CS/CS/HB 405

1	A bill to be entitled
2	An act relating to health insurance claims payments;
3	amending s. 624.443, F.S.; authorizing the Office of
4	Insurance Regulation to waive certain principal place of
5	business and records availability requirements for certain
6	multiple-employer welfare arrangements under specified
7	circumstances; amending s. 627.638, F.S.; including
8	licensed ambulance providers under provisions for direct
9	payment for certain services; deleting an insurance
10	contract limitation on payment of benefits directly to
11	providers; authorizing attestations assigning benefits;
12	providing for transfer of attestations electronically;
13	requiring insurers to make payments directly to preferred
14	providers under certain circumstances; providing an
15	insurance contract prohibition and claims form requirement
16	relating to payment of benefits directly to providers;
17	providing a payment limitation; amending s. 627.6471,
18	F.S.; prohibiting insurers and plan administrators from
19	reimbursing preferred providers at an alternative or
20	reduced rate for covered services under certain
21	circumstances; providing exceptions; prohibiting preferred
22	provider contract parties from selling, leasing, or
23	transferring contract payment or reimbursement terms
24	information under certain circumstances; amending s.
25	641.31, F.S.; requiring health maintenance organizations
26	to pay benefits directly to certain providers under
27	certain circumstances; prohibiting health maintenance
28	contracts from prohibiting and requiring claims form to
29	provide the option for payment of benefits directly to
30	certain providers; amending s. 641.315, F.S.; prohibiting
31	health maintenance organizations from selling, leasing, or
32	transferring contract payment or reimbursement terms
33	information under certain circumstances; amending s.
34	641.3155, F.S.; decreasing the period of time authorized
35	for overpayment claims of health maintenance organizations
36	against providers; providing an effective date.
37
38	Be It Enacted by the Legislature of the State of Florida:
39
40	Section 1.  Section 624.443, Florida Statutes, is amended
41	to read:
42	624.443  Place of business; maintenance of records.--Each
43	arrangement shall have and maintain its principal place of
44	business in this state and shall therein make available to the
45	office complete records of its assets, transactions, and affairs
46	in accordance with such methods and systems as are customary
47	for, or suitable to, the kind or kinds of business transacted.
48	The office may waive this requirement if an arrangement has been
49	operating in another state for at least 25 years, has been
50	licensed in such state for at least 10 years, and has a minimum
51	fund balance of $25 million at the time of licensure.
52	Section 2.  Section 627.638, Florida Statutes, is amended
53	to read:
54	627.638  Direct payment for hospital, ambulance, and
55	medical services.--
56	(1)  Any health insurance policy insuring against loss or
57	expense due to hospital confinement or to medical and related
58	services may provide for payment of benefits directly to any
59	recognized hospital, licensed ambulance provider, doctor, or
60	other person who provided the services, in accordance with the
61	provisions of the policy. To comply with this section, the words
62	"or to the hospital, licensed ambulance provider, doctor, or
63	person rendering services covered by this policy," or similar
64	words appropriate to the terms of the policy, shall be added to
65	applicable provisions of the policy.
66	(2)  Whenever, in any health insurance claim form, an
67	insured specifically authorizes payment of benefits directly to
68	any recognized hospital, licensed ambulance provider, physician,
69	or dentist, or other person who provided the services, in
70	accordance with the provisions of the policy, the insurer shall
71	make such payment to the designated provider of such services,
72	unless otherwise provided in the insurance contract. The
73	insurance contract may not prohibit, and claims forms must
74	provide an option for, the payment of benefits directly to a
75	licensed hospital, licensed ambulance provider, physician, or
76	dentist, or other person who provided services for care provided
77	pursuant to s. 395.1041 or part III of chapter 401. The insurer
78	may require an written attestation assigning of assignment of
79	benefits, which attestation may be in written or electronic
80	form, at the discretion of the insured. If the attestation is in
81	electronic form, the attestation may be transferred to the
82	insurer electronically. An insurer may not require an
83	attestation in both electronic and written form. Payment to the
84	provider from the insurer may not be more than the amount that
85	the insurer would otherwise have paid without the assignment.
86	(3)  Whenever, in any health insurance claim form, an
87	insured specifically authorizes payment of benefits directly to
88	a preferred provider as defined in s. 627.6471(1)(b), the
89	insurer shall make such payment to the preferred provider. The
90	insurance contract may not prohibit, and claims forms must
91	provide an option for, the payment of benefits directly to the
92	preferred provider. An attestation assigning benefits may be
93	transferred to the insurer in electronic form. Payment to the
94	provider from the insurer may not be more than the amount that
95	the insurer would otherwise have paid without the assignment.
96	(4)  Notwithstanding the provisions of subsections (2) and
97	(3), if an insured authorizes payment of benefits directly to a
98	licensed hospital for health care services provided pursuant to
99	s. 395.1041, the insurer shall make such payment to the
100	designated provider of such services. The insurer shall accept a
101	provider's claim form that properly indicates that the insured
102	has assigned payment of benefits directly to the hospital.
103	Payment to the hospital from the insurer may not be more than
104	the amount the insurer would otherwise have paid without the
105	assignment.
106	Section 3.  Subsection (7) is added to section 627.6471,
107	Florida Statutes, to read:
108	627.6471  Contracts for reduced rates of payment;
109	limitations; coinsurance and deductibles.--
110	(7)(a)  An insurer or an administrator may not reimburse a
111	preferred provider at an alternative or a reduced rate of
112	payment for covered services that are provided to an insured
113	unless:
114	1.  The insurer or administrator has contracted with the
115	preferred provider and has agreed to provide coverage for those
116	health care services under the health insurance policy.
117	2.  The preferred provider has agreed to the contract and
118	to provide health care services under the terms of the contract.
119	(b)  A party to a preferred provider contract may not sell,
120	lease, or otherwise transfer information regarding the payment
121	or reimbursement terms of the contract without the express
122	authority of and prior adequate notification to the other
123	contracting parties.
124	Section 4.  Subsection (41) is added to section 641.31,
125	Florida Statutes, to read:
126	641.31  Health maintenance contracts.--
127	(41)  Whenever, in any health maintenance organization
128	claim form, a subscriber specifically authorizes payment of
129	benefits directly to any contracted hospital, ambulance
130	provider, physician, dentist, or other person who provided
131	services, the health maintenance organization shall make such
132	payment to the designated provider of such services, provided
133	any benefits are due to the subscriber under the terms of the
134	agreement between the subscriber and the health maintenance
135	organization. The health maintenance organization contract may
136	not prohibit, and claims forms must provide an option for, the
137	payment of benefits directly to a licensed hospital, ambulance
138	provider, physician, or dentist for covered services provided,
139	for services provided pursuant to s. 395.1041, and for ambulance
140	transport and treatment provided pursuant to part III of chapter
141	401. The attestation of assignment of benefits may be in written
142	or electronic form. Payment to the provider from the health
143	maintenance organization may not be more than the amount that
144	the insurer would otherwise have paid without the assignment.
145	Nothing in this subsection affects the applicability of ss.
146	641.3154 and 641.513 with respect to services provided and
147	payment for such services provided pursuant to this subsection.
148	Section 5.  Subsection (11) is added to section 641.315,
149	Florida Statutes, to read:
150	641.315  Provider contracts.--
151	(11)  A health maintenance organization may not sell,
152	lease, or otherwise transfer information regarding the payment
153	of reimbursement terms of a contract with a health care
154	practitioner without the express authority of and prior adequate
155	notification to the contracting parties.
156	Section 6.  Subsection (5) of section 641.3155, Florida
157	Statutes, is amended to read:
158	641.3155  Prompt payment of claims.--
159	(5)  If a health maintenance organization determines that
160	it has made an overpayment to a provider for services rendered
161	to a subscriber, the health maintenance organization must make a
162	claim for such overpayment to the provider's designated
163	location. A health maintenance organization that makes a claim
164	for overpayment to a provider under this section shall give the
165	provider a written or electronic statement specifying the basis
166	for the retroactive denial or payment adjustment. The health
167	maintenance organization must identify the claim or claims, or
168	overpayment claim portion thereof, for which a claim for
169	overpayment is submitted.
170	(a)  If an overpayment determination is the result of
171	retroactive review or audit of coverage decisions or payment
172	levels not related to fraud, a health maintenance organization
173	shall adhere to the following procedures:
174	1.  All claims for overpayment must be submitted to a
175	provider within 12 30 months after the health maintenance
176	organization's payment of the claim. A provider must pay, deny,
177	or contest the health maintenance organization's claim for
178	overpayment within 40 days after the receipt of the claim. All
179	contested claims for overpayment must be paid or denied within
180	120 days after receipt of the claim. Failure to pay or deny
181	overpayment and claim within 140 days after receipt creates an
182	uncontestable obligation to pay the claim.
183	2.  A provider that denies or contests a health maintenance
184	organization's claim for overpayment or any portion of a claim
185	shall notify the organization, in writing, within 35 days after
186	the provider receives the claim that the claim for overpayment
187	is contested or denied. The notice that the claim for
188	overpayment is denied or contested must identify the contested
189	portion of the claim and the specific reason for contesting or
190	denying the claim and, if contested, must include a request for
191	additional information. If the organization submits additional
192	information, the organization must, within 35 days after receipt
193	of the request, mail or electronically transfer the information
194	to the provider. The provider shall pay or deny the claim for
195	overpayment within 45 days after receipt of the information. The
196	notice is considered made on the date the notice is mailed or
197	electronically transferred by the provider.
198	3.  The health maintenance organization may not reduce
199	payment to the provider for other services unless the provider
200	agrees to the reduction in writing or fails to respond to the
201	health maintenance organization's overpayment claim as required
202	by this paragraph.
203	4.  Payment of an overpayment claim is considered made on
204	the date the payment was mailed or electronically transferred.
205	An overdue payment of a claim bears simple interest at the rate
206	of 12 percent per year. Interest on an overdue payment for a
207	claim for an overpayment payment begins to accrue when the claim
208	should have been paid, denied, or contested.
209	(b)  A claim for overpayment shall not be permitted beyond
210	12 30 months after the health maintenance organization's payment
211	of a claim, except that claims for overpayment may be sought
212	beyond that time from providers convicted of fraud pursuant to
213	s. 817.234.
214	Section 7.  This act shall take effect July 1, 2008.

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