Florida Senate - 2009 SB 416
By Senator Fasano
11-00376B-09 2009416__
1 A bill to be entitled
2 An act relating to health care management; amending s.
3 627.6044, F.S.; prohibiting certain insurers from
4 engaging in actions that encourage insureds not to
5 make payments before medical service is rendered or
6 before receipt of an insurer's explanation of
7 benefits; amending s. 627.6131, F.S.; providing
8 additional circumstances in which a health insurer may
9 not retroactively deny a claim; amending s. 627.6141,
10 F.S.; requiring a claimant whose claim is denied for
11 failure to obtain an authorization under certain
12 circumstances to be provided an opportunity for an
13 appeal; requiring that the insurer reverse a denial
14 under certain circumstances; requiring the insurer to
15 submit a written justification for a determination of
16 a service that was not medically necessary; amending
17 ss. 627.6474 and 641.315, F.S.; prohibiting a health
18 insurer or health maintenance organization from
19 modifying a policy or procedure that would affect the
20 underlying contract terms without having a written
21 mutual agreement; amending s. 641.3155, F.S.;
22 providing additional circumstances in which a health
23 maintenance organization may not retroactively deny a
24 claim; amending s. 641.3156, F.S.; requiring a health
25 maintenance organization to conduct a retrospective
26 review of the medical necessity of a service under
27 certain circumstances; requiring the insurer to submit
28 a written justification for a determination of a
29 service that was not medically necessary; amending s.
30 641.54, F.S.; prohibiting a health maintenance
31 organization from engaging in certain actions that
32 encourage subscribers not to make payments before
33 medical service is rendered or before receipt of the
34 health maintenance organization’s explanation of
35 benefits; creating a study group to evaluate increases
36 in a patient's financial responsibility for hospital
37 services; providing for membership; requiring the
38 Office of Insurance Regulation, the Agency for Health
39 Care Administration, and the organizations appointing
40 members to the study group to provide organizational
41 support; providing for the duties of the study group;
42 providing for per diem and travel expenses for
43 members; requiring the study group to present a final
44 report to the Legislature; providing an effective
45 date.
46
47 Be It Enacted by the Legislature of the State of Florida:
48
49 Section 1. Subsection (3) is added to section 627.6044,
50 Florida Statutes, to read:
51 627.6044 Use of a specific methodology for payment of
52 claims.—
53 (3) An insurer issuing a policy that provides for payment
54 of claims based on a specific methodology may not take any
55 action, such as providing a printed statement to an insured,
56 which encourages the insured to refuse to pay a copayment,
57 coinsurance, a portion of a deductible, or any other form of a
58 patient's financial responsibility before a medical service is
59 rendered or before receipt of an insurer's explanation of
60 benefits.
61 Section 2. Subsection (11) of section 627.6131, Florida
62 Statutes, is amended to read:
63 627.6131 Payment of claims.—
64 (11) A health insurer may not retroactively deny a claim
65 because of insured ineligibility:
66 (a) More than 1 year after the date of payment of the
67 claim;.
68 (b) If the health insurer verified the eligibility of an
69 insured at the time of treatment and provided an authorization
70 number; or
71 (c) If, at the time of service, the health insurer provided
72 the insured with a magnetic or smart identification as provided
73 in s. 627.642 which identified the insured as eligible to
74 receive services.
75 Section 3. Section 627.6141, Florida Statutes, is amended
76 to read:
77 627.6141 Denial of claims.—Each claimant, or provider
78 acting for a claimant, who has had a claim denied as not
79 medically necessary or for failure to obtain authorization or
80 partial authorization due to an unintentional act of error or
81 omission must be provided an opportunity for an appeal to the
82 insurer's licensed physician who is responsible for the medical
83 necessity reviews under the plan or is a member of the plan's
84 peer review group. If the insurer determines upon review that
85 the service was medically necessary, the insurer must reverse
86 the denial and pay the claim. If the insurer determines that the
87 service was not medically necessary, the insurer shall submit to
88 the provider specific written clinical justification for the
89 determination. The appeal may be by telephone, and the insurer's
90 licensed physician must respond within a reasonable time, not to
91 exceed 15 business days.
92 Section 4. Section 627.6474, Florida Statutes, is amended
93 to read:
94 627.6474 Provider contracts.—
95 (1) A health insurer shall not require a contracted health
96 care practitioner as defined in s. 456.001(4) to accept the
97 terms of other health care practitioner contracts with the
98 insurer or any other insurer, or health maintenance
99 organization, under common management and control with the
100 insurer, including Medicare and Medicaid practitioner contracts
101 and those authorized by s. 627.6471, s. 627.6472, or s. 641.315,
102 except for a practitioner in a group practice as defined in s.
103 456.053 who must accept the terms of a contract negotiated for
104 the practitioner by the group, as a condition of continuation or
105 renewal of the contract. Any contract provision that violates
106 this section is void. A violation of this section is not subject
107 to the criminal penalty specified in s. 624.15.
108 (2) A health insurer may not modify, amend, or change any
109 policy, procedure, or equivalent document adopted by reference
110 in a contract in effect with a provider which would affect,
111 directly or indirectly, the underlying contract terms without a
112 mutual written agreement between the provider and the insurer.
113 Written notice of any proposed change must be provided by the
114 health insurer to the provider at least 45 days before the date
115 the proposed change is implemented.
116 Section 5. Subsection (11) is added to section 641.315,
117 Florida Statutes, to read:
118 641.315 Provider contracts.—
119 (11) A health maintenance organization may not modify,
120 amend, or change any policy, procedure, or equivalent document
121 adopted by reference in a contract in effect with a provider
122 which would affect, directly or indirectly, the underlying
123 contract terms without a mutual written agreement between the
124 provider and the organization. Written notice of any proposed
125 change must be provided by the health maintenance organization
126 to the provider at least 45 days before the date the proposed
127 change is implemented.
128 Section 6. Subsection (10) of section 641.3155, Florida
129 Statutes, is amended to read:
130 641.3155 Prompt payment of claims.—
131 (10) A health maintenance organization may not
132 retroactively deny a claim because of subscriber ineligibility:
133 (a) More than 1 year after the date of payment of the
134 claim;.
135 (b) If the health maintenance organization verified the
136 eligibility of a subscriber at the time of treatment and
137 provided an authorization number; or
138 (c) If, at the time of service, the health maintenance
139 organization provided the subscriber with a magnetic or smart
140 identification as provided in s. 627.642 which identified the
141 subscriber as eligible to receive services.
142 Section 7. Section 641.3156, Florida Statutes, is amended
143 to read:
144 641.3156 Treatment authorization; payment of claims.—
145 (1) A health maintenance organization must pay any
146 hospital-service or referral-service claim for treatment for an
147 eligible subscriber which was authorized by a provider empowered
148 by contract with the health maintenance organization to
149 authorize or direct the patient's utilization of health care
150 services and which was also authorized in accordance with the
151 health maintenance organization's current and communicated
152 procedures, unless the provider provided information to the
153 health maintenance organization with the willful intention to
154 misinform the health maintenance organization.
155 (2) A claim for treatment may not be denied if a provider
156 follows the health maintenance organization's authorization
157 procedures and receives authorization for a covered service for
158 an eligible subscriber, unless the provider provided information
159 to the health maintenance organization with the willful
160 intention to misinform the health maintenance organization.
161 (3) If a hospital-service or referral-service claim is
162 denied because the provider, due to an unintentional act of
163 error or omission, failed to obtain authorization or obtained
164 only partial authorization, the provider may appeal the denial,
165 and the health maintenance organization must conduct and
166 complete, within 30 days after the submitted appeal, a
167 retrospective review of the medical necessity of the service. If
168 the health maintenance organization determines that the service
169 is medically necessary, the health maintenance organization must
170 reverse the denial and pay the claim. If the health maintenance
171 organization determines that the service is not medically
172 necessary, the health maintenance organization shall provide the
173 provider with specific written clinical justification for the
174 determination.
175 (4)(3) Emergency services are subject to the provisions of
176 s. 641.513 and are not subject to the provisions of this
177 section.
178 Section 8. Present subsection (7) of section 641.54,
179 Florida Statutes, is renumbered as subsection (8), and a new
180 subsection (7) is added to that section, to read:
181 641.54 Information disclosure.—
182 (7) A health maintenance organization may not take any
183 action, such as issuing a printed statement to a subscriber,
184 which encourages a subscriber to refuse to pay a copayment, a
185 coinsurance percentage, a deductible, or any other portion of a
186 patient's financial responsibility before a medical service is
187 rendered or before receipt of the health maintenance
188 organization’s explanation of benefits.
189 Section 9. (1) A 12-person study group is created for the
190 purpose of evaluating increases in a patient's financial
191 responsibility for hospital services and the resulting effect on
192 the affordability and accessibility of private, employer
193 sponsored health insurance. A representative of an employer who
194 purchases health insurance for its employees, appointed by the
195 Florida Chamber of Commerce, and an employer who provides health
196 insurance through a self-insured plan, appointed by Associated
197 Industries of Florida, shall act as co-chairs of the study
198 group. The remaining 10 members of the study group shall be
199 appointed as follows:
200 (a) Two members appointed by the Florida Hospital
201 Association;
202 (b) Two members appointed by the Florida Chamber of
203 Commerce, representing purchasers of health insurance;
204 (c) Two members appointed by Associated Industries of
205 Florida, representing purchasers of health insurance;
206 (d) One member of the Senate appointed by the President of
207 the Senate;
208 (e) One member of the House of Representatives appointed by
209 the Speaker of the House of Representatives; and
210 (f) Two representatives of health insurance plans appointed
211 by the Chief Financial Officer.
212 (2) Organizational support for the study group shall be
213 provided by the Office of Insurance Regulation, the Agency for
214 Health Care Administration, and the organizations appointing
215 members to the study group.
216 (3) The study group shall evaluate and develop findings and
217 recommendations regarding:
218 (a) Changes in a patient's financial responsibility
219 associated with hospital services in the form of copayments,
220 coinsurance, and deductibles over the last few years as data is
221 available;
222 (b) The effect of patient-payment requirements on access to
223 hospital services;
224 (c) The effect of financial disincentives regarding the
225 inappropriate use of hospital emergency rooms and ways to
226 strengthen such incentives;
227 (d) The effect of patient-payment requirements on the cost
228 of employer-sponsored health insurance;
229 (e) Methods to ensure that financial requirements for
230 patients are met;
231 (f) Impediments to collections from patients at the point
232 of service; and
233 (g) Methods to improve accurate collections from patients
234 at the point of service.
235 (4) Members of the study group shall serve without
236 compensation. The organizations appointing members shall pay per
237 diem and travel expenses for their respective members for the
238 meetings of the study group. All meetings shall be held in
239 Tallahassee.
240 (5) The members of the study group shall be appointed by
241 July 30, 2009, and shall hold their first meeting by September
242 1, 2009. The final report of the study group shall be presented
243 to the President of the Senate and to the Speaker of the House
244 of Representatives by January 29, 2010.
245 Section 10. This act shall take effect July 1, 2009.