Florida Senate - 2008 (Reformatted) SB 1012
By Senator Gaetz
4-02808-08 20081012__
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A bill to be entitled
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An act relating to health insurance claims payments;
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insurance contracts and health maintenance contracts from
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prohibiting or restricting insureds from assigning plan
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benefits to certain noncontract providers for certain
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covered services; requiring payment by an insurer of plan
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benefits under assignment and acceptance by noncontract
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providers; requiring noncontract providers accepting such
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assignments to accept any payments from plan benefit
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insurers and prohibiting such providers from collecting
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any balances from insureds; amending s. 627.6471, F.S.;
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prohibiting insurers and plan administrators from
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reimbursing preferred providers at alternative or reduced
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rates for covered services under certain circumstances;
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providing exceptions; prohibiting preferred provider
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contract parties from selling, leasing, or transferring
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contract payment or reimbursement terms information under
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certain circumstances; amending s. 641.315, F.S.;
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prohibiting health maintenance organizations from selling,
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leasing, or transferring contract payment or reimbursement
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terms information under certain circumstances; amending s.
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641.3155, F.S.; decreasing the period of time authorized
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for overpayment claims of health maintenance organizations
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against providers; providing an effective date.
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Be It Enacted by the Legislature of the State of Florida:
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Section 1. Subsection (18) is added to section 627.6131,
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Florida Statutes, to read:
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627.6131 Payment of claims.--
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(18)(a) A contract with a health insurer may not prohibit
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or restrict an insured from assigning plan benefits to providers
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not under contract with the insurer for covered health care
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services rendered by the provider to the insured.
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(b) Any assignment by an insured of plan benefits which
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designates that the assignment has been accepted by a provider
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not under contract with the health insurer must be paid to the
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provider pursuant to this section.
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(c) Except for providers who are providing services
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assignment pursuant to this subsection agrees, by submitting the
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claim to the health insurer, to accept the amount paid by the
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health insurer as payment in full for the health care services
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provided and to not collect any balance from the insured.
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Section 2. Subsection (7) is added to section 627.6471,
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Florida Statutes, to read:
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627.6471 Contracts for reduced rates of payment;
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limitations; coinsurance and deductibles.--
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(7)(a) An insurer or an administrator may not reimburse a
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preferred provider at an alternative or a reduced rate of payment
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for covered services that are provided to an insured unless:
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1. The insurer or administrator has contracted with the
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preferred provider and has agreed to provide coverage for those
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health care services under the health insurance policy.
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2. The preferred provider has agreed to the contract and to
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provide health care services under the terms of the contract.
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(b) A party to a preferred provider contract may not sell,
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lease, or otherwise transfer information regarding the payment or
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reimbursement terms of the contract without the express authority
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of and prior adequate notification to the other contracting
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parties.
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Section 3. Subsection (41) is added to section 641.31,
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Florida Statutes, to read:
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641.31 Health maintenance contracts.--
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(41)(a) A health maintenance organization contract may not
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prohibit or restrict a subscriber from assigning plan benefits to
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providers not under contract with the organization for covered
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health care services rendered by the provider to the subscriber.
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(b) Any assignment by a subscriber of plan benefits which
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designates that the assignment has been accepted by a provider
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not under contract with the organization must be paid to the
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provider pursuant to s. 641.3155.
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(c) Except for providers providing service pursuant to s.
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641.513, any provider who accepts an assignment pursuant to this
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subsection agrees, by submitting the claim to the health
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maintenance organization, to accept the amount paid by the health
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maintenance organization as payment in full for the health care
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services provided and to not collect any balance from the
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subscriber.
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Section 4. Subsection (11) is added to section 641.315,
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Florida Statutes, to read:
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641.315 Provider contracts.--
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(11) A health maintenance organization may not sell, lease,
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or otherwise transfer information regarding the payment of
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reimbursement terms of a contract with a health care practitioner
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without the express authority of and prior adequate notification
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to the contracting parties.
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Section 5. Subsection (5) of section 641.3155, Florida
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Statutes, is amended to read:
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641.3155 Prompt payment of claims.--
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(5) If a health maintenance organization determines that it
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has made an overpayment to a provider for services rendered to a
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subscriber, the health maintenance organization must make a claim
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for such overpayment to the provider's designated location. A
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health maintenance organization that makes a claim for
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overpayment to a provider under this section shall give the
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provider a written or electronic statement specifying the basis
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for the retroactive denial or payment adjustment. The health
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maintenance organization must identify the claim or claims, or
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overpayment claim portion thereof, for which a claim for
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overpayment is submitted.
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(a) If an overpayment determination is the result of
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retroactive review or audit of coverage decisions or payment
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levels not related to fraud, a health maintenance organization
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shall adhere to the following procedures:
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1. All claims for overpayment must be submitted to a
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provider within 6 30 months after the health maintenance
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organization's payment of the claim. A provider must pay, deny,
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or contest the health maintenance organization's claim for
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overpayment within 40 days after the receipt of the claim. All
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contested claims for overpayment must be paid or denied within
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120 days after receipt of the claim. Failure to pay or deny
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overpayment and claim within 140 days after receipt creates an
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uncontestable obligation to pay the claim.
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2. A provider that denies or contests a health maintenance
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organization's claim for overpayment or any portion of a claim
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shall notify the organization, in writing, within 35 days after
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the provider receives the claim that the claim for overpayment is
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contested or denied. The notice that the claim for overpayment is
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denied or contested must identify the contested portion of the
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claim and the specific reason for contesting or denying the claim
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and, if contested, must include a request for additional
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information. If the organization submits additional information,
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the organization must, within 35 days after receipt of the
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request, mail or electronically transfer the information to the
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provider. The provider shall pay or deny the claim for
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overpayment within 45 days after receipt of the information. The
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notice is considered made on the date the notice is mailed or
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electronically transferred by the provider.
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3. The health maintenance organization may not reduce
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payment to the provider for other services unless the provider
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agrees to the reduction in writing or fails to respond to the
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health maintenance organization's overpayment claim as required
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by this paragraph.
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4. Payment of an overpayment claim is considered made on
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the date the payment was mailed or electronically transferred. An
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overdue payment of a claim bears simple interest at the rate of
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12 percent per year. Interest on an overdue payment for a claim
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for an overpayment payment begins to accrue when the claim should
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have been paid, denied, or contested.
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(b) A claim for overpayment shall not be permitted beyond 6
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30 months after the health maintenance organization's payment of
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a claim, except that claims for overpayment may be sought beyond
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that time from providers convicted of fraud pursuant to s.
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Section 6. This act shall take effect July 1, 2008.
CODING: Words stricken are deletions; words underlined are additions.