Proposed Committee Substitute by the Committee on Banking and

Insurance

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A bill to be entitled

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An act relating to motor vehicle insurance; amending s.

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627.736, F.S.; revising the schedule of maximum charges on

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which an insurer may base a limited reimbursement for

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certain medical services, supplies, and care for injured

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persons covered by personal injury protection; specifying

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a minimum amount for the applicable fee schedule or

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payment limitation under Medicare for such reimbursements;

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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.  Paragraph (a) of subsection (5) of section

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627.736, Florida Statutes, is amended to read:

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     627.736  Required personal injury protection benefits;

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exclusions; priority; claims.--

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     (5)  CHARGES FOR TREATMENT OF INJURED PERSONS.--

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     (a)1.  Any physician, hospital, clinic, or other person or

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institution lawfully rendering treatment to an injured person for

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a bodily injury covered by personal injury protection insurance

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may charge the insurer and injured party only a reasonable amount

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pursuant to this section for the services and supplies rendered,

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and the insurer providing such coverage may pay for such charges

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directly to such person or institution lawfully rendering such

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treatment, if the insured receiving such treatment or his or her

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guardian has countersigned the properly completed invoice, bill,

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or claim form approved by the office upon which such charges are

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to be paid for as having actually been rendered, to the best

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knowledge of the insured or his or her guardian. In no event,

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however, may such a charge be in excess of the amount the person

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or institution customarily charges for like services or supplies.

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With respect to a determination of whether a charge for a

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particular service, treatment, or otherwise is reasonable,

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consideration may be given to evidence of usual and customary

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charges and payments accepted by the provider involved in the

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dispute, and reimbursement levels in the community and various

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federal and state medical fee schedules applicable to automobile

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and other insurance coverages, and other information relevant to

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the reasonableness of the reimbursement for the service,

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treatment, or supply.

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     2.  The insurer may limit reimbursement to 80 percent of the

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following schedule of maximum charges:

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     a.  For emergency transport and treatment by providers

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licensed under chapter 401, 200 percent of Medicare.

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     b.  For emergency services and care provided by a hospital

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licensed under chapter 395, 75 percent of the hospital's usual

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and customary charges.

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     c.  For emergency services and care as defined by s.

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395.002(10) provided in a facility licensed under chapter 395

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rendered by a physician or dentist, and related hospital

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inpatient services rendered by a physician or dentist, the usual

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and customary charges in the community.

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     d.  For hospital inpatient services, other than emergency

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services and care, 200 percent of the Medicare Part A prospective

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payment applicable to the specific hospital providing the

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inpatient services.

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     e.  For hospital outpatient services, other than emergency

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services and care, 200 percent of the Medicare Part A Ambulatory

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Payment Classification for the specific hospital providing the

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outpatient services.

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     f.  For all other medical services, supplies, and care, 200

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percent of the applicable Medicare Part B fee schedule for

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participating physicians. However, if such services, supplies, or

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care is not reimbursable under Medicare Part B, the insurer may

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limit reimbursement to 80 percent of the maximum reimbursable

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allowance under workers' compensation, as determined under s.

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440.13 and rules adopted thereunder which are in effect at the

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time such services, supplies, or care is provided. Services,

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supplies, or care that is not reimbursable under Medicare or

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workers' compensation is not required to be reimbursed by the

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insurer.

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     3.  For purposes of subparagraph 2., the applicable fee

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schedule or payment limitation under Medicare is the fee schedule

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or payment limitation in effect at the time the services,

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supplies, or care was rendered and for the area in which such

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services were rendered, except that it may not be less than the

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applicable 2007 Medicare Part B fee schedule for participating

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physicians for medical services, supplies, and care subject to

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Medicare Part B.

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     4.  Subparagraph 2. does not allow the insurer to apply any

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limitation on the number of treatments or other utilization

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limits that apply under Medicare or workers' compensation. An

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insurer that applies the allowable payment limitations of

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subparagraph 2. must reimburse a provider who lawfully provided

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care or treatment under the scope of his or her license,

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regardless of whether such provider would be entitled to

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reimbursement under Medicare due to restrictions or limitations

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on the types or discipline of health care providers who may be

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reimbursed for particular procedures or procedure codes.

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     5.  If an insurer limits payment as authorized by

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subparagraph 2., the person providing such services, supplies, or

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care may not bill or attempt to collect from the insured any

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amount in excess of such limits, except for amounts that are not

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covered by the insured's personal injury protection coverage due

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to the coinsurance amount or maximum policy limits.

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     Section 2.  This act shall take effect upon becoming a law.