((LATE FILED FOR: 4/21/2008 2:00:00 PM))	Amendment
Bill No. CS/CS/HB 405

Amendment No. 718453

CHAMBER ACTION
Senate		House
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1	Representative Galvano offered the following:
2
3	Amendment (with title amendment)
4	Remove lines 52-155 and insert:
5	Section 2.  Subsections (18) and (19) are added to section
6	627.6131, Florida Statutes, to read:
7	627.6131  Payment of claims.--
8	(18)  Notwithstanding the 30-month period provided in
9	subsection (6), all claims for overpayment submitted to a
10	provider licensed under chapter 458, chapter 459, chapter 460,
11	chapter 461, or chapter 466 must be submitted to the provider
12	within 12 months after the health insurer's payment of the
13	claim. A claim for overpayment shall not be permitted beyond 12
14	months after the health insurer's payment of a claim, except
15	that claims for overpayment may be sought beyond that time from
16	providers convicted of fraud pursuant to s. 817.234.
17	(19)  Notwithstanding any other provision of this section,
18	all claims for underpayment from a provider licensed under
19	chapter 458, chapter 459, chapter 460, chapter 461, or chapter
20	466 must be submitted to the insurer within 12 months after the
21	health insurer's payment of the claim. A claim for underpayment
22	shall not be permitted beyond 12 months after the health
23	insurer's payment of a claim.
24	Section 3.  Section 627.638, Florida Statutes, is amended
25	to read:
26	627.638  Direct payment for hospital, medical services.--
27	(1)  Any health insurance policy insuring against loss or
28	expense due to hospital confinement or to medical and related
29	services may provide for payment of benefits directly to any
30	recognized hospital, licensed ambulance provider, doctor, or
31	other person who provided the services, in accordance with the
32	provisions of the policy. To comply with this section, the words
33	"or to the hospital, licensed ambulance provider, doctor, or
34	person rendering services covered by this policy," or similar
35	words appropriate to the terms of the policy, shall be added to
36	applicable provisions of the policy.
37	(2)  Whenever, in any health insurance claim form, an
38	insured specifically authorizes payment of benefits directly to
39	any recognized hospital, licensed ambulance provider, physician,
40	or dentist, the insurer shall make such payment to the
41	designated provider of such services, unless otherwise provided
42	in the insurance contract. The insurance contract may not
43	prohibit, and claims forms must provide an option for, the
44	payment of benefits directly to a licensed hospital, licensed
45	ambulance provider, physician, or dentist for care provided
46	pursuant to s. 395.1041 or part III of chapter 401. The insurer
47	may require written attestation of assignment of benefits.
48	Payment to the provider from the insurer may not be more than
49	the amount that the insurer would otherwise have paid without
50	the assignment.
51	(3)  Any insurer that has contracted with a preferred
52	provider as defined in s. 627.6471(1)(b) for the delivery of
53	health care services to its insureds shall make payments
54	directly to the preferred provider for such services.
55	Section 4.  Section 627.64731, Florida Statutes, is created
56	to read:
57	627.64731  Leasing, renting, or granting access to a
58	participating provider.--
59	(1)  As used in this section:
60	(a)  "Contracting entity" means any person or entity that
61	is engaged in the act of contracting with participating
62	providers and has a direct contract with a participating
63	provider for the delivery of health care services or the selling
64	or assigning of physicians or physician panels to other health
65	care entities.
66	(b)  "Participating provider" means a physician licensed
67	under chapter 458, chapter 459, chapter 460, chapter 461, or
68	chapter 466 or a physician group practice that has a health care
69	contract with a contracting entity and is entitled to
70	reimbursement for health care services rendered to an enrollee
71	under the health care contract and includes both preferred
72	providers as defined in s. 627.6471 and exclusive providers as
73	defined in s. 627.6472.
74	(2)  A contracting entity may not sell, lease, rent, or
75	otherwise grant access to the health care services of a
76	participating provider under a health care contract unless
77	expressly authorized by the health care contract. At the time a
78	health care contract is entered into with a participating
79	provider, the contracting entity shall, to the extent possible,
80	identify any third party to which the contracting entity has
81	granted access to the health care services of the participating
82	provider.
83	(3)  Upon a request by a participating provider, a
84	contracting entity must provide the identity of any third party
85	that has been granted access to the health care services of the
86	participating provider.
87	(4)  A contracting entity that leases, rents, or otherwise
88	grants access to the health care services of a participating
89	provider must maintain an Internet website or a toll-free
90	telephone number through which the provider may obtain a
91	listing, updated at least every 90 days, of the third parties
92	that have been granted access to the provider's health care
93	services.
94	(5)  A contracting entity that leases, rents, or otherwise
95	grants access to a participating provider's health care services
96	must ensure that an explanation of benefits or remittance advice
97	furnished to the participating provider that delivers health
98	care services under the health care contract identifies the
99	contractual source of any applicable discount.
100	(6)  Subject to applicable continuity of care laws, the
101	right of a third party to exercise the rights and
102	responsibilities of a contracting entity under a health care
103	contract terminates on the day after the termination of the
104	participating provider's contract with the contracting entity.
105	(7)  The provisions of this section do not apply if the
106	third party that is granted access to a participating provider's
107	health care services under a health care contract is:
108	(a)  An employer or other entity providing coverage for
109	health care services to the employer's employees or the entity's
110	members and the employer or entity has a contract with the
111	contracting entity or the contracting entity's affiliate for the
112	administration or processing of claims for payment or services
113	provided under the health care contract;
114	(b)  An entity providing administrative services to, or
115	receiving administrative services from, the contracting entity
116	or the contracting entity's affiliate or subsidiary; or
117	(c)  An affiliate or a subsidiary of a contracting entity
118	or other entity if operating under the same brand licensee
119	program as the contracting entity.
120	(8)  A health care contract may provide for arbitration of
121	disputes arising under this section.
122	(9)  A contracting entity shall ensure that all third
123	parties to which the contracting entity has sold, rented,
124	assigned, or otherwise given access to the participating
125	provider's discounted rate comply with the physician contract,
126	including all requirements to encourage access to the
127	participating provider, and pay the provider pursuant to the
128	rates of payment and methodology set forth in that contract,
129	unless otherwise agreed to by a participating provider.
130	(10)  Notwithstanding any other provision of this section,
131	no contracting entity shall sell, rent, lease, or give a third
132	party the contracting entity's rights to a participating
133	provider's services pursuant to the contracting entity's health
134	care contract with the participating provider unless one of the
135	following applies:
136	(a)  The third party accessing the participating provider's
137	services under the health care contract is an employer or other
138	entity providing coverage for health care services to its
139	employees or members, and that employer or entity has a contract
140	with the contracting entity or its affiliate for the
141	administration or processing of claims for payment for services
142	provided pursuant to the health care contract with the
143	participating provider.
144	(b)  The third party accessing the participating provider's
145	services under the health care contract is an affiliate or
146	subsidiary of the contracting entity, is an entity operating
147	under the same brand licensee program as the contracting entity,
148	or is providing administrative services to or receiving
149	administrative services from the contracting entity or an
150	affiliate or subsidiary of the contracting entity.
151	(c)  The health care contract specifically provides that it
152	applies to network rental arrangements and states that one
153	purpose of the contract is selling, renting, or giving the
154	contracting entity's rights to the services of the participating
155	provider, including other preferred provider organizations, and
156	the third party accessing the participating provider's services
157	is:
158	1.  A payor or a third-party administrator or other entity
159	responsible for administering claims on behalf of the payor;
160	2.  A preferred provider organization or preferred provider
161	network that receives access to the participating provider's
162	services pursuant to an arrangement with the preferred provider
163	organization or preferred provider network in a contract with
164	the participating provider and is required to comply with all of
165	the terms, conditions, and affirmative obligations to which the
166	originally contracted primary participating provider network is
167	bound under its contract with the participating provider,
168	including, but not limited to, obligations concerning patient
169	steerage and the timeliness and manner of reimbursement; or
170	3.  An entity that is engaged in the business of providing
171	electronic claims transport between the contracting entity and
172	the payor or third-party administrator and complies with all of
173	the applicable terms, conditions, and affirmative obligations of
174	the contracting entity's contract with the participating
175	provider, including, but not limited to, obligations concerning
176	patient steerage and the timeliness and manner of reimbursement.
177	(11)  A contracting entity is deemed in compliance with
178	this section when the insured's identification card provides,
179	written or electronically, information that identifies the
180	preferred provider network or networks to be utilized to
181	reimburse the provider for covered services.
182	(12)  This section shall not apply to a contract between a
183	contracting entity and a discount medical plan organization
184	licensed or exempt under part II of chapter 636.
185	Section 5.  Subsections (11), (12), and (13) of section
186	627.662, Florida Statutes, are renumbered as subsections (12),
187	(13), and (14), respectively, and a new subsection (11) is added
188	to that section to read:
189	627.662  Other provisions applicable.--The following
190	provisions apply to group health insurance, blanket health
191	insurance, and franchise health insurance:
192	(11)  Section 627.64731, relating to leasing, renting, or
193	granting access to a participating provider.
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199	T I T L E  A M E N D M E N T
200	Remove lines 7-33 and insert:
201	circumstances; amending s. 627.6131, F.S.; providing
202	requirements for and prohibitions against certain claims for
203	overpayment and claims for underpayment; amending s. 627.638,
204	F.S.; revising provisions providing for direct payment to
205	certain providers for certain services to include licensed
206	ambulance providers; requiring certain insurers to make payments
207	directly to contracted preferred providers for certain services;
208	creating s. 627.64731, F.S.; providing definitions; providing
209	requirements, limitations, and procedures for leasing, renting,
210	or granting access to participating providers by third parties;
211	providing exceptions; providing for arbitration; prohibiting
212	third party access to certain services under certain
213	circumstances; providing exceptions; providing application;
214	amending s. 627.662, F.S.; expanding the list of applicable
215	sections to certain types of insurance; amending s.

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