicians Compliance Guidelines, rules of the Agency for
22 Health Care Administration, the Florida Health Information
23 Management Association (FHIMA), and other authoritative
24 treatises.
25 5. A statement of medical services may not include
26 charges for medical services of a person or entity that
27 performed such services without possessing all valid
28 qualifications and licenses required to lawfully provide and
29 bill for such services.
30 6. For purposes of subsection (9), an insurer shall
31 not be considered to have been furnished with notice of the
11
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 amount of covered loss or medical bills due unless the
2 statements or bills comply with this paragraph, and unless the
3 statements or bills are properly completed in their entirety
4 as to all material provisions, with all required information
5 being provided therein.
6 7. An insurer may not systematically downcode with the
7 intent to deny reimbursement otherwise due. Such action
8 constitutes a material misrepresentation under s.
9 626.9541(1)(i)2.
10 (c) Direct billing an insurer for personal injury
11 protection benefits.--
12 1. Any physician, hospital, clinic, or other person or
13 institution lawfully rendering treatment to an injured person
14 for a bodily injury covered by personal injury protection
15 insurance may charge the insurer and injured person only a
16 reasonable amount pursuant to this section for the services
17 and supplies rendered.
18 2. The insurer providing such coverage may pay for
19 such charges directly to such person or institution lawfully
20 rendering such treatment.
21 3. The insured receiving such treatment or his or her
22 guardian, if a minor, shall countersign the properly completed
23 CMS 1500 or UB 92 form submitted for payment.
24 4. In no event, however, may such a charge be in
25 excess of _____ percent of the maximum allowance for each
26 procedure as set forth in the Medicare Parts A and B
27 participating fee schedule in effect at the time services are
28 performed for the region in which services are performed.
29 Treatment and charges not compensable under the Medicare fee
30 schedules are not compensable by the insurer.
31
12
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 (d) Nonemergency services.--With respect to any
2 treatment or service, other than medical services billed by a
3 hospital or other provider for emergency services as defined
4 in s. 395.002 or inpatient services rendered at a
5 hospital-owned facility, the statement of charges must be
6 furnished to the insurer by the provider and may not include,
7 and the insurer is not required to pay, charges for treatment
8 or services rendered more than 35 days before the postmark
9 date of the statement, except for the following:
10 1. Past due amounts previously billed on a timely
11 basis under this subsection.
12 2. If the provider submits to the insurer a notice of
13 initiation of treatment within 21 days after its first
14 examination or treatment of the claimant, the statement may
15 include charges for treatment or services rendered up to, but
16 not more than, 50 days before the postmark date of the
17 statement. The injured person is not liable for, and the
18 provider shall not bill the injured person for, charges that
19 are unpaid because of the provider's failure to comply with
20 this paragraph. Any agreement requiring the injured person or
21 insured to pay for such charges is unenforceable.
22 3. If the insured fails to furnish the provider with
23 the correct name and address of the insured's personal injury
24 protection insurer, the provider has 35 days from the date the
25 provider obtains the correct information to furnish the
26 insurer with a statement of the charges. The insurer is not
27 required to pay for such charges unless the provider includes
28 with the statement documentary evidence that was provided by
29 the insured during the 35-day period demonstrating that the
30 provider reasonably relied on erroneous information from the
31 insured and either:
13
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-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 (e) Emergency services.--
6 1. For emergency services and care as defined in s.
7 395.002 rendered in a hospital emergency department or for
8 transport and treatment rendered by an ambulance provider
9 licensed pursuant to part III of chapter 401, the provider is
10 not required to furnish the statement of charges within the
11 time periods established by this subsection; however, such
12 charges must be submitted within 75 days after the date the
13 treatment was rendered, and the insurer shall not be
14 considered to have been furnished with notice of the amount of
15 covered loss for purposes of subsection (9) until it receives
16 a statement complying with subsection (7), or copy thereof,
17 which specifically identifies the place of service to be a
18 hospital emergency department or an ambulance.
19 2. The injured person is not liable for, and the
20 provider shall not bill the injured person for, charges that
21 are unpaid because of the provider's failure to comply with
22 this paragraph. Any agreement requiring the injured person or
23 insured to pay for such charges is unenforceable.
24 (f) Billing notice and disclosures.--
25 1. Each notice of insured's rights under s. 627.7401
26 must include the following statement in type no smaller than
27 12-point font:
28
29 BILLING REQUIREMENTS.--Florida Statutes provide
30 that with respect to any treatment or services,
31 other than certain hospital and emergency
14
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 services, the statement of charges furnished to
2 the insurer by the provider may not include,
3 and the insurer and the injured person are not
4 required to pay, charges for treatment or
5 services rendered more than 35 days before the
6 postmark date of the statement, except for past
7 due amounts previously billed on a timely
8 basis, and except that, if the provider submits
9 to the insurer a notice of initiation of
10 treatment within 21 days after its first
11 examination or treatment of the claimant, the
12 statement may include charges for treatment or
13 services rendered up to, but not more than, 50
14 days before the postmark date of the statement.
15
16 2. At the time of service and immediately following
17 the service, the health care provider shall provide to the
18 insured patient a written bill, superbill, fee slip, or other
19 similar document that establishes in plain language a detailed
20 description of the service provided and the cost associated
21 with the service. The insured must sign the written bill,
22 superbill, fee slip, or other similar document immediately
23 after having received services. Copies of such disclosures
24 shall be maintained as part of the patient's medical records
25 in accordance with minimal record keeping standards.
26 (g) Upon request, the insured and his or her assigns
27 shall be sent a copy itemizing all payments made, the
28 applicable insurance declarations page, and a copy of the
29 insurance policy within 30 days after the written request.
30 Such request shall state that it is a "request under s.
31 627.736(7)" and shall state with specificity:
15
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 1. The name of the insured upon whom such benefits are
2 being sought, including a copy of the assignment giving rights
3 to the claimant if the claimant is not the insured.
4 2. The claim number or policy number upon which such
5 claim was originally submitted to the insurer.
6
7 Such request must be sent to the person and address specified
8 by the insurer for the purposes of receiving notices or
9 requests under this section.
10 (8) ASSIGNMENT OF BENEFITS.--
11 (a) Personal injury protection benefits are
12 nonassignable, except that the insured may assign the
13 after-loss personal injury protection benefits to any health
14 care provider sufficient to cover any cost or expense
15 associated with the provision of health care. Any such
16 assignment of benefits covers the provider's present and
17 future medical expenses.
18 (b) An insured may execute an assignment of benefits
19 to different health care providers. All such assignments of
20 benefits are irrevocable. The insurer shall pay the claims
21 when the insurer obtains sufficient information to determine
22 that the claims are properly payable. The insurer is not
23 required to reserve personal injury protection benefits for
24 any provider during the investigation of its bills and shall
25 timely pay all bills in its possession which are properly
26 payable.
27 (c) An assignment of personal injury protection
28 benefits to the provider shall be deemed a novation. The
29 insured is relieved of all obligations for the medical bills
30 once an assignment of benefits is executed. Any agreement
31 requiring the injured person or insured to pay for charges is
16
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 unenforceable. Notwithstanding such assignment of benefits,
2 the insured shall be responsible for all required copayments,
3 any deductible, and the provider's bills once benefits have
4 been exhausted.
5 (d) A provider's attorney's fees shall not be
6 recoverable pursuant to s. 627.428 if the provider did not
7 accept a valid assignment of benefits. A valid assignment of
8 benefits must contain the words: "I irrevocably assign my
9 benefits to..." and does not create any personal liability for
10 the insured to the extent personal injury protection benefits
11 are available and properly payable.
12 (e) If the insured's actions result in no coverage for
13 the loss, or if the insured notifies the insurer in writing of
14 his or her election to use all personal injury protection
15 benefits for disability benefits, the assignment of benefits
16 received after such notice shall be deemed void as a matter of
17 law.
18 (f) To the extent that the insured's obligations in a
19 direction to pay or a letter of protection conflict with the
20 insured's obligation pursuant to the assignment of benefits,
21 the assignment of benefits shall void the terms of the
22 direction to pay and letter of protection.
23 (g) For the purposes of this subsection, the term:
24 1. "Letter of protection" means an agreement between a
25 health care provider and an insured wherein the health care
26 provider agrees to forbear its right to immediate payment in
27 exchange for the insured's agreeing to pay the health care
28 provider out of the proceeds of any settlement or judgment
29 resulting from a bodily injury or uninsured motorist claim.
30
31
17
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 2. "Direction to pay" means a written instruction from
2 the insured to the insurer directing the insurer to pay the
3 health care provider directly.
4 (9) OVERDUE PERSONAL INJURY PROTECTION BENEFITS.--
5 (a)(b) Personal injury protection insurance benefits
6 paid pursuant to this section shall be overdue if not paid
7 within 30 days after the insurer is furnished written notice
8 of the amount fact of a covered loss, including a properly
9 completed CMS 1500 or UB 92 form, medical records, assignment
10 of benefits, or, in the case of disability benefits, proper
11 written documentation of the claim and of the amount of same.
12 If such written notice is not furnished to the insurer as to
13 the entire claim, any partial amount supported by written
14 notice is overdue if not paid within 30 days after such
15 written notice is furnished to the insurer. Any part or all
16 of the remainder of the claim that is subsequently supported
17 by written notice is overdue if not paid within 30 days after
18 such written notice is furnished to the insurer. When an
19 insurer pays only a portion of a claim or rejects a claim, the
20 insurer shall provide at the time of the partial payment or
21 rejection an itemized specification of each item that the
22 insurer had reduced, omitted, or declined to pay and any
23 information that the insurer desires the claimant to consider
24 related to the medical necessity of the denied treatment or to
25 explain the reasonableness of the reduced charge, provided
26 that this shall not limit the introduction of evidence at
27 trial; and the insurer shall include the name and address of
28 the person to whom the claimant should respond and a claim
29 number to be referenced in future correspondence. However,
30 notwithstanding the fact that written notice has been
31 furnished to the insurer, any payment shall not be deemed
18
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 overdue when the insurer has reasonable proof to establish
2 that the insurer is not responsible for the payment. For the
3 purpose of calculating the extent to which any benefits are
4 overdue, payment shall be treated as being made on the date a
5 draft or other valid instrument which is equivalent to payment
6 was placed in the United States mail in a properly addressed,
7 postpaid envelope or, if not so posted, on the date of
8 delivery.
9 (b) Timely payment by an insurer This paragraph does
10 not preclude or limit the ability of the insurer to assert
11 that the claim was unrelated, was for services not lawfully
12 performed, was not medically necessary, or was unreasonable or
13 that the amount of the charge was in excess of that permitted
14 under, or in violation of, this section subsection (5). Such
15 assertion by the insurer may be made at any time, including
16 after payment of the claim or after the 30-day time period for
17 payment set forth in this subsection paragraph.
18 (c) All overdue payments shall bear simple interest at
19 the rate established under s. 55.03 or the rate established in
20 the insurance contract, whichever is greater, for the year in
21 which the payment became overdue, calculated from the date the
22 insurer was furnished with written notice of the amount of
23 covered loss. Interest shall be due at the time payment of the
24 overdue claim is made.
25 (d) The insurer of the owner of a motor vehicle shall
26 pay personal injury protection benefits for:
27 1. Accidental bodily injury sustained in this state by
28 the owner while occupying a motor vehicle, or while not an
29 occupant of a self-propelled vehicle if the injury is caused
30 by physical contact with a motor vehicle.
31
19
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 2. Accidental bodily injury sustained outside this
2 state, but within the United States of America or its
3 territories or possessions or Canada, by the owner while
4 occupying the owner's motor vehicle.
5 3. Accidental bodily injury sustained by a relative of
6 the owner residing in the same household, under the
7 circumstances described in subparagraph 1. or subparagraph 2.,
8 provided the relative at the time of the accident is domiciled
9 in the owner's household and is not himself or herself the
10 owner of a motor vehicle with respect to which security is
11 required under ss. 627.730-627.7405.
12 4. Accidental bodily injury sustained in this state by
13 any other person while occupying the owner's motor vehicle or,
14 if a resident of this state, while not an occupant of a
15 self-propelled vehicle, if the injury is caused by physical
16 contact with such motor vehicle, provided the injured person
17 is not himself or herself:
18 a. The owner of a motor vehicle with respect to which
19 security is required under ss. 627.730-627.7405; or
20 b. Entitled to personal injury benefits from the
21 insurer of the owner or owners of such a motor vehicle.
22 (e) If two or more insurers are liable to pay personal
23 injury protection benefits for the same injury to any one
24 person, the maximum payable shall be as specified in
25 subsection (1), and any insurer paying the benefits shall be
26 entitled to recover from each of the other insurers an
27 equitable pro rata share of the benefits paid and expenses
28 incurred in processing the claim.
29 (c)(f) It is a violation of the insurance code for an
30 insurer to fail to timely provide benefits as required by this
31
20
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 section with such frequency as to constitute a general
2 business practice.
3 (10) CALCULATION OF TIME OF PAYMENT.--For the purpose
4 of calculating the extent to which any benefits are overdue,
5 payment shall be treated as being made on the date a draft or
6 other valid instrument that is equivalent to payment was
7 placed in the United States mail in a properly addressed,
8 postpaid envelope or, if not so posted, on the date of
9 delivery.
10 (11) INTEREST ON OVERDUE PAYMENTS.--All overdue
11 payments shall bear simple interest at the rate established
12 under s. 55.03 or the rate established in the insurance
13 contract, whichever is greater, for the year in which the
14 payment became overdue, calculated from the date the insurer
15 was furnished with written notice of the amount of covered
16 loss. In the case of payment made by an insurer to the
17 insured, or insured's assignee, interest shall be due at the
18 time payment of the overdue claim is made. All amounts
19 repayable to the insurer shall bear simple interest at the
20 rate established under s. 55.03 for the year in which the
21 payment became repayable, calculated from the date the insurer
22 tendered payment.
23 (g) Benefits shall not be due or payable to or on the
24 behalf of an insured person if that person has committed, by a
25 material act or omission, any insurance fraud relating to
26 personal injury protection coverage under his or her policy,
27 if the fraud is admitted to in a sworn statement by the
28 insured or if it is established in a court of competent
29 jurisdiction. Any insurance fraud shall void all coverage
30 arising from the claim related to such fraud under the
31 personal injury protection coverage of the insured person who
21
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 committed the fraud, irrespective of whether a portion of the
2 insured person's claim may be legitimate, and any benefits
3 paid prior to the discovery of the insured person's insurance
4 fraud shall be recoverable by the insurer from the person who
5 committed insurance fraud in their entirety. The prevailing
6 party is entitled to its costs and attorney's fees in any
7 action in which it prevails in an insurer's action to enforce
8 its right of recovery under this paragraph.
9 (5) CHARGES FOR TREATMENT OF INJURED PERSONS.--
10 (a) Any physician, hospital, clinic, or other person
11 or institution lawfully rendering treatment to an injured
12 person for a bodily injury covered by personal injury
13 protection insurance may charge the insurer and injured party
14 only a reasonable amount pursuant to this section for the
15 services and supplies rendered, and the insurer providing such
16 coverage may pay for such charges directly to such person or
17 institution lawfully rendering such treatment, if the insured
18 receiving such treatment or his or her guardian has
19 countersigned the properly completed invoice, bill, or claim
20 form approved by the office upon which such charges are to be
21 paid for as having actually been rendered, to the best
22 knowledge of the insured or his or her guardian. In no event,
23 however, may such a charge be in excess of the amount the
24 person or institution customarily charges for like services or
25 supplies. With respect to a determination of whether a charge
26 for a particular service, treatment, or otherwise is
27 reasonable, consideration may be given to evidence of usual
28 and customary charges and payments accepted by the provider
29 involved in the dispute, and reimbursement levels in the
30 community and various federal and state medical fee schedules
31 applicable to automobile and other insurance coverages, and
22
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 other information relevant to the reasonableness of the
2 reimbursement for the service, treatment, or supply.
3 (12) CLAIMS NOT PROPERLY PAYABLE.--
4 (b)1. An insurer or insured is not required to pay a
5 claim or charges:
6 (a)a. Made by a broker or by a person making a claim
7 on behalf of a broker;
8 (b)b. For any service or treatment that was not lawful
9 at the time rendered;
10 (c)c. To any person who knowingly submits a false or
11 misleading statement relating to the claim or charges;
12 (d)d. With respect to a bill or statement that does
13 not substantially meet the applicable requirements of
14 paragraph (7)(b) (d);
15 (e)e. For any treatment or service that is upcoded, or
16 that is unbundled when such treatment or services should be
17 bundled, in accordance with subsection (7) paragraph (d). To
18 facilitate prompt payment of lawful services, an insurer may
19 change codes that it determines to have been improperly or
20 incorrectly upcoded or unbundled, and may make payment based
21 on the changed codes, without affecting the right of the
22 provider to dispute the change by the insurer, provided that
23 before doing so, the insurer must contact the health care
24 provider and discuss the reasons for the insurer's change and
25 the health care provider's reason for the coding, or make a
26 reasonable good faith effort to do so, as documented in the
27 insurer's file; and
28 (f)f. For medical services or treatment billed by a
29 physician and not provided in a hospital unless such services
30 are rendered by the physician or are incident to his or her
31 professional services and are included on the physician's
23
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 bill, including documentation verifying that the physician is
2 responsible for the medical services that were rendered and
3 billed.
4 2. Charges for medically necessary cephalic
5 thermograms, peripheral thermograms, spinal ultrasounds,
6 extremity ultrasounds, video fluoroscopy, and surface
7 electromyography shall not exceed the maximum reimbursement
8 allowance for such procedures as set forth in the applicable
9 fee schedule or other payment methodology established pursuant
10 to s. 440.13.
11 3. Allowable amounts that may be charged to a personal
12 injury protection insurance insurer and insured for medically
13 necessary nerve conduction testing when done in conjunction
14 with a needle electromyography procedure and both are
15 performed and billed solely by a physician licensed under
16 chapter 458, chapter 459, chapter 460, or chapter 461 who is
17 also certified by the American Board of Electrodiagnostic
18 Medicine or by a board recognized by the American Board of
19 Medical Specialties or the American Osteopathic Association or
20 who holds diplomate status with the American Chiropractic
21 Neurology Board or its predecessors shall not exceed 200
22 percent of the allowable amount under the participating
23 physician fee schedule of Medicare Part B for year 2001, for
24 the area in which the treatment was rendered, adjusted
25 annually on August 1 to reflect the prior calendar year's
26 changes in the annual Medical Care Item of the Consumer Price
27 Index for All Urban Consumers in the South Region as
28 determined by the Bureau of Labor Statistics of the United
29 States Department of Labor.
30 4. Allowable amounts that may be charged to a personal
31 injury protection insurance insurer and insured for medically
24
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 necessary nerve conduction testing that does not meet the
2 requirements of subparagraph 3. shall not exceed the
3 applicable fee schedule or other payment methodology
4 established pursuant to s. 440.13.
5 5. Allowable amounts that may be charged to a personal
6 injury protection insurance insurer and insured for magnetic
7 resonance imaging services shall not exceed 175 percent of the
8 allowable amount under the participating physician fee
9 schedule of Medicare Part B for year 2001, for the area in
10 which the treatment was rendered, adjusted annually on August
11 1 to reflect the prior calendar year's changes in the annual
12 Medical Care Item of the Consumer Price Index for All Urban
13 Consumers in the South Region as determined by the Bureau of
14 Labor Statistics of the United States Department of Labor for
15 the 12-month period ending June 30 of that year, except that
16 allowable amounts that may be charged to a personal injury
17 protection insurance insurer and insured for magnetic
18 resonance imaging services provided in facilities accredited
19 by the Accreditation Association for Ambulatory Health Care,
20 the American College of Radiology, or the Joint Commission on
21 Accreditation of Healthcare Organizations shall not exceed 200
22 percent of the allowable amount under the participating
23 physician fee schedule of Medicare Part B for year 2001, for
24 the area in which the treatment was rendered, adjusted
25 annually on August 1 to reflect the prior calendar year's
26 changes in the annual Medical Care Item of the Consumer Price
27 Index for All Urban Consumers in the South Region as
28 determined by the Bureau of Labor Statistics of the United
29 States Department of Labor for the 12-month period ending June
30 30 of that year. This paragraph does not apply to charges for
31 magnetic resonance imaging services and nerve conduction
25
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 testing for inpatients and emergency services and care as
2 defined in chapter 395 rendered by facilities licensed under
3 chapter 395.
4 6. The Department of Health, in consultation with the
5 appropriate professional licensing boards, shall adopt, by
6 rule, a list of diagnostic tests deemed not to be medically
7 necessary for use in the treatment of persons sustaining
8 bodily injury covered by personal injury protection benefits
9 under this section. The initial list shall be adopted by
10 January 1, 2004, and shall be revised from time to time as
11 determined by the Department of Health, in consultation with
12 the respective professional licensing boards. Inclusion of a
13 test on the list of invalid diagnostic tests shall be based on
14 lack of demonstrated medical value and a level of general
15 acceptance by the relevant provider community and shall not be
16 dependent for results entirely upon subjective patient
17 response. Notwithstanding its inclusion on a fee schedule in
18 this subsection, an insurer or insured is not required to pay
19 any charges or reimburse claims for any invalid diagnostic
20 test as determined by the Department of Health.
21 (c)1. With respect to any treatment or service, other
22 than medical services billed by a hospital or other provider
23 for emergency services as defined in s. 395.002 or inpatient
24 services rendered at a hospital-owned facility, the statement
25 of charges must be furnished to the insurer by the provider
26 and may not include, and the insurer is not required to pay,
27 charges for treatment or services rendered more than 35 days
28 before the postmark date of the statement, except for past due
29 amounts previously billed on a timely basis under this
30 paragraph, and except that, if the provider submits to the
31 insurer a notice of initiation of treatment within 21 days
26
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 after its first examination or treatment of the claimant, the
2 statement may include charges for treatment or services
3 rendered up to, but not more than, 75 days before the postmark
4 date of the statement. The injured party is not liable for,
5 and the provider shall not bill the injured party for, charges
6 that are unpaid because of the provider's failure to comply
7 with this paragraph. Any agreement requiring the injured
8 person or insured to pay for such charges is unenforceable.
9 2. If, however, the insured fails to furnish the
10 provider with the correct name and address of the insured's
11 personal injury protection insurer, the provider has 35 days
12 from the date the provider obtains the correct information to
13 furnish the insurer with a statement of the charges. The
14 insurer is not required to pay for such charges unless the
15 provider includes with the statement documentary evidence that
16 was provided by the insured during the 35-day period
17 demonstrating that the provider reasonably relied on erroneous
18 information from the insured and either:
19 a. A denial letter from the incorrect insurer; or
20 b. Proof of mailing, which may include an affidavit
21 under penalty of perjury, reflecting timely mailing to the
22 incorrect address or insurer.
23 3. For emergency services and care as defined in s.
24 395.002 rendered in a hospital emergency department or for
25 transport and treatment rendered by an ambulance provider
26 licensed pursuant to part III of chapter 401, the provider is
27 not required to furnish the statement of charges within the
28 time periods established by this paragraph; and the insurer
29 shall not be considered to have been furnished with notice of
30 the amount of covered loss for purposes of paragraph (4)(b)
31 until it receives a statement complying with paragraph (d), or
27
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 copy thereof, which specifically identifies the place of
2 service to be a hospital emergency department or an ambulance
3 in accordance with billing standards recognized by the Health
4 Care Finance Administration.
5 4. Each notice of insured's rights under s. 627.7401
6 must include the following statement in type no smaller than
7 12 points:
8
9 BILLING REQUIREMENTS.--Florida Statutes provide
10 that with respect to any treatment or services,
11 other than certain hospital and emergency
12 services, the statement of charges furnished to
13 the insurer by the provider may not include,
14 and the insurer and the injured party are not
15 required to pay, charges for treatment or
16 services rendered more than 35 days before the
17 postmark date of the statement, except for past
18 due amounts previously billed on a timely
19 basis, and except that, if the provider submits
20 to the insurer a notice of initiation of
21 treatment within 21 days after its first
22 examination or treatment of the claimant, the
23 statement may include charges for treatment or
24 services rendered up to, but not more than, 75
25 days before the postmark date of the statement.
26
27 (d) All statements and bills for medical services
28 rendered by any physician, hospital, clinic, or other person
29 or institution shall be submitted to the insurer on a properly
30 completed Centers for Medicare and Medicaid Services (CMS)
31 1500 form, UB 92 forms, or any other standard form approved by
28
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 the office or adopted by the commission for purposes of this
2 paragraph. All billings for such services rendered by
3 providers shall, to the extent applicable, follow the
4 Physicians' Current Procedural Terminology (CPT) or Healthcare
5 Correct Procedural Coding System (HCPCS), or ICD-9 in effect
6 for the year in which services are rendered and comply with
7 the Centers for Medicare and Medicaid Services (CMS) 1500 form
8 instructions and the American Medical Association Current
9 Procedural Terminology (CPT) Editorial Panel and Healthcare
10 Correct Procedural Coding System (HCPCS). All providers other
11 than hospitals shall include on the applicable claim form the
12 professional license number of the provider in the line or
13 space provided for "Signature of Physician or Supplier,
14 Including Degrees or Credentials." In determining compliance
15 with applicable CPT and HCPCS coding, guidance shall be
16 provided by the Physicians' Current Procedural Terminology
17 (CPT) or the Healthcare Correct Procedural Coding System
18 (HCPCS) in effect for the year in which services were
19 rendered, the Office of the Inspector General (OIG),
20 Physicians Compliance Guidelines, and other authoritative
21 treatises designated by rule by the Agency for Health Care
22 Administration. No statement of medical services may include
23 charges for medical services of a person or entity that
24 performed such services without possessing the valid licenses
25 required to perform such services. For purposes of paragraph
26 (4)(b), an insurer shall not be considered to have been
27 furnished with notice of the amount of covered loss or medical
28 bills due unless the statements or bills comply with this
29 paragraph, and unless the statements or bills are properly
30 completed in their entirety as to all material provisions,
31 with all relevant information being provided therein.
29
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 (14) DEMAND LETTER.--
2 (a) As a condition precedent to filing any action for
3 benefits under this section, the insurer must be provided with
4 written notice of an intent to initiate litigation. Such
5 notice may not be sent until the claim is overdue, including
6 any additional time the insurer has to pay the claim pursuant
7 to subsection (9).
8 (b) The notice required shall state that it is a
9 "demand letter under s. 627.736(14)" and shall state with
10 specificity:
11 1. The name of the insured upon whom such benefits are
12 being sought, including a copy of the assignment giving rights
13 to the claimant if the claimant is not the insured.
14 2. The claim number or policy number upon which such
15 claim was originally submitted to the insurer.
16 3. To the extent applicable, the name of any medical
17 provider who rendered to an insured the treatment, services,
18 accommodations, or supplies that form the basis of such claim;
19 and an itemized statement specifying each exact amount, the
20 date of treatment, service, or accommodation, and the type of
21 benefit claimed to be due. A completed form satisfying the
22 requirements of subsection (7) or the lost-wage statement
23 previously submitted may be used as the itemized statement. To
24 the extent that the demand involves an insurer's withdrawal of
25 payment under subsection (17) for future treatment not yet
26 rendered, the claimant shall attach a copy of the insurer's
27 notice withdrawing such payment and an itemized statement of
28 the type, frequency, and duration of future treatment claimed
29 to be reasonable and medically necessary.
30 (c) Each notice required by this subsection must be
31 delivered to the insurer by United States certified or
30
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 registered mail, return receipt requested. Such postal costs
2 shall be reimbursed by the insurer if so requested by the
3 claimant in the notice, when the insurer pays the claim. Such
4 notice must be sent to the person and address specified by the
5 insurer for the purposes of receiving notices under this
6 subsection. Each licensed insurer, whether domestic, foreign,
7 or alien, shall file with the office designation of the name
8 and address of the person to whom notices pursuant to this
9 subsection shall be sent which the office shall make available
10 on its Internet website. The name and address on file with the
11 office pursuant to s. 624.422 shall be deemed the authorized
12 representative to accept notice pursuant to this subsection in
13 the event no other designation has been made.
14 (d) If, within 21 days after receipt of notice by the
15 insurer, the overdue claim specified in the notice is paid by
16 the insurer together with applicable interest and a penalty of
17 10 percent of the overdue amount paid by the insurer, subject
18 to a maximum penalty of $250, no action may be brought against
19 the insurer. If the demand involves an insurer's withdrawal of
20 payment under subsection (17) for future treatment not yet
21 rendered, no action may be brought against the insurer if,
22 within 21 days after its receipt of the notice, the insurer
23 mails to the person filing the notice a written statement of
24 the insurer's agreement to pay for such treatment in
25 accordance with the notice and to pay a penalty of 10 percent,
26 subject to a maximum penalty of $250, when it pays for such
27 future treatment in accordance with the requirements of this
28 section. To the extent the insurer determines not to pay any
29 amount demanded, the penalty shall not be payable in any
30 subsequent action. For purposes of this subsection, payment or
31 the insurer's agreement shall be treated as being made on the
31
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 date a draft or other valid instrument that is equivalent to
2 payment, or the insurer's written statement of agreement, is
3 placed in the United States mail in a properly addressed,
4 postpaid envelope, or if not so posted, on the date of
5 delivery. The insurer is not obligated to pay any attorney's
6 fees if the insurer pays the claim or mails its agreement to
7 pay for future treatment within the time prescribed by this
8 subsection.
9 (e) The applicable statute of limitation for an action
10 under this section shall be tolled for a period of 21 business
11 days by the mailing of the notice required by this subsection.
12 (f) Any insurer making a general business practice of
13 not paying valid claims until receipt of the notice required
14 by this subsection is engaging in an unfair trade practice
15 under the insurance code.
16 (15) DISCLOSURE AND ACKNOWLEDGEMENT FORM.--
17 (a)(e)1. At the initial treatment or service provided,
18 each physician, other licensed professional, clinic, or other
19 medical institution providing medical services upon which a
20 claim for personal injury protection benefits is based shall
21 require an insured person, or his or her guardian, to execute
22 a disclosure and acknowledgment form, which reflects at a
23 minimum that:
24 1.a. The insured, or his or her guardian, must
25 countersign the form attesting to the fact that the services
26 set forth therein were actually rendered;
27 2.b. The insured, or his or her guardian, has both the
28 right and affirmative duty to confirm that the services were
29 actually rendered;
30
31
32
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 3.c. The insured, or his or her guardian, was not
2 solicited by any person to seek any services from the medical
3 provider;
4 4.d. That the physician, other licensed professional,
5 clinic, or other medical institution rendering services for
6 which payment is being claimed explained the services to the
7 insured or his or her guardian; and
8 5.e. If the insured notifies the insurer in writing of
9 a billing error, the insured may be entitled to a certain
10 percentage of a reduction in the amounts paid by the insured's
11 motor vehicle insurer.
12 (b)2. The physician, other licensed professional,
13 clinic, or other medical institution rendering services for
14 which payment is being claimed has the affirmative duty to
15 explain the services rendered to the insured, or his or her
16 guardian, so that the insured, or his or her guardian,
17 countersigns the form with informed consent.
18 (c)3. Countersignature by the insured, or his or her
19 guardian, is not required for the reading of diagnostic tests
20 or other services that are of such a nature that they are not
21 required to be performed in the presence of the insured.
22 (d)4. The licensed medical professional rendering
23 treatment for which payment is being claimed must sign, by his
24 or her own hand, the form complying with this subsection
25 paragraph.
26 (e)5. The original completed disclosure and
27 acknowledgment form shall be furnished to the insurer pursuant
28 to subsection (9) paragraph (4)(b) and may not be
29 electronically furnished.
30 (f)6. This disclosure and acknowledgment form is not
31 required for services billed by a provider for emergency
33
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 services as defined in s. 395.002, for emergency services and
2 care as defined in s. 395.002 rendered in a hospital emergency
3 department, or for transport and treatment rendered by an
4 ambulance provider licensed pursuant to part III of chapter
5 401.
6 (g)7. The Financial Services Commission shall adopt,
7 by rule, a standard disclosure and acknowledgment form that
8 shall be used to fulfill the requirements of this subsection
9 paragraph, effective 90 days after such form is adopted and
10 becomes final. The commission shall adopt a proposed rule by
11 October 1, 2003. Until the rule is final, the provider may use
12 a form of its own which otherwise complies with the
13 requirements of this paragraph.
14 (h)8. As used in this subsection paragraph,
15 "countersigned" means a second or verifying signature, as on a
16 previously signed document, and is not satisfied by the
17 statement "signature on file" or any similar statement.
18 (i)9. The requirements of This subsection applies
19 paragraph apply only with respect to the initial treatment or
20 service of the insured by a provider. For subsequent
21 treatments or service, the provider must maintain a patient
22 log signed by the patient, in chronological order by date of
23 service, that is consistent with the services being rendered
24 to the patient as claimed. The requirements of this paragraph
25 subparagraph for maintaining a patient log signed by the
26 patient may be met by a hospital that maintains medical
27 records as required by s. 395.3025 and applicable rules and
28 makes such records available to the insurer upon request.
29 (f) Upon written notification by any person, an
30 insurer shall investigate any claim of improper billing by a
31 physician or other medical provider. The insurer shall
34
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 determine if the insured was properly billed for only those
2 services and treatments that the insured actually received. If
3 the insurer determines that the insured has been improperly
4 billed, the insurer shall notify the insured, the person
5 making the written notification and the provider of its
6 findings and shall reduce the amount of payment to the
7 provider by the amount determined to be improperly billed. If
8 a reduction is made due to such written notification by any
9 person, the insurer shall pay to the person 20 percent of the
10 amount of the reduction, up to $500. If the provider is
11 arrested due to the improper billing, then the insurer shall
12 pay to the person 40 percent of the amount of the reduction,
13 up to $500.
14 (g) An insurer may not systematically downcode with
15 the intent to deny reimbursement otherwise due. Such action
16 constitutes a material misrepresentation under s.
17 626.9541(1)(i)2.
18 (6) DISCOVERY OF FACTS ABOUT AN INJURED PERSON;
19 DISPUTES.--
20 (a) Every employer shall, if a request is made by an
21 insurer providing personal injury protection benefits under
22 ss. 627.730-627.7405 against whom a claim has been made,
23 furnish forthwith, in a form approved by the office, a sworn
24 statement of the earnings, since the time of the bodily injury
25 and for a reasonable period before the injury, of the person
26 upon whose injury the claim is based.
27 (16) DISCOVERY OF FACTS ABOUT AN INJURED PERSON;
28 DISPUTES.--
29 (a)(b) Every physician, hospital, clinic, or other
30 medical institution providing, before or after bodily injury
31 upon which a claim for personal injury protection insurance
35
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 benefits is based, any products, services, or accommodations
2 in relation to that or any other injury, or in relation to a
3 condition claimed to be connected with that or any other
4 injury, shall, if requested to do so by the insurer against
5 whom the claim has been made:,
6 1. Furnish forthwith a written report of the history,
7 condition, treatment, dates, and costs of such treatment of
8 the injured person and why the items identified by the insurer
9 were reasonable in amount and medically necessary.,
10 2. Provide together with a sworn statement that the
11 treatment or services rendered were reasonable and necessary
12 with respect to the bodily injury sustained. Such sworn
13 statement shall read as follows: "Under penalty of perjury, I
14 declare that I have read the foregoing, and the facts alleged
15 are true, to the best of my knowledge and belief."
16 3. Identify and identifying which portion of the
17 expenses for such treatment or services was incurred as a
18 result of such bodily injury.,
19 4. and Produce forthwith, and permit the inspection
20 and copying of, his or her or its records regarding such
21 history, condition, treatment, dates, and costs of treatment;
22 provided that this shall not limit the introduction of
23 evidence at trial. Such sworn statement shall read as follows:
24 "Under penalty of perjury, I declare that I have read the
25 foregoing, and the facts alleged are true, to the best of my
26 knowledge and belief."
27 (b) However, if the records are maintained at an
28 alternative location, the requested records shall be made
29 available at the principal place of business within 5 working
30 days after the request. Records not produced at the time of
31 the request shall be deemed to be nonexistent. At the time of
36
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 the records inspection, the health care provider shall allow
2 the insurer to inspect records and photograph the equipment
3 and associated documents associated with the insured's
4 treatment, services, or supplies.
5 (c) The insured, the assignee of the insured, the
6 health care provider, the providers' billing and medical
7 records custodians, or any other person seeking payment under
8 an automobile policy directly or as an assignee must submit to
9 examination under oath by any person named by the insurer when
10 and as often as the insurer may reasonably require. If an
11 examination under oath is requested of a health care provider
12 licensed under chapter 457, chapter 458, chapter 459, chapter
13 460, chapter 461, chapter 462, chapter 463, chapter 466,
14 chapter 467, chapter 484, chapter 486, chapter 490, or chapter
15 491, part I, part III, part X, part XIII, or part XIV of
16 chapter 468, or s. 464.012, the insurer shall pay the person
17 $175 per hour for attendance at the examination under oath.
18 Time spent in preparation for the examination under oath is
19 noncompensable. Once requested, the examination under oath is
20 a condition precedent to filing suit.
21 (d) A No cause of action for violation of the
22 physician-patient privilege or invasion of the right of
23 privacy is not shall be permitted against any physician,
24 hospital, clinic, or other medical institution complying with
25 the provisions of this section.
26 (e) The person requesting such records and such sworn
27 statement shall pay all reasonable costs connected therewith.
28 (f) If an insurer makes a written request for
29 documentation or information under this paragraph within 30
30 days after having received notice of the amount of a covered
31 loss under subsection (7) paragraph (4)(a), the amount or the
37
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 partial amount that which is the subject of the insurer's
2 inquiry shall become overdue if the insurer does not pay in
3 accordance with subsection (9) paragraph (4)(b) or within 15
4 10 days after the insurer's receipt of the requested
5 documentation or information, whichever occurs later. For
6 purposes of this paragraph, the term "receipt" includes, but
7 is not limited to, inspection and copying pursuant to this
8 subsection paragraph.
9 (g) Any insurer that requests documentation or
10 information pertaining to reasonableness of charges or medical
11 necessity under this subsection paragraph without a reasonable
12 basis for such requests as a general business practice is
13 engaging in an unfair trade practice under the insurance code.
14 (h)(c) In the event of any dispute regarding an
15 insurer's right to discovery of facts under this section, the
16 insurer may petition a court of competent jurisdiction to
17 enter an order permitting such discovery. The order may be
18 made only on motion for good cause shown and upon notice to
19 all persons having an interest, and it shall specify the time,
20 place, manner, conditions, and scope of the discovery. Such
21 court may, in order to protect against annoyance,
22 embarrassment, or oppression, as justice requires, enter an
23 order refusing discovery or specifying conditions of discovery
24 and may order payments of costs and expenses of the
25 proceeding, including reasonable fees for the appearance of
26 attorneys at the proceedings, as justice requires.
27 (i)(d) The injured person shall be furnished, upon
28 request, a copy of all information obtained by the insurer
29 under the provisions of this section, and shall pay a
30 reasonable charge, if required by the insurer.
31
38
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 (j)(e) Notice to an insurer of the existence of a
2 claim shall not be unreasonably withheld by an insured. In no
3 event may this notice be later than 1 year after the
4 occurrence. The insurer may contract for such notice to be
5 less than 1 year.
6 (17) INDEPENDENT MEDICAL EXAMINATIONS (7) MENTAL AND
7 PHYSICAL EXAMINATION OF INJURED PERSON; REPORTS.--
8 (a) Whenever the mental or physical condition of an
9 injured person covered by personal injury protection is
10 material to any claim that has been or may be made for past or
11 future personal injury protection insurance benefits, such
12 person shall, upon the request of an insurer, submit to mental
13 or physical examination by a physician or physicians.
14 (b) The costs of any examinations requested by an
15 insurer shall be borne entirely by the insurer, except that,
16 if the insured has unreasonably failed to appear for the
17 examinations, the cost for nonappearance, if any, shall be
18 paid from the insured's benefits.
19 (c) Such examination shall be conducted within the
20 municipality where the insured is receiving treatment, or in a
21 location reasonably accessible to the insured, which, for
22 purposes of this paragraph, means any location within the
23 municipality in which the insured resides, or any location
24 within 10 miles by road of the insured's residence, provided
25 such location is within the county in which the insured
26 resides.
27 (d) If the examination is to be conducted in a
28 location reasonably accessible to the insured, and if there is
29 no qualified physician to conduct the examination in a
30 location reasonably accessible to the insured, then such
31 examination shall be conducted in an area of the closest
39
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 proximity to the insured's residence. The insurer shall pay
2 lost wages for time missed from work as a result of attending
3 any such examination.
4 (e) Personal protection Insurers are authorized to
5 include reasonable provisions in personal injury protection
6 insurance policies for mental and physical examination of
7 those claiming personal injury protection insurance benefits.
8 (f) An insurer may not withdraw payment of a treating
9 physician without the consent of the injured person covered by
10 the personal injury protection, unless the insurer first
11 obtains a valid report by a Florida physician licensed under
12 the same chapter as the treating physician whose treatment
13 authorization is sought to be withdrawn, stating that
14 treatment was not reasonable, related, or necessary.
15 (g) A valid report is one that is prepared and signed
16 by the physician examining the injured person or reviewing the
17 treatment records of the injured person and is factually
18 supported by the examination, and treatment records, or other
19 relevant information if reviewed and that has not been
20 modified by anyone other than the physician.
21 (h) The physician preparing the report must be in
22 active practice, unless the physician is physically disabled.
23 Active practice means that during the 3 years immediately
24 preceding the date of the physical examination or review of
25 the treatment records the physician must have devoted
26 professional time to the active clinical practice of
27 evaluation, diagnosis, or treatment of medical conditions or
28 to the instruction of students in an accredited health
29 professional school or accredited residency program or a
30 clinical research program that is affiliated with an
31
40
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 accredited health professional school or teaching hospital or
2 accredited residency program.
3 (i) The physician preparing a report at the request of
4 an insurer and physicians rendering expert opinions on behalf
5 of persons claiming medical benefits for personal injury
6 protection, or on behalf of an insured through an attorney or
7 another entity, shall maintain, for at least 3 years, copies
8 of all examination reports as medical records and shall
9 maintain, for at least 3 years, records of all payments for
10 the examinations and reports.
11 (j) Neither an insurer nor any person acting at the
12 direction of or on behalf of an insurer may materially change
13 an opinion in a report prepared under this subsection
14 paragraph or direct the physician preparing the report to
15 change such opinion. The denial of a payment as the result of
16 such a changed opinion constitutes a material
17 misrepresentation under s. 626.9541(1)(i)2.; however, this
18 provision does not preclude the insurer from calling to the
19 attention of the physician errors of fact in the report based
20 upon information in the claim file or on new information that
21 will become part of the claim file.
22 (k)(b) If requested by the person examined, a party
23 causing an examination to be made shall deliver to him or her
24 a copy of every written report concerning the examination
25 rendered by an examining physician, at least one of which
26 reports must set out the examining physician's findings and
27 conclusions in detail. After such request and delivery, the
28 party causing the examination to be made is entitled, upon
29 request, to receive from the person examined every written
30 report available to him or her or his or her representative
31 concerning any examination, previously or thereafter made, of
41
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 the same mental or physical condition. By requesting and
2 obtaining a report of the examination so ordered, or by taking
3 the deposition of the examiner, the person examined waives any
4 privilege he or she may have, in relation to the claim for
5 benefits, regarding the testimony of every other person who
6 has examined, or may thereafter examine, him or her in respect
7 to the same mental or physical condition. If a person
8 unreasonably fails to attend a confirmed, scheduled
9 examination or unreasonably refuses to submit to an
10 examination, the personal injury protection carrier is no
11 longer liable for subsequent personal injury protection
12 benefits.
13 (l) During the examination, neither the insurer, the
14 insured, nor the assignee of the insured may have counsel, a
15 court reporter, or a videographer present.
16 (8) APPLICABILITY OF PROVISION REGULATING ATTORNEY'S
17 FEES.--With respect to any dispute under the provisions of ss.
18 627.730-627.7405 between the insured and the insurer, or
19 between an assignee of an insured's rights and the insurer,
20 the provisions of s. 627.428 shall apply, except as provided
21 in subsection (11).
22 (18)(9) CANCELLATION OR NONRENEWAL.--
23 (a) Each insurer that which has issued a policy
24 providing personal injury protection benefits shall report the
25 renewal, cancellation, or nonrenewal thereof to the Department
26 of Highway Safety and Motor Vehicles within 45 days from the
27 effective date of the renewal, cancellation, or nonrenewal.
28 (b) Upon the issuance of a policy providing personal
29 injury protection benefits to a named insured not previously
30 insured by the insurer thereof during that calendar year, the
31 insurer shall report the issuance of the new policy to the
42
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 Department of Highway Safety and Motor Vehicles within 30
2 days. The report shall be in such form and format and contain
3 such information as is may be required by the Department of
4 Highway Safety and Motor Vehicles which shall include a format
5 compatible with the data processing capabilities of such said
6 department, and the Department of Highway Safety and Motor
7 Vehicles is authorized to adopt rules necessary with respect
8 thereto. Failure by an insurer to file proper reports with the
9 Department of Highway Safety and Motor Vehicles as required by
10 this subsection or rules adopted with respect to the
11 requirements of this subsection constitutes a violation of the
12 Florida Insurance Code.
13 (c) Reports of cancellations and policy renewals and
14 reports of the issuance of new policies received by the
15 Department of Highway Safety and Motor Vehicles are
16 confidential and exempt from the provisions of s. 119.07(1).
17 (d) These records are to be used for enforcement and
18 regulatory purposes only, including the generation by the
19 department of data regarding compliance by owners of motor
20 vehicles with financial responsibility coverage requirements.
21 In addition, the Department of Highway Safety and Motor
22 Vehicles shall release, upon a written request by a person
23 involved in a motor vehicle accident, by the person's
24 attorney, or by a representative of the person's motor vehicle
25 insurer, the name of the insurance company and the policy
26 number for the policy covering the vehicle named by the
27 requesting party. The written request must include a copy of
28 the appropriate accident form as provided in s. 316.065, s.
29 316.066, or s. 316.068.
30 (e)(b) Every insurer with respect to each insurance
31 policy providing personal injury protection benefits shall
43
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 notify the named insured or in the case of a commercial fleet
2 policy, the first named insured in writing that any
3 cancellation or nonrenewal of the policy will be reported by
4 the insurer to the Department of Highway Safety and Motor
5 Vehicles. The notice shall also inform the named insured that
6 failure to maintain personal injury protection and property
7 damage liability insurance on a motor vehicle when required by
8 law may result in the loss of registration and driving
9 privileges in this state, and the notice shall inform the
10 named insured of the amount of the reinstatement fees required
11 by s. 627.733(7). This notice is for informational purposes
12 only, and no civil liability shall attach to an insurer due to
13 failure to provide this notice.
14 (19) ATTORNEY'S FEES.--With respect to any dispute
15 under ss. 627.730-627.7405 between the insured and the
16 insurer, or between an assignee of an insured's rights and the
17 insurer, s. 627.428 shall apply, except as provided in
18 subsection (14). A contingency risk multiplier shall not be
19 applied to any attorney's fee award in any dispute under ss.
20 627.730-627.7405.
21 (20)(10) PREFERRED PROVIDERS.--An insurer may
22 negotiate and enter into contracts with licensed health care
23 providers for the benefits described in this section, referred
24 to in this section as "preferred providers," which shall
25 include health care providers licensed under chapters 458,
26 459, 460, 461, and 463. The insurer may provide an option to
27 an insured to use a preferred provider at the time of purchase
28 of the policy for personal injury protection benefits, if the
29 requirements of this subsection are met. If the insured
30 elects to use a provider who is not a preferred provider,
31 whether the insured purchased a preferred provider policy or a
44
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 nonpreferred provider policy, the medical benefits provided by
2 the insurer shall be as required by this section. If the
3 insured elects to use a provider who is a preferred provider,
4 the insurer may pay medical benefits in excess of the benefits
5 required by this section and may waive or lower the amount of
6 any deductible that applies to such medical benefits. If the
7 insurer offers a preferred provider policy to a policyholder
8 or applicant, it must also offer a nonpreferred provider
9 policy. The insurer shall provide each policyholder with a
10 current roster of preferred providers in the county in which
11 the insured resides at the time of purchase of such policy,
12 and shall make such list available for public inspection
13 during regular business hours at the principal office of the
14 insurer within the state.
15 (11) DEMAND LETTER.--
16 (a) As a condition precedent to filing any action for
17 benefits under this section, the insurer must be provided with
18 written notice of an intent to initiate litigation. Such
19 notice may not be sent until the claim is overdue, including
20 any additional time the insurer has to pay the claim pursuant
21 to paragraph (4)(b).
22 (b) The notice required shall state that it is a
23 "demand letter under s. 627.736(11)" and shall state with
24 specificity:
25 1. The name of the insured upon which such benefits
26 are being sought, including a copy of the assignment giving
27 rights to the claimant if the claimant is not the insured.
28 2. The claim number or policy number upon which such
29 claim was originally submitted to the insurer.
30 3. To the extent applicable, the name of any medical
31 provider who rendered to an insured the treatment, services,
45
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 accommodations, or supplies that form the basis of such claim;
2 and an itemized statement specifying each exact amount, the
3 date of treatment, service, or accommodation, and the type of
4 benefit claimed to be due. A completed form satisfying the
5 requirements of paragraph (5)(d) or the lost-wage statement
6 previously submitted may be used as the itemized statement. To
7 the extent that the demand involves an insurer's withdrawal of
8 payment under paragraph (7)(a) for future treatment not yet
9 rendered, the claimant shall attach a copy of the insurer's
10 notice withdrawing such payment and an itemized statement of
11 the type, frequency, and duration of future treatment claimed
12 to be reasonable and medically necessary.
13 (c) Each notice required by this subsection must be
14 delivered to the insurer by United States certified or
15 registered mail, return receipt requested. Such postal costs
16 shall be reimbursed by the insurer if so requested by the
17 claimant in the notice, when the insurer pays the claim. Such
18 notice must be sent to the person and address specified by the
19 insurer for the purposes of receiving notices under this
20 subsection. Each licensed insurer, whether domestic, foreign,
21 or alien, shall file with the office designation of the name
22 and address of the person to whom notices pursuant to this
23 subsection shall be sent which the office shall make available
24 on its Internet website. The name and address on file with the
25 office pursuant to s. 624.422 shall be deemed the authorized
26 representative to accept notice pursuant to this subsection in
27 the event no other designation has been made.
28 (d) If, within 15 days after receipt of notice by the
29 insurer, the overdue claim specified in the notice is paid by
30 the insurer together with applicable interest and a penalty of
31 10 percent of the overdue amount paid by the insurer, subject
46
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 to a maximum penalty of $250, no action may be brought against
2 the insurer. If the demand involves an insurer's withdrawal of
3 payment under paragraph (7)(a) for future treatment not yet
4 rendered, no action may be brought against the insurer if,
5 within 15 days after its receipt of the notice, the insurer
6 mails to the person filing the notice a written statement of
7 the insurer's agreement to pay for such treatment in
8 accordance with the notice and to pay a penalty of 10 percent,
9 subject to a maximum penalty of $250, when it pays for such
10 future treatment in accordance with the requirements of this
11 section. To the extent the insurer determines not to pay any
12 amount demanded, the penalty shall not be payable in any
13 subsequent action. For purposes of this subsection, payment or
14 the insurer's agreement shall be treated as being made on the
15 date a draft or other valid instrument that is equivalent to
16 payment, or the insurer's written statement of agreement, is
17 placed in the United States mail in a properly addressed,
18 postpaid envelope, or if not so posted, on the date of
19 delivery. The insurer shall not be obligated to pay any
20 attorney's fees if the insurer pays the claim or mails its
21 agreement to pay for future treatment within the time
22 prescribed by this subsection.
23 (e) The applicable statute of limitation for an action
24 under this section shall be tolled for a period of 15 business
25 days by the mailing of the notice required by this subsection.
26 (f) Any insurer making a general business practice of
27 not paying valid claims until receipt of the notice required
28 by this subsection is engaging in an unfair trade practice
29 under the insurance code.
30 (12) CIVIL ACTION FOR INSURANCE FRAUD.--An insurer
31 shall have a cause of action against any person convicted of,
47
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 or who, regardless of adjudication of guilt, pleads guilty or
2 nolo contendere to insurance fraud under s. 817.234, patient
3 brokering under s. 817.505, or kickbacks under s. 456.054,
4 associated with a claim for personal injury protection
5 benefits in accordance with this section. An insurer
6 prevailing in an action brought under this subsection may
7 recover compensatory, consequential, and punitive damages
8 subject to the requirements and limitations of part II of
9 chapter 768, and attorney's fees and costs incurred in
10 litigating a cause of action against any person convicted of,
11 or who, regardless of adjudication of guilt, pleads guilty or
12 nolo contendere to insurance fraud under s. 817.234, patient
13 brokering under s. 817.505, or kickbacks under s. 456.054,
14 associated with a claim for personal injury protection
15 benefits in accordance with this section.
16 (21)(13) MINIMUM BENEFIT COVERAGE.--If the Financial
17 Services Commission determines that the cost savings under
18 personal injury protection insurance benefits paid by insurers
19 have been realized due to the provisions of this act, prior
20 legislative reforms, or other factors, the commission may
21 increase the minimum $10,000 benefit coverage requirement. In
22 establishing the amount of such increase, the commission must
23 determine that the additional premium for such coverage is
24 approximately equal to the premium cost savings that have been
25 realized for the personal injury protection coverage with
26 limits of $10,000.
27 (22) CIVIL MONETARY REMEDIES.--
28 (a) An insurer has a civil cause of action to recover
29 all amounts paid and all expenses incurred against a person
30 who knowingly presents or causes to be presented to an insurer
31
48
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 a claim for personal injury protection benefits that a court
2 determines:
3 1. Is for health care services, equipment, or supplies
4 that the person knew or should have known were not provided as
5 claimed;
6 2. Is a claim for health care services, equipment, or
7 supplies which the person knew or should have known was false
8 or fraudulent;
9 3. Is for health care services, or incident to the
10 provision of such services, and the person knew or should have
11 known that the individual furnishing or supervising the
12 furnishing of health care services:
13 a. Was not licensed as a health care provider;
14 b. Was licensed as a health care provider, but such
15 license was obtained through a misrepresentation of material
16 fact; or
17 c. Represented to the insured or legal guardian at the
18 time the health care services were furnished that the
19 individual was licensed or certified in a medical specialty by
20 a medical specialty board when the individual was not so
21 licensed or certified;
22 4. Is for health care services, equipment, or supplies
23 and the claim demonstrates a pattern or practice by the person
24 of presenting or causing to be presented claims that the
25 person knew or should have known are not medically necessary;
26 5. Is for health care services, equipment, or supplies
27 and the claim was based on codes that the person knew or
28 should have known would result in greater payment to that
29 person than the codes the person knew or should have known are
30 applicable to the service, equipment, or supplies actually
31 provided;
49
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 6. Is based on the payment or offer of payment to an
2 individual and the person knew or should have known such
3 payment or offer may have caused the individual to order or
4 receive health care services, equipment, or supplies from a
5 health care provider, in whole or in part, under a policy of
6 insurance;
7 7. Constitutes a violation of chapter 812 or chapter
8 817; or
9 8. Is for health care services, equipment, or supplies
10 where the person has intentionally misrepresented a material
11 fact whether before or after the insured loss. Such
12 intentional misrepresentation shall void all coverage arising
13 from the claim related to such misrepresentation under the
14 personal injury protection coverage of the person who
15 committed the misrepresentation, irrespective of whether a
16 portion of the person's claim may be properly payable. Any
17 benefits paid prior to the discovery of the misrepresentation
18 are recoverable by the insurer in their entirety from the
19 person who committed the misrepresentation.
20 (b) An insurer has a civil cause of action to recover
21 all amounts paid and all expenses incurred against a person
22 who knowingly presents or causes to be presented to an insurer
23 a claim that is based on an application for motor vehicle
24 insurance or is based on an application for personal injury
25 protection benefits that contains false or fraudulent
26 information that the person knew or should have known could
27 reasonably be expected to influence the decision of an insurer
28 to issue a policy of insurance or extend coverage under a
29 policy of insurance.
30 (c) An insurer has a civil cause of action to recover
31 all amounts paid and all expenses incurred against a person
50
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 who knowingly presents or causes to be presented to an insurer
2 a claim when the person received payment under such claim and
3 knew or should have known the payment constituted an
4 overpayment and the overpayment had been received and retained
5 for more than 90 days after the date of receipt of such
6 overpayment.
7 (d) Whenever an insurer has a good faith basis to
8 believe that a violation of this subsection has occurred, the
9 insurer may file suit to recover all amounts previously paid.
10 The prevailing party in any action brought under this
11 subsection may recover compensatory, consequential, and
12 punitive damages subject to the requirements and limitations
13 of part II of chapter 768 and attorney's fees and costs
14 incurred.
15 (e) The term "person" has the same meaning as in s.
16 1.01.
17 (f) An insurer may receive direct payment on any
18 judgment, including interest, costs, and attorney's fees
19 thereon, by crediting the provider any amount due from any
20 future claim. The credited amount shall be treated as payment
21 toward the final judgment. Any amount credited towards a final
22 judgment is not a confession of judgment in any litigation and
23 is not recoverable from the respective insured.
24 (g) A principal is liable for damages under this
25 section for the actions of the principal's agent acting within
26 the scope of the agency.
27 (23) REWARD.--Upon written notification by any person,
28 an insurer shall investigate any claim of improper billing by
29 a physician or other medical provider. The insurer shall
30 determine if the insured was properly billed for only those
31 services and treatments that the insured actually received. If
51
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2006 (PROPOSED COMMITTEE BILL) SPB 7094
597-1265D-06
1 the insurer determines that the insured has been improperly
2 billed, the insurer shall notify the insured, the person
3 making the written notification and the provider of its
4 findings and shall reduce the amount of payment to the
5 provider by the amount determined to be improperly billed. If
6 a reduction is made due to such written notification by any
7 person, the insurer shall pay to the person 20 percent of the
8 amount of the reduction. If the provider is arrested due to
9 the improper billing, the insurer shall pay to the person 40
10 percent of the amount of the reduction.
11 (24) VENUE.--Venue for any personal injury protection
12 claim shall be in the jurisdiction where the insured resides,
13 where the accident occurs, or, in the case of an assignment of
14 benefits, where the disputed health care services were
15 performed. Venue may be raised at any time. The cost of
16 transferring venue shall be borne by the plaintiff, and such
17 costs shall not be recoverable as plaintiff's damages.
18 (25) NONPREEMPTION.--This section shall not be deemed
19 to preempt or supersede any cause of action that may otherwise
20 be available.
21 Section 3. Section 19 of chapter 2003-411, Laws of
22 Florida, is repealed.
23 Section 4. This act shall take effect October 1, 2006.
24
25 *****************************************
26 SENATE SUMMARY
27 Substantially revises and reorganizes s. 627.736, F.S.,
relating to personal injury protection benefits to
28 improve comprehension. Additionally, makes substantive
changes, including provisions relating to notification of
29 insurers, priority of claims, assignment of benefits,
time periods for various actions, and recovery of
30 payments. Abrogates the repeal of the Florida Motor
Vehicle No-Fault Law. (See bill for details.)
31
52
CODING: Words stricken are deletions; words underlined are additions.