Florida Senate - 2011 COMMITTEE AMENDMENT
Bill No. SB 1930
Barcode 328022
LEGISLATIVE ACTION
Senate . House
Comm: WD .
04/13/2011 .
.
.
.
—————————————————————————————————————————————————————————————————
—————————————————————————————————————————————————————————————————
The Committee on Banking and Insurance (Bogdanoff) recommended
the following:
1 Senate Amendment to Amendment (243424) (with title
2 amendment)
3
4 Delete lines 3 - 30
5 and insert:
6 Delete everything after the enacting clause
7 and insert:
8 Section 1. Subsection (1) of section 316.066, Florida
9 Statutes, is amended to read:
10 316.066 Written reports of crashes.—
11 (1)(a) A Florida Traffic Crash Report, Long Form, must is
12 required to be completed and submitted to the department within
13 10 days after completing an investigation is completed by the
14 every law enforcement officer who in the regular course of duty
15 investigates a motor vehicle crash:
16 1. That resulted in death, or personal injury, or any
17 indication of complaints of pain or discomfort by any of the
18 parties or passengers involved in the crash;.
19 2. That involved one or more passengers, other than the
20 drivers of the vehicles, in any of the vehicles involved in the
21 crash;
22 3.2. That involved a violation of s. 316.061(1) or s.
23 316.193; or.
24 4.3. In which a vehicle was rendered inoperative to a
25 degree that required a wrecker to remove it from traffic, if
26 such action is appropriate, in the officer’s discretion.
27 (b) In every crash for which a Florida Traffic Crash
28 Report, Long Form, is not required by this section, the law
29 enforcement officer may complete a short-form crash report or
30 provide a short-form crash report to be completed by each party
31 involved in the crash. Short-form crash reports prepared by the
32 law enforcement officer shall be maintained by the officer’s
33 agency.
34 (c) The long-form and the short-form report must include:
35 1. The date, time, and location of the crash.
36 2. A description of the vehicles involved.
37 3. The names and addresses of the parties involved.
38 4. The names and addresses of all passengers in all
39 vehicles involved in the crash, each clearly identified as being
40 a passenger and the identification of the vehicle in which they
41 were a passenger.
42 5.4. The names and addresses of witnesses.
43 6.5. The name, badge number, and law enforcement agency of
44 the officer investigating the crash.
45 7.6. The names of the insurance companies for the
46 respective parties involved in the crash.
47 (d)(c) Each party to the crash must shall provide the law
48 enforcement officer with proof of insurance, which must to be
49 included in the crash report. If a law enforcement officer
50 submits a report on the accident, proof of insurance must be
51 provided to the officer by each party involved in the crash. Any
52 party who fails to provide the required information commits a
53 noncriminal traffic infraction, punishable as a nonmoving
54 violation as provided in chapter 318, unless the officer
55 determines that due to injuries or other special circumstances
56 such insurance information cannot be provided immediately. If
57 the person provides the law enforcement agency, within 24 hours
58 after the crash, proof of insurance that was valid at the time
59 of the crash, the law enforcement agency may void the citation.
60 (e)(d) The driver of a vehicle that was in any manner
61 involved in a crash resulting in damage to any vehicle or other
62 property in an amount of $500 or more, which crash was not
63 investigated by a law enforcement agency, shall, within 10 days
64 after the crash, submit a written report of the crash to the
65 department or traffic records center. The entity receiving the
66 report may require witnesses of the crash crashes to render
67 reports and may require any driver of a vehicle involved in a
68 crash of which a written report must be made as provided in this
69 section to file supplemental written reports if whenever the
70 original report is deemed insufficient by the receiving entity.
71 (f) The investigating law enforcement officer may testify
72 at trial or provide a signed affidavit to confirm or supplement
73 the information included on the long-form or short-form report.
74 (e) Short-form crash reports prepared by law enforcement
75 shall be maintained by the law enforcement officer’s agency.
76 Section 2. Subsection (6) is added to section 400.991,
77 Florida Statutes, to read:
78 400.991 License requirements; background screenings;
79 prohibitions.—
80 (6) All forms that constitute part of the application for
81 licensure or exemption from licensure under this part must
82 contain the following statement:
83
84 INSURANCE FRAUD NOTICE.—Submitting a false,
85 misleading, or fraudulent application or other
86 document when applying for licensure as a health care
87 clinic, when seeking an exemption from licensure as a
88 health care clinic, or when demonstrating compliance
89 with part X of chapter 400, Florida Statutes, is a
90 fraudulent insurance act, as defined in s. 626.989 or
91 s. 817.234, Florida Statutes, subject to investigation
92 by the Division of Insurance Fraud, and is grounds for
93 discipline by the appropriate licensing board of the
94 Florida Department of Health.
95 Section 3. Section 626.9894, Florida Statutes, is created
96 to read:
97 626.9894 Motor vehicle insurance fraud direct-support
98 organization.—
99 (1) DEFINITIONS.—As used in this section, the term:
100 (a) “Division” means the Division of Insurance Fraud of the
101 Department of Financial Services.
102 (b) “Motor vehicle insurance fraud” means any act defined
103 as a “fraudulent insurance act” under s. 626.989, which relates
104 to the coverage of motor vehicle insurance as described in part
105 XI of chapter 627.
106 (c) “Organization” means the direct-support organization
107 established under this section.
108 (2) ORGANIZATION ESTABLISHED.—The division may establish a
109 direct-support organization, to be known as the “Automobile
110 Insurance Fraud Strike Force,” whose sole purpose is to support
111 the prosecution, investigation, and prevention of motor vehicle
112 insurance fraud. The organization shall:
113 (a) Be a not-for-profit corporation incorporated under
114 chapter 617 and approved by the Department of State.
115 (b) Be organized and operated to conduct programs and
116 activities; to raise funds; to request and receive grants,
117 gifts, and bequests of money; to acquire, receive, hold, invest,
118 and administer, in its own name, securities, funds, objects of
119 value, or other property, real or personal; and to make grants
120 and expenditures to or for the direct or indirect benefit of the
121 division, state attorneys’ offices, the statewide prosecutor,
122 the Agency for Health Care Administration, and the Department of
123 Health to the extent that such grants and expenditures are to be
124 used exclusively to advance the purpose of prosecuting,
125 investigating, or preventing motor vehicle insurance fraud.
126 Grants and expenditures may include the cost of salaries or
127 benefits of dedicated motor vehicle insurance fraud
128 investigators, prosecutors, or support personnel if such grants
129 and expenditures do not interfere with prosecutorial
130 independence or otherwise create conflicts of interest which
131 threaten the success of prosecutions.
132 (c) Be determined by the division to operate in a manner
133 that promotes the goals of laws relating to motor vehicle
134 insurance fraud, that is in the best interest of the state, and
135 that is in accordance with the adopted goals and mission of the
136 division.
137 (d) Use all of its grants and expenditures solely for the
138 purpose of preventing and decreasing motor vehicle insurance
139 fraud, and not for the purpose of lobbying as defined in s.
140 11.045.
141 (e) Be subject to an annual financial audit in accordance
142 with s. 215.981.
143 (3) CONTRACT.—The organization shall operate under written
144 contract with the division. The contract must provide for:
145 (a) Approval of the articles of incorporation and bylaws of
146 the organization by the division.
147 (b) Submission of an annual budget for the approval of the
148 division. The budget must require the organization to minimize
149 costs to the division and its members at all times by using
150 existing personnel and property and allowing for telephonic
151 meetings when appropriate.
152 (c) Certification by the division that the direct-support
153 organization is complying with the terms of the contract and in
154 a manner consistent with the goals and purposes of the
155 department and in the best interest of the state. Such
156 certification must be made annually and reported in the official
157 minutes of a meeting of the organization.
158 (d) Allocation of funds to address motor vehicle insurance
159 fraud.
160 (e) Reversion of moneys and property held in trust by the
161 organization for motor vehicle insurance fraud prosecution,
162 investigation, and prevention to the division if the
163 organization is no longer approved to operate for the department
164 or if the organization ceases to exist, or to the state if the
165 division ceases to exist.
166 (f) Specific criteria to be used by the organization’s
167 board of directors to evaluate the effectiveness of funding used
168 to combat motor vehicle insurance fraud.
169 (g) The fiscal year of the organization, which begins July
170 1 of each year and ends June 30 of the following year.
171 (h) Disclosure of the material provisions of the contract,
172 and distinguishing between the department and the organization
173 to donors of gifts, contributions, or bequests, including
174 providing such disclosure on all promotional and fundraising
175 publications.
176 (4) BOARD OF DIRECTORS.—The board of directors of the
177 organization shall consist of the following seven members:
178 (a) The Chief Financial Officer, or designee, who shall
179 serve as chair.
180 (b) Two state attorneys, one of whom shall be appointed by
181 the Chief Financial Officer and one of whom shall be appointed
182 by the Attorney General.
183 (c) Two representatives of motor vehicle insurers appointed
184 by the Chief Financial Officer.
185 (d) Two representatives of local law enforcement agencies,
186 both of whom shall be appointed by the Chief Financial Officer.
187
188 The officer who appointed a member of the board may remove that
189 member for cause. The term of office of an appointed member
190 expires at the same time as the term of the officer who
191 appointed him or her or at such earlier time as the person
192 ceases to be qualified.
193 (5) USE OF PROPERTY.—The department may authorize, without
194 charge, appropriate use of fixed property and facilities of the
195 division by the organization, subject to this subsection.
196 (a) The department may prescribe any condition with which
197 the organization must comply in order to use the division’s
198 property or facilities.
199 (b) The department may not authorize the use of the
200 division’s property or facilities if the organization does not
201 provide equal membership and employment opportunities to all
202 persons regardless of race, religion, sex, age, or national
203 origin.
204 (c) The department shall adopt rules prescribing the
205 procedures by which the organization is governed and any
206 conditions with which the organization must comply to use the
207 division’s property or facilities.
208 (6) CONTRIBUTIONS.—Any contributions made by an insurer to
209 the organization shall be allowed as appropriate business
210 expenses for all regulatory purposes.
211 (7) DEPOSITORY.—Any moneys received by the organization may
212 be held in a separate depository account in the name of the
213 organization and subject to the provisions of the contract with
214 the division.
215 (8) DIVISION’S RECEIPT OF PROCEEDS.—If the division
216 receives proceeds from the organization, those proceeds shall be
217 deposited into the Insurance Regulatory Trust Fund.
218 Section 4. Subsection (3) is added to section 627.4137,
219 Florida Statutes, to read:
220 627.4137 Disclosure of certain information required.—
221 (3) Any request made to a self-insured corporation pursuant
222 to this section shall be sent by certified mail to the
223 registered agent of the disclosing entity.
224 Section 5. Section 627.730, Florida Statutes, is amended to
225 read:
226 627.730 Florida Motor Vehicle No-Fault Law.—Sections
227 627.730-627.7407 627.730-627.7405 may be cited and known as the
228 “Florida Motor Vehicle No-Fault Law.”
229 Section 6. Section 627.731, Florida Statutes, is amended to
230 read:
231 627.731 Purpose; legislative intent.—The purpose of the no
232 fault law ss. 627.730-627.7405 is to provide for medical,
233 surgical, funeral, and disability insurance benefits without
234 regard to fault, and to require motor vehicle insurance securing
235 such benefits, for motor vehicles required to be registered in
236 this state and, with respect to motor vehicle accidents, a
237 limitation on the right to claim damages for pain, suffering,
238 mental anguish, and inconvenience.
239 (1) The Legislature finds that automobile insurance fraud
240 remains a major problem for state consumers and insurers.
241 According to the National Insurance Crime Bureau, in recent
242 years this state has been among those states that have the
243 highest number of fraudulent and questionable claims.
244 (2) The Legislature intends to balance the insured’s
245 interest in prompt payment of valid claims for insurance
246 benefits under the no-fault law with the public’s interest in
247 reducing fraud, abuse, and overuse of the no-fault system. To
248 that end, the Legislature intends that the investigation and
249 prevention of fraudulent insurance acts in this state be
250 enhanced, that additional sanctions for such acts be imposed,
251 and that the no-fault law be revised to remove incentives for
252 fraudulent insurance acts. The Legislature intends that the no
253 fault law be construed according to the plain language of the
254 statutory provisions, which are designed to meet these goals.
255 (3) The Legislature intends that:
256 (a) Insurers properly investigate claims, and as such, be
257 allowed to obtain examinations under oath and sworn statements
258 from any claimant seeking no-fault insurance benefits, and to
259 request mental and physical examinations of persons seeking
260 personal injury protection coverage or benefits.
261 (b) Any false, misleading, or otherwise fraudulent activity
262 associated with a claim render the entire claim invalid. An
263 insurer must be able to raise fraud as a defense to a claim for
264 no-fault insurance benefits irrespective of any prior
265 adjudication of guilt or determination of fraud by the
266 Department of Financial Services.
267 (c) Insurers toll the payment or denial of a claim, with
268 respect to any portion of a claim for which the insurer has a
269 reasonable belief that a fraudulent insurance act, as defined in
270 s. 626.989, has been committed.
271 (d) Insurers discover the names of all passengers involved
272 in an automobile accident before paying claims or benefits
273 pursuant to an insurance policy governed by the no-fault law. A
274 rebuttable presumption must be established that a person was not
275 involved in the event giving rise to the claim if that person’s
276 name does not appear on the police report.
277 (e) The insured’s interest in obtaining competent counsel
278 must be balanced with the public’s interest in preventing a no
279 fault system that encourages litigation by allowing for
280 exorbitant attorney’s fees. Courts should limit attorney fee
281 awards so as to eliminate the incentive for attorneys to
282 manufacture unnecessary litigation.
283 Section 7. Section 627.7311, Florida Statutes, is created
284 to read:
285 627.7311 Implementation of no-fault law.—The provisions,
286 schedules, and procedures authorized under the no-fault law
287 shall be implemented by insurers and have full force and effect
288 regardless of their express inclusion in an insurance policy,
289 and an insurer is not required to amend its policy to implement
290 such provisions, schedules, or procedures.
291 Section 8. Section 627.732, Florida Statutes, is reordered
292 and amended to read:
293 627.732 Definitions.—As used in the no-fault law ss.
294 627.730-627.7405, the term:
295 (1) “Broker” means any person not possessing a license
296 under chapter 395, chapter 400, chapter 429, chapter 458,
297 chapter 459, chapter 460, chapter 461, or chapter 641 who
298 charges or receives compensation for any use of medical
299 equipment and is not the 100-percent owner or the 100-percent
300 lessee of such equipment. For purposes of this section, such
301 owner or lessee may be an individual, a corporation, a
302 partnership, or any other entity and any of its 100-percent
303 owned affiliates and subsidiaries. For purposes of this
304 subsection, the term “lessee” means a long-term lessee under a
305 capital or operating lease, but does not include a part-time
306 lessee. The term “broker” does not include a hospital or
307 physician management company whose medical equipment is
308 ancillary to the practices managed, a debt collection agency, or
309 an entity that has contracted with the insurer to obtain a
310 discounted rate for such services; or nor does the term include
311 a management company that has contracted to provide general
312 management services for a licensed physician or health care
313 facility and whose compensation is not materially affected by
314 the usage or frequency of usage of medical equipment or an
315 entity that is 100-percent owned by one or more hospitals or
316 physicians. The term “broker” does not include a person or
317 entity that certifies, upon request of an insurer, that:
318 (a) It is a clinic licensed under ss. 400.990-400.995;
319 (b) It is a 100-percent owner of medical equipment; and
320 (c) The owner’s only part-time lease of medical equipment
321 for personal injury protection patients is on a temporary basis,
322 not to exceed 30 days in a 12-month period, and such lease is
323 solely for the purposes of necessary repair or maintenance of
324 the 100-percent-owned medical equipment or pending the arrival
325 and installation of the newly purchased or a replacement for the
326 100-percent-owned medical equipment, or for patients for whom,
327 because of physical size or claustrophobia, it is determined by
328 the medical director or clinical director to be medically
329 necessary that the test be performed in medical equipment that
330 is open-style. The leased medical equipment may not cannot be
331 used by patients who are not patients of the registered clinic
332 for medical treatment of services. Any person or entity making a
333 false certification under this subsection commits insurance
334 fraud as defined in s. 817.234. However, the 30-day period
335 provided in this paragraph may be extended for an additional 60
336 days as applicable to magnetic resonance imaging equipment if
337 the owner certifies that the extension otherwise complies with
338 this paragraph.
339 (9)(2) “Medically necessary” refers to a medical service or
340 supply that a prudent physician would provide for the purpose of
341 preventing, diagnosing, or treating an illness, injury, disease,
342 or symptom in a manner that is:
343 (a) In accordance with generally accepted standards of
344 medical practice;
345 (b) Clinically appropriate in terms of type, frequency,
346 extent, site, and duration; and
347 (c) Not primarily for the convenience of the patient,
348 physician, or other health care provider.
349 (10)(3) “Motor vehicle” means a any self-propelled vehicle
350 with four or more wheels which is of a type both designed and
351 required to be licensed for use on the highways of this state,
352 and any trailer or semitrailer designed for use with such
353 vehicle, and includes:
354 (a) A “private passenger motor vehicle,” which is any motor
355 vehicle that which is a sedan, station wagon, or jeep-type
356 vehicle and, if not used primarily for occupational,
357 professional, or business purposes, a motor vehicle of the
358 pickup, panel, van, camper, or motor home type.
359 (b) A “commercial motor vehicle,” which is any motor
360 vehicle that which is not a private passenger motor vehicle.
361
362 The term “motor vehicle” does not include a mobile home or any
363 motor vehicle that which is used in mass transit, other than
364 public school transportation, and designed to transport more
365 than five passengers exclusive of the operator of the motor
366 vehicle and that which is owned by a municipality, a transit
367 authority, or a political subdivision of the state.
368 (11)(4) “Named insured” means a person, usually the owner
369 of a vehicle, identified in a policy by name as the insured
370 under the policy.
371 (12) “No-fault law” means the Florida Motor Vehicle No
372 Fault Law codifed at ss. 627.730-627.7407.
373 (13)(5) “Owner” means a person who holds the legal title to
374 a motor vehicle; or, if in the event a motor vehicle is the
375 subject of a security agreement or lease with an option to
376 purchase with the debtor or lessee having the right to
377 possession, then the debtor or lessee is shall be deemed the
378 owner for the purposes of the no-fault law ss. 627.730-627.7405.
379 (15)(6) “Relative residing in the same household” means a
380 relative of any degree by blood or by marriage who usually makes
381 her or his home in the same family unit, whether or not
382 temporarily living elsewhere.
383 (2)(7) “Certify” means to swear or attest to being true or
384 represented in writing.
385 (3) “Claimant” means the person, organization, or entity
386 seeking benefits, including all assignees.
387 (5)(8) “Immediate personal supervision,” as it relates to
388 the performance of medical services by nonphysicians not in a
389 hospital, means that an individual licensed to perform the
390 medical service or provide the medical supplies must be present
391 within the confines of the physical structure where the medical
392 services are performed or where the medical supplies are
393 provided such that the licensed individual can respond
394 immediately to any emergencies if needed.
395 (6)(9) “Incident,” with respect to services considered as
396 incident to a physician’s professional service, for a physician
397 licensed under chapter 458, chapter 459, chapter 460, or chapter
398 461, if not furnished in a hospital, means such services that
399 are must be an integral, even if incidental, part of a covered
400 physician’s service.
401 (7)(10) “Knowingly” means that a person, with respect to
402 information, has actual knowledge of the information,; acts in
403 deliberate ignorance of the truth or falsity of the
404 information,; or acts in reckless disregard of the information.,
405 and Proof of specific intent to defraud is not required.
406 (8)(11) “Lawful” or “lawfully” means in substantial
407 compliance with all relevant applicable criminal, civil, and
408 administrative requirements of state and federal law related to
409 the provision of medical services or treatment.
410 (4)(12) “Hospital” means a facility that, at the time
411 services or treatment were rendered, was licensed under chapter
412 395.
413 (14)(13) “Properly completed” means providing truthful,
414 substantially complete, and substantially accurate responses as
415 to all material elements of to each applicable request for
416 information or statement by a means that may lawfully be
417 provided and that complies with this section, or as agreed by
418 the parties.
419 (17)(14) “Upcoding” means submitting an action that submits
420 a billing code that would result in payment greater in amount
421 than would be paid using a billing code that accurately
422 describes the services performed. The term does not include an
423 otherwise lawful bill by a magnetic resonance imaging facility,
424 which globally combines both technical and professional
425 components, if the amount of the global bill is not more than
426 the components if billed separately; however, payment of such a
427 bill constitutes payment in full for all components of such
428 service.
429 (16)(15) “Unbundling” means submitting an action that
430 submits a billing code that is properly billed under one billing
431 code, but that has been separated into two or more billing
432 codes, and would result in payment greater than the in amount
433 that than would be paid using one billing code.
434 Section 9. Subsections (1) and (4) of section 627.736,
435 Florida Statutes, are amended, subsections (5) through (16) of
436 that section are redesignated as subsections (6) through (17),
437 respectively, a new subsection (5) is added to that section,
438 present subsection (5), paragraph (b) of present subsection (6),
439 paragraph (b) of present subsection (7), and present subsections
440 (8), (9), and (10) of that section are amended, to read:
441 627.736 Required personal injury protection benefits;
442 exclusions; priority; claims.—
443 (1) REQUIRED BENEFITS.—Every insurance policy complying
444 with the security requirements of s. 627.733 must shall provide
445 personal injury protection to the named insured, relatives
446 residing in the same household, persons operating the insured
447 motor vehicle, passengers in such motor vehicle, and other
448 persons struck by such motor vehicle and suffering bodily injury
449 while not an occupant of a self-propelled vehicle, subject to
450 the provisions of subsection (2) and paragraph (4)(h) (4)(e), to
451 a limit of $10,000 for loss sustained by any such person as a
452 result of bodily injury, sickness, disease, or death arising out
453 of the ownership, maintenance, or use of a motor vehicle as
454 follows:
455 (a) Medical benefits.—Eighty percent of all reasonable
456 expenses, charged pursuant to subsection (6), for medically
457 necessary medical, surgical, X-ray, dental, and rehabilitative
458 services, including prosthetic devices, and for medically
459 necessary ambulance, hospital, and nursing services. However,
460 the medical benefits shall provide reimbursement only for such
461 services and care that are lawfully provided, supervised,
462 ordered, or prescribed by a physician licensed under chapter 458
463 or chapter 459, a dentist licensed under chapter 466, or a
464 chiropractic physician licensed under chapter 460 or that are
465 provided by any of the following persons or entities:
466 1. A hospital or ambulatory surgical center licensed under
467 chapter 395.
468 2. A person or entity licensed under part III of chapter
469 401 which ss. 401.2101-401.45 that provides emergency
470 transportation and treatment.
471 3. An entity wholly owned by one or more physicians
472 licensed under chapter 458 or chapter 459, chiropractic
473 physicians licensed under chapter 460, or dentists licensed
474 under chapter 466 or by such practitioner or practitioners and
475 the spouse, parent, child, or sibling of such that practitioner
476 or those practitioners.
477 4. An entity wholly owned, directly or indirectly, by a
478 hospital or hospitals.
479 5. A health care clinic licensed under part X of chapter
480 400 which ss. 400.990-400.995 that is:
481 a. Accredited by the Joint Commission on Accreditation of
482 Healthcare Organizations, the American Osteopathic Association,
483 the Commission on Accreditation of Rehabilitation Facilities, or
484 the Accreditation Association for Ambulatory Health Care, Inc.;
485 or
486 b. A health care clinic that:
487 (I) Has a medical director licensed under chapter 458,
488 chapter 459, or chapter 460;
489 (II) Has been continuously licensed for more than 3 years
490 or is a publicly traded corporation that issues securities
491 traded on an exchange registered with the United States
492 Securities and Exchange Commission as a national securities
493 exchange; and
494 (III) Provides at least four of the following medical
495 specialties:
496 (A) General medicine.
497 (B) Radiography.
498 (C) Orthopedic medicine.
499 (D) Physical medicine.
500 (E) Physical therapy.
501 (F) Physical rehabilitation.
502 (G) Prescribing or dispensing outpatient prescription
503 medication.
504 (H) Laboratory services.
505 6. An acupuncturist licensed under chapter 457.
506
507 If any services under this paragraph are provided by an entity
508 or clinic described in subparagraph 3., subparagraph 4., or
509 subparagraph 5., the entity or clinic must provide the insurer
510 at the initial submission of the claim with a form adopted by
511 the Department of Financial Services which documents that the
512 entity or clinic meets applicable criteria for such entity or
513 clinic and includes a sworn statement or affidavit to that
514 effect. Any change in ownership requires the filing of a new
515 form within 10 days after the date of the change in ownership.
516 The Financial Services Commission shall adopt by rule the form
517 that must be used by an insurer and a health care provider
518 specified in subparagraph 3., subparagraph 4., or subparagraph
519 5. to document that the health care provider meets the criteria
520 of this paragraph, which rule must include a requirement for a
521 sworn statement or affidavit.
522 (b) Disability benefits.—Sixty percent of any loss of gross
523 income and loss of earning capacity per individual from
524 inability to work proximately caused by the injury sustained by
525 the injured person, plus all expenses reasonably incurred in
526 obtaining from others ordinary and necessary services in lieu of
527 those that, but for the injury, the injured person would have
528 performed without income for the benefit of his or her
529 household. All disability benefits payable under this provision
530 must shall be paid at least not less than every 2 weeks.
531 (c) Death benefits.—Death benefits equal to the lesser of
532 $5,000 or the remainder of unused personal injury protection
533 benefits per individual. The insurer may pay such benefits to
534 the executor or administrator of the deceased, to any of the
535 deceased’s relatives by blood, or legal adoption, or connection
536 by marriage, or to any person appearing to the insurer to be
537 equitably entitled thereto.
538
539 Only insurers writing motor vehicle liability insurance in this
540 state may provide the required benefits of this section, and no
541 such insurers may not insurer shall require the purchase of any
542 other motor vehicle coverage other than the purchase of property
543 damage liability coverage as required by s. 627.7275 as a
544 condition for providing such required benefits. Insurers may not
545 require that property damage liability insurance in an amount
546 greater than $10,000 be purchased in conjunction with personal
547 injury protection. Such insurers shall make benefits and
548 required property damage liability insurance coverage available
549 through normal marketing channels. An Any insurer writing motor
550 vehicle liability insurance in this state who fails to comply
551 with such availability requirement as a general business
552 practice violates shall be deemed to have violated part IX of
553 chapter 626, and such violation constitutes shall constitute an
554 unfair method of competition or an unfair or deceptive act or
555 practice involving the business of insurance. An; and any such
556 insurer committing such violation is shall be subject to the
557 penalties afforded in such part, as well as those that are which
558 may be afforded elsewhere in the insurance code.
559 (4) BENEFITS; WHEN DUE.—Benefits due from an insurer under
560 the no-fault law are ss. 627.730-627.7405 shall be primary,
561 except that benefits received under any workers’ compensation
562 law shall be credited against the benefits provided by
563 subsection (1) and are shall be due and payable as loss accrues,
564 upon the receipt of reasonable proof of such loss and the amount
565 of expenses and loss incurred which are covered by the policy
566 issued under the no-fault law ss. 627.730-627.7405. If When the
567 Agency for Health Care Administration provides, pays, or becomes
568 liable for medical assistance under the Medicaid program related
569 to injury, sickness, disease, or death arising out of the
570 ownership, maintenance, or use of a motor vehicle, the benefits
571 are under ss. 627.730-627.7405 shall be subject to the
572 provisions of the Medicaid program.
573 (a) An insurer may require written notice to be given as
574 soon as practicable after an accident involving a motor vehicle
575 with respect to which the policy affords the security required
576 by the no-fault law ss. 627.730-627.7405.
577 (b) Personal injury protection insurance benefits paid
578 pursuant to this section are shall be overdue if not paid within
579 30 days after the insurer is furnished written notice of the
580 fact of a covered loss and of the amount of same. If such
581 written notice is not furnished to the insurer as to the entire
582 claim, any partial amount supported by written notice is overdue
583 if not paid within 30 days after such written notice is
584 furnished to the insurer. Any part or all of the remainder of
585 the claim that is subsequently supported by written notice is
586 overdue if not paid within 30 days after such written notice is
587 furnished to the insurer.
588 (c) If When an insurer pays only a portion of a claim or
589 rejects a claim, the insurer shall provide at the time of the
590 partial payment or rejection an itemized specification of each
591 item that the insurer had reduced, omitted, or declined to pay
592 and any information that the insurer desires the claimant to
593 consider related to the medical necessity of the denied
594 treatment or to explain the reasonableness of the reduced
595 charge, provided that this does shall not limit the introduction
596 of evidence at trial.; and The insurer must shall include the
597 name and address of the person to whom the claimant should
598 respond and a claim number to be referenced in future
599 correspondence. An insurer’s failure to send an itemized
600 specification or explanation of benefits does not waive other
601 grounds for rejecting an invalid claim.
602 (d) A However, notwithstanding the fact that written notice
603 has been furnished to the insurer, Any payment is shall not be
604 deemed overdue if when the insurer has reasonable proof to
605 establish that the insurer is not responsible for the payment.
606 An insurer may obtain evidence and assert any ground for
607 adjustment or rejection of a For the purpose of calculating the
608 extent to which any benefits are overdue, payment shall be
609 treated as being made on the date a draft or other valid
610 instrument which is equivalent to payment was placed in the
611 United States mail in a properly addressed, postpaid envelope
612 or, if not so posted, on the date of delivery. This paragraph
613 does not preclude or limit the ability of the insurer to assert
614 that the claim that is was unrelated, was not medically
615 necessary, or was unreasonable, or submitted that the amount of
616 the charge was in excess of that permitted under, or in
617 violation of, subsection (6) (5). Such assertion by the insurer
618 may be made at any time, including after payment of the claim,
619 or after the 30-day time period for payment set forth in this
620 paragraph (b), or after the filing of a lawsuit.
621 (e) The 30-day period for payment is tolled while the
622 insurer investigates a fraudulent insurance act, as defined in
623 s. 626.989, with respect to any portion of a claim for which the
624 insurer has a reasonable belief that a fraudulent insurance act
625 has been committed. The insurer must notify the claimant in
626 writing that it is investigating a fraudulent insurance act
627 within 30 days after the date it has a reasonable belief that
628 such act has been committed. The insurer must pay or deny the
629 claim, in full or in part, within 90 days after the date the
630 written notice of the fact of a covered loss and of the amount
631 of the loss was provided to the insurer. However, no payment is
632 due to a claimant that has violated paragraph (k).
633 (f)(c) Notwithstanding any local lien law, upon receiving
634 notice of an accident that is potentially covered by personal
635 injury protection benefits, the insurer must reserve $5,000 of
636 personal injury protection benefits for payment to physicians
637 licensed under chapter 458 or chapter 459 or dentists licensed
638 under chapter 466 who provide emergency services and care, as
639 defined in s. 395.002(9), or who provide hospital inpatient
640 care. The amount required to be held in reserve may be used only
641 to pay claims from such physicians or dentists until 30 days
642 after the date the insurer receives notice of the accident.
643 After the 30-day period, any amount of the reserve for which the
644 insurer has not received notice of such a claim from a physician
645 or dentist who provided emergency services and care or who
646 provided hospital inpatient care may then be used by the insurer
647 to pay other claims. The time periods specified in paragraph (b)
648 for required payment of personal injury protection benefits are
649 shall be tolled for the period of time that an insurer is
650 required by this paragraph to hold payment of a claim that is
651 not from a physician or dentist who provided emergency services
652 and care or who provided hospital inpatient care to the extent
653 that the personal injury protection benefits not held in reserve
654 are insufficient to pay the claim. This paragraph does not
655 require an insurer to establish a claim reserve for insurance
656 accounting purposes.
657 (g)(d) All overdue payments shall bear simple interest at
658 the rate established under s. 55.03 or the rate established in
659 the insurance contract, whichever is greater, for the year in
660 which the payment became overdue, calculated from the date the
661 insurer was furnished with written notice of the amount of
662 covered loss. However, interest on a payment that is overdue
663 pursuant to paragraph (e) shall be calculated from the date the
664 insurer denies payment. Interest is shall be due at the time
665 payment of the overdue claim is made.
666 (h)(e) The insurer of the owner of a motor vehicle shall
667 pay personal injury protection benefits for:
668 1. Accidental bodily injury sustained in this state by the
669 owner while occupying a motor vehicle, or while not an occupant
670 of a self-propelled vehicle if the injury is caused by physical
671 contact with a motor vehicle.
672 2. Accidental bodily injury sustained outside this state,
673 but within the United States of America or its territories or
674 possessions or Canada, by the owner while occupying the owner’s
675 motor vehicle.
676 3. Accidental bodily injury sustained by a relative of the
677 owner residing in the same household, under the circumstances
678 described in subparagraph 1. or subparagraph 2. if, provided the
679 relative at the time of the accident is domiciled in the owner’s
680 household and is not himself or herself the owner of a motor
681 vehicle with respect to which security is required under the no
682 fault law ss. 627.730-627.7405.
683 4. Accidental bodily injury sustained in this state by any
684 other person while occupying the owner’s motor vehicle or, if a
685 resident of this state, while not an occupant of a self
686 propelled vehicle, if the injury is caused by physical contact
687 with such motor vehicle if, provided the injured person is not
688 himself or herself:
689 a. The owner of a motor vehicle with respect to which
690 security is required under the no-fault law ss. 627.730
691 627.7405; or
692 b. Entitled to personal injury benefits from the insurer of
693 the owner or owners of such a motor vehicle.
694 (i)(f) If two or more insurers are liable to pay personal
695 injury protection benefits for the same injury to any one
696 person, the maximum payable is shall be as specified in
697 subsection (1), and any insurer paying the benefits is shall be
698 entitled to recover from each of the other insurers an equitable
699 pro rata share of the benefits paid and expenses incurred in
700 processing the claim.
701 (j)(g) It is a violation of the insurance code for an
702 insurer to fail to timely provide benefits as required by this
703 section with such frequency as to constitute a general business
704 practice.
705 (k)(h) Benefits are shall not be due or payable to a
706 claimant who knowingly: or on the behalf of an insured person if
707 that person has
708 1. Submits a false or misleading statement, document,
709 record, or bill;
710 2. Submits false or misleading information; or
711 3. Has otherwise committed or attempted to commit a
712 fraudulent insurance act as defined in s. 626.989.
713
714 A claimant that violates this paragraph is not entitled to any
715 personal injury protection benefits or payment for any bills and
716 services, regardless of whether a portion of the claim may be
717 legitimate. However, a claimant that does not violate this
718 paragraph may not be denied benefits solely due to a violation
719 by another claimant.
720 (l) Notwithstanding any remedies afforded by law, the
721 insurer may recover from a claimant who violates paragraph (k)
722 any sums previously paid to a claimant and may bring any
723 available common law and statutory causes of action. A claimant
724 has violated paragraph (k) committed, by a material act or
725 omission, any insurance fraud relating to personal injury
726 protection coverage under his or her policy, if the fraud is
727 admitted to in a sworn statement by the insured or if it is
728 established in a court of competent jurisdiction. Any insurance
729 fraud voids shall void all coverage arising from the claim
730 related to such fraud under the personal injury protection
731 coverage of the claimant insured person who committed the fraud,
732 irrespective of whether a portion of the insured person’s claim
733 may be legitimate, and any benefits paid before prior to the
734 discovery of the insured person’s insurance fraud is shall be
735 recoverable by the insurer from the claimant person who
736 committed insurance fraud in their entirety. The prevailing
737 party is entitled to its costs and attorney’s fees in any action
738 in which it prevails in an insurer’s action to enforce its right
739 of recovery under this paragraph. This paragraph does not
740 preclude or limit an insurer’s right to deny a claim based on
741 other evidence of fraud or affect an insurer’s right to plead
742 and prove a claim or defense of fraud under common law. If a
743 physician, hospital, clinic, or other medical institution
744 violates paragraph (k), the injured party is not liable for, and
745 the physician, hospital, clinic, or other medical institution
746 may not bill the insured for, charges that are unpaid because of
747 failure to comply with paragraph (k). Any agreement requiring
748 the injured person or insured to pay for such charges is
749 unenforceable.
750 (5) INSURER INVESTIGATIONS.—An insurer has the right and
751 duty to conduct a reasonable investigation of a claim. In the
752 course of the insurer’s investigation of a claim:
753 (a) Any records review need not be based on a physical
754 examination and may be obtained at any time, including after
755 reduction or denial of the claim.
756 1. The records review must be conducted by a practitioner
757 within the same licensing chapter as the medical provider whose
758 records are being reviewed unless the records review is
759 performed by a physician licensed under chapter 458 or chapter
760 459.
761 2. The 30-day period for payment under paragraph (4)(b) is
762 tolled from the date the insurer sends its request for treatment
763 records to the date that the insurer receives the treatment
764 records.
765 3. The insured, claimant, or medical provider may impose a
766 reasonable, cost-based fee that includes only the cost of
767 copying and postage and not the cost of labor for copying.
768 (b) In all circumstances, an insured seeking benefits under
769 the no-fault law must comply with the terms of the policy, which
770 includes, but is not limited to, submitting to examinations
771 under oath. Compliance with this paragraph is a condition
772 precedent to receiving benefits.
773 (c) An insurer may deny benefits if the insured, claimant,
774 or medical provider fails to:
775 1. Cooperate in the insurer’s investigation;
776 2. Commits a fraud or material misrepresentation; or
777 3. Comply with this subsection.
778 (d) The claimant may not file suit unless and until it
779 complies with this subsection.
780 (6)(5) CHARGES FOR TREATMENT OF INJURED PERSONS.—
781 (a)1. Any physician, hospital, clinic, or other person or
782 institution lawfully rendering treatment to an injured person
783 for a bodily injury covered by personal injury protection
784 insurance may charge the insurer and injured party only a
785 reasonable amount pursuant to this section for the services and
786 supplies rendered, and the insurer providing such coverage may
787 pay for such charges directly to such person or institution
788 lawfully rendering such treatment, if the insured receiving such
789 treatment or his or her guardian has countersigned the properly
790 completed invoice, bill, or claim form approved by the office
791 upon which such charges are to be paid for as having actually
792 been rendered, to the best knowledge of the insured or his or
793 her guardian. In no event, However, may such charges may not
794 exceed the reimbursement schedule under this paragraph a charge
795 be in excess of the amount the person or institution customarily
796 charges for like services or supplies. With respect to a
797 determination of whether a charge for a particular service,
798 treatment, or otherwise is reasonable, consideration may be
799 given to evidence of usual and customary charges and payments
800 accepted by the provider involved in the dispute, and
801 reimbursement levels in the community and various federal and
802 state medical fee schedules applicable to automobile and other
803 insurance coverages, and other information relevant to the
804 reasonableness of the reimbursement for the service, treatment,
805 or supply.
806 1.2. The insurer shall may limit reimbursement to no more
807 than 80 percent of the following schedule of maximum charges:
808 a. For emergency transport and treatment by providers
809 licensed under chapter 401, 200 percent of Medicare.
810 b. For emergency services and care provided by a hospital
811 licensed under chapter 395, 75 percent of the hospital’s usual
812 and customary charges.
813 c. For emergency services and care as defined by s.
814 395.002(9) provided in a facility licensed under chapter 395
815 rendered by a physician or dentist, and related hospital
816 inpatient services rendered by a physician or dentist, the usual
817 and customary charges in the community.
818 d. For hospital inpatient services, other than emergency
819 services and care, 200 percent of the Medicare Part A
820 prospective payment applicable to the specific hospital
821 providing the inpatient services.
822 e. For hospital outpatient services, other than emergency
823 services and care, 200 percent of the Medicare Part A Ambulatory
824 Payment Classification for the specific hospital providing the
825 outpatient services.
826 f. For all other medical services, supplies, and care, 200
827 percent of the allowable amount under the participating
828 physicians schedule of Medicare Part B. For all other supplies
829 and care, including durable medical equipment and care and
830 services rendered by ambulatory surgical centers and clinical
831 laboratories, 200 percent of the allowable amount under Medicare
832 Part B. However, if such services, supplies, or care is not
833 reimbursable under Medicare Part B, the insurer may limit
834 reimbursement to 80 percent of the maximum reimbursable
835 allowance under workers’ compensation, as determined under s.
836 440.13 and rules adopted thereunder which are in effect at the
837 time such services, supplies, or care is provided. Services,
838 supplies, or care that is not reimbursable under Medicare or
839 workers’ compensation is not required to be reimbursed by the
840 insurer.
841 2.3. For purposes of subparagraph 1. 2., the applicable fee
842 schedule or payment limitation under Medicare is the fee
843 schedule or payment limitation in effect on January 1 of the
844 year in which at the time the services, supplies, or care was
845 rendered and for the area in which such services were rendered,
846 which shall apply throughout the remainder of the year
847 notwithstanding any subsequent changes made to the fee schedule
848 or payment limitation, except that it may not be less than the
849 allowable amount under the participating physicians schedule of
850 Medicare Part B for 2007 for medical services, supplies, and
851 care subject to Medicare Part B.
852 3.4. Subparagraph 1. 2. does not allow the insurer to apply
853 any limitation on the number of treatments or other utilization
854 limits that apply under Medicare or workers’ compensation. An
855 insurer that applies the allowable payment limitations of
856 subparagraph 1. 2. must reimburse a provider who lawfully
857 provided care or treatment under the scope of his or her
858 license, regardless of whether such provider is would be
859 entitled to reimbursement under Medicare due to restrictions or
860 limitations on the types or discipline of health care providers
861 who may be reimbursed for particular procedures or procedure
862 codes.
863 4.5. If an insurer limits payment as authorized by
864 subparagraph 1. 2., the person providing such services,
865 supplies, or care may not bill or attempt to collect from the
866 insured any amount in excess of such limits, except for amounts
867 that are not covered by the insured’s personal injury protection
868 coverage due to the coinsurance amount or maximum policy limits.
869 (b)1. An insurer or insured is not required to pay a claim
870 or charges:
871 a. Made by a broker or by a person making a claim on behalf
872 of a broker;
873 b. For any service or treatment that was not lawful at the
874 time rendered;
875 c. To any person who knowingly submits a false or
876 misleading statement relating to the claim or charges;
877 d. With respect to A bill or statement that does not
878 substantially meet the applicable requirements of paragraphs
879 (c), paragraph (d), and (e);
880 e. Except for emergency treatment and care, if the insured
881 failed to countersign a billing form or patient log related to
882 such claim or charges. Failure to submit a countersigned billing
883 form or patient log creates a rebuttable presumption that the
884 insured did not receive the alleged treatment. The insurer is
885 not considered to have been furnished with notice of the subject
886 treatment and loss until the insurer is able to verify that the
887 insured received the alleged treatment. As used in this sub
888 subparagraph, the term “countersigned” means a second or
889 verifying signature, as on a previously signed document, and is
890 not satisfied by the statement “signature on file” or any
891 similar statement;
892 f.e. For any treatment or service that is upcoded, or that
893 is unbundled if when such treatment or services should be
894 bundled, in accordance with paragraph (d). To facilitate prompt
895 payment of lawful services, an insurer may change codes that it
896 determines to have been improperly or incorrectly upcoded or
897 unbundled, and may make payment based on the changed codes,
898 without affecting the right of the provider to dispute the
899 change by the insurer if, provided that before doing so, the
900 insurer contacts must contact the health care provider and
901 discusses discuss the reasons for the insurer’s change and the
902 health care provider’s reason for the coding, or makes make a
903 reasonable good faith effort to do so, as documented in the
904 insurer’s file; and
905 g.f. For medical services or treatment billed by a
906 physician and not provided in a hospital unless such services
907 are rendered by the physician or are incident to his or her
908 professional services and are included on the physician’s bill,
909 including documentation verifying that the physician is
910 responsible for the medical services that were rendered and
911 billed.
912 2. The Department of Health, in consultation with the
913 appropriate professional licensing boards, shall adopt, by rule,
914 a list of diagnostic tests deemed not to be medically necessary
915 for use in the treatment of persons sustaining bodily injury
916 covered by personal injury protection benefits under this
917 section. The initial list shall be adopted by January 1, 2004,
918 and shall be revised from time to time as determined by the
919 Department of Health, in consultation with the respective
920 professional licensing boards. Inclusion of a test on the list
921 must of invalid diagnostic tests shall be based on lack of
922 demonstrated medical value and a level of general acceptance by
923 the relevant provider community and may shall not be dependent
924 for results entirely upon subjective patient response.
925 Notwithstanding its inclusion on a fee schedule in this
926 subsection, an insurer or insured is not required to pay any
927 charges or reimburse claims for any invalid diagnostic test as
928 determined by the Department of Health.
929 (c)1. With respect to any treatment or service, other than
930 medical services billed by a hospital or other provider for
931 emergency services as defined in s. 395.002 or inpatient
932 services rendered at a hospital-owned facility, the statement of
933 charges must be furnished to the insurer by the provider and may
934 not include, and the insurer is not required to pay, charges for
935 treatment or services rendered more than 35 days before the
936 postmark date or electronic transmission date of the statement,
937 except for past due amounts previously billed on a timely basis
938 under this paragraph, and except that, if the provider submits
939 to the insurer a notice of initiation of treatment within 21
940 days after its first examination or treatment of the claimant,
941 the statement may include charges for treatment or services
942 rendered up to, but not more than, 75 days before the postmark
943 date of the statement. The injured party is not liable for, and
944 the provider may shall not bill the injured party for, charges
945 that are unpaid because of the provider’s failure to comply with
946 this paragraph. Any agreement requiring the injured person or
947 insured to pay for such charges is unenforceable.
948 1.2. If, however, the insured fails to furnish the provider
949 with the correct name and address of the insured’s personal
950 injury protection insurer, the provider has 35 days from the
951 date the provider obtains the correct information to furnish the
952 insurer with a statement of the charges. The insurer is not
953 required to pay for such charges unless the provider includes
954 with the statement documentary evidence that was provided by the
955 insured during the 35-day period demonstrating that the provider
956 reasonably relied on erroneous information from the insured and
957 either:
958 a. A denial letter from the incorrect insurer; or
959 b. Proof of mailing, which may include an affidavit under
960 penalty of perjury, reflecting timely mailing to the incorrect
961 address or insurer.
962 2.3. For emergency services and care as defined in s.
963 395.002 rendered in a hospital emergency department or for
964 transport and treatment rendered by an ambulance provider
965 licensed pursuant to part III of chapter 401, the provider is
966 not required to furnish the statement of charges within the time
967 periods established by this paragraph,; and the insurer is shall
968 not be considered to have been furnished with notice of the
969 amount of covered loss for purposes of paragraph (4)(b) until it
970 receives a statement complying with paragraph (d), or copy
971 thereof, which specifically identifies the place of service to
972 be a hospital emergency department or an ambulance in accordance
973 with billing standards recognized by the Centers for Medicare
974 and Medicaid Services Health Care Finance Administration.
975 3.4. Each notice of the insured’s rights under s. 627.7401
976 must include the following statement in type no smaller than 12
977 points:
978
979 BILLING REQUIREMENTS.—Florida Statutes provide that
980 with respect to any treatment or services, other than
981 certain hospital and emergency services, the statement
982 of charges furnished to the insurer by the provider
983 may not include, and the insurer and the injured party
984 are not required to pay, charges for treatment or
985 services rendered more than 35 days before the
986 postmark date of the statement, except for past due
987 amounts previously billed on a timely basis, and
988 except that, if the provider submits to the insurer a
989 notice of initiation of treatment within 21 days after
990 its first examination or treatment of the claimant,
991 the first billing cycle statement may include charges
992 for treatment or services rendered up to, but not more
993 than, 75 days before the postmark date of the
994 statement.
995
996 (d) All statements and bills for medical services rendered
997 by any physician, hospital, clinic, or other person or
998 institution shall be submitted to the insurer on a properly
999 completed Centers for Medicare and Medicaid Services (CMS) 1500
1000 form, UB 92 forms, or any other standard form approved by the
1001 office or adopted by the commission for purposes of this
1002 paragraph. All billings for such services rendered by providers
1003 must shall, to the extent applicable, follow the Physicians’
1004 Current Procedural Terminology (CPT) or Healthcare Correct
1005 Procedural Coding System (HCPCS), or ICD-9 in effect for the
1006 year in which services are rendered and comply with the Centers
1007 for Medicare and Medicaid Services (CMS) 1500 form instructions
1008 and the American Medical Association Current Procedural
1009 Terminology (CPT) Editorial Panel and Healthcare Correct
1010 Procedural Coding System (HCPCS). All providers other than
1011 hospitals shall include on the applicable claim form the
1012 professional license number of the provider in the line or space
1013 provided for “Signature of Physician or Supplier, Including
1014 Degrees or Credentials.” In determining compliance with
1015 applicable CPT and HCPCS coding, guidance shall be provided by
1016 the Physicians’ Current Procedural Terminology (CPT) or the
1017 Healthcare Correct Procedural Coding System (HCPCS) in effect
1018 for the year in which services were rendered, the Office of the
1019 Inspector General (OIG), Physicians Compliance Guidelines, and
1020 other authoritative treatises designated by rule by the Agency
1021 for Health Care Administration. A No statement of medical
1022 services may not include charges for medical services of a
1023 person or entity that performed such services without possessing
1024 the valid licenses required to perform such services. For
1025 purposes of paragraph (4)(b), an insurer is shall not be
1026 considered to have been furnished with notice of the amount of
1027 covered loss or medical bills due unless the statements or bills
1028 comply with this paragraph, and unless the statements or bills
1029 are comply with this paragraph, and unless the statements or
1030 bills are properly completed in their entirety as to all
1031 material provisions, with all relevant information being
1032 provided therein. If an insurer denies a claim due to a
1033 provider’s failure to submit a properly completed form, the
1034 insurer shall notify the provider as to the provisions that were
1035 improperly completed, and the provider shall have 15 days after
1036 the receipt of such notice to submit a properly completed form.
1037 If the provider fails to comply with this requirement, the
1038 insurer is not required to pay for the services that were billed
1039 on the improperly completed form.
1040 (e)1. At the initial treatment or service provided, each
1041 physician, other licensed professional, clinic, or other medical
1042 institution providing medical services upon which a claim for
1043 personal injury protection benefits is based shall require an
1044 insured person, or his or her guardian, to execute a disclosure
1045 and acknowledgment form, which reflects at a minimum that:
1046 a. The insured, or his or her guardian, must countersign
1047 the form attesting to the fact that the services set forth
1048 therein were actually rendered. The services shall be described
1049 and listed on the disclosure and acknowledgement form in words
1050 readable by the insured. If the insured cannot read, the
1051 provider should verify, under penalty of perjury, that the
1052 services listed on the form were verbally explained to the
1053 insured before the insured signs the form. Listing CPT codes or
1054 other coding on the disclosure and acknowledgment form does not
1055 satisfy this requirement;
1056 b. The insured, or his or her guardian, has both the right
1057 and affirmative duty to confirm that the services were actually
1058 rendered;
1059 c. The insured, or his or her guardian, was not solicited
1060 by any person to seek any services from the medical provider;
1061 d. The physician, other licensed professional, clinic, or
1062 other medical institution rendering services for which payment
1063 is being claimed explained the services to the insured or his or
1064 her guardian; and
1065 e. If the insured notifies the insurer in writing of a
1066 billing error, the insured may be entitled to a certain
1067 percentage of a reduction in the amounts paid by the insured’s
1068 motor vehicle insurer.
1069 2. The physician, other licensed professional, clinic, or
1070 other medical institution rendering services for which payment
1071 is being claimed has the affirmative duty to explain the
1072 services rendered to the insured, or his or her guardian, so
1073 that the insured, or his or her guardian, countersigns the form
1074 with informed consent.
1075 3. Countersignature by the insured, or his or her guardian,
1076 is not required for the reading of diagnostic tests or other
1077 services that are of such a nature that they are not required to
1078 be performed in the presence of the insured.
1079 4. The licensed medical professional rendering treatment
1080 for which payment is being claimed must sign, by his or her own
1081 hand, the form complying with this paragraph.
1082 5. An insurer is not considered to have been furnished with
1083 notice of the amount of a covered loss or medical bills unless
1084 the original completed disclosure and acknowledgment form is
1085 shall be furnished to the insurer pursuant to paragraph (4)(b)
1086 and sub-subparagraph 1.a. The disclosure and acknowledgement
1087 form may not be electronically furnished. A disclosure and
1088 acknowledgement form that does not meet the minimum requirements
1089 of sub-subparagraph 1.a. does not provide an insurer with notice
1090 of the amount of a covered loss or medical bills due.
1091 6. This disclosure and acknowledgment form is not required
1092 for services billed by a provider for emergency services as
1093 defined in s. 395.002, for emergency services and care as
1094 defined in s. 395.002 rendered in a hospital emergency
1095 department, or for transport and treatment rendered by an
1096 ambulance provider licensed pursuant to part III of chapter 401.
1097 7. The Financial Services Commission shall adopt, by rule,
1098 a standard disclosure and acknowledgment form to that shall be
1099 used to fulfill the requirements of this paragraph, effective 90
1100 days after such form is adopted and becomes final. The
1101 commission shall adopt a proposed rule by October 1, 2003. Until
1102 the rule is final, the provider may use a form of its own which
1103 otherwise complies with the requirements of this paragraph.
1104 8. As used in this paragraph, the term “countersigned” or
1105 “countersignature” means a second or verifying signature, as on
1106 a previously signed document, and is not satisfied by the
1107 statement “signature on file” or any similar statement.
1108 9. The requirements of this paragraph apply only with
1109 respect to the initial treatment or service of the insured by a
1110 provider. For subsequent treatments or service, the provider
1111 must maintain a patient log signed by the patient, in
1112 chronological order by date of service, which describes the
1113 treatment rendered in a language readable by the insured that is
1114 consistent with the services being rendered to the patient as
1115 claimed. Listing CPT codes or other coding on the patient log
1116 does not satisfy this requirement. The provider must provide
1117 copies of the patient log to the insurer within 30 days after
1118 receiving a written request from the insurer. Failure to
1119 maintain a patient log renders the treatment unlawful and
1120 noncompensable. The requirements of this subparagraph for
1121 maintaining a patient log signed by the patient may be met by a
1122 hospital that maintains medical records as required by s.
1123 395.3025 and applicable rules and makes such records available
1124 to the insurer upon request.
1125 (f) Upon written notification by any person, an insurer
1126 shall investigate any claim of improper billing by a physician
1127 or other medical provider. The insurer shall determine if the
1128 insured was properly billed for only those services and
1129 treatments that the insured actually received. If the insurer
1130 determines that the insured has been improperly billed, the
1131 insurer shall notify the insured, the person making the written
1132 notification, and the provider of its findings and shall reduce
1133 the amount of payment to the provider by the amount determined
1134 to be improperly billed. If a reduction is made due to such
1135 written notification by any person, the insurer shall pay to the
1136 person 20 percent of the amount of the reduction, up to $500. If
1137 the provider is arrested due to the improper billing, then the
1138 insurer shall pay to the person 40 percent of the amount of the
1139 reduction, up to $500.
1140 (g) An insurer may not systematically downcode with the
1141 intent to deny reimbursement otherwise due. Such action
1142 constitutes a material misrepresentation under s.
1143 626.9541(1)(i)2.
1144 (7)(6) DISCOVERY OF FACTS ABOUT AN INJURED PERSON;
1145 DISPUTES.—
1146 (b) Every physician, hospital, clinic, or other medical
1147 institution providing, before or after bodily injury upon which
1148 a claim for personal injury protection insurance benefits is
1149 based, any products, services, or accommodations in relation to
1150 that or any other injury, or in relation to a condition claimed
1151 to be connected with that or any other injury, shall, if
1152 requested to do so by the insurer against whom the claim has
1153 been made, permit the insurer or the insurer’s representative to
1154 conduct an onsite physical review and examination of the
1155 treatment location, treatment apparatuses, diagnostic devices,
1156 and any other medical equipment used for the services rendered
1157 within 10 days after the insurer’s request, and furnish
1158 forthwith a written report of the history, condition, treatment,
1159 dates, and costs of such treatment of the injured person and why
1160 the items identified by the insurer were reasonable in amount
1161 and medically necessary, together with a sworn statement that
1162 the treatment or services rendered were reasonable and necessary
1163 with respect to the bodily injury sustained and identifying
1164 which portion of the expenses for such treatment or services was
1165 incurred as a result of such bodily injury, and produce
1166 forthwith, and permit the inspection and copying of, his or her
1167 or its records regarding such history, condition, treatment,
1168 dates, and costs of treatment if; provided that this does shall
1169 not limit the introduction of evidence at trial. Such sworn
1170 statement must shall read as follows: “Under penalty of perjury,
1171 I declare that I have read the foregoing, and the facts alleged
1172 are true, to the best of my knowledge and belief.” A No cause of
1173 action for violation of the physician-patient privilege or
1174 invasion of the right of privacy may not be brought shall be
1175 permitted against any physician, hospital, clinic, or other
1176 medical institution complying with the provisions of this
1177 section. The person requesting such records and such sworn
1178 statement shall pay all reasonable costs connected therewith.
1179 1. If an insurer makes a written request for documentation
1180 or information under this paragraph within 30 days after having
1181 received notice of the amount of a covered loss under paragraph
1182 (4)(a), the amount or the partial amount that which is the
1183 subject of the insurer’s inquiry is shall become overdue if the
1184 insurer does not pay in accordance with paragraph (4)(b) or
1185 within 10 days after the insurer’s receipt of the requested
1186 documentation or information, whichever occurs later. For
1187 purposes of this subparagraph paragraph, the term “receipt”
1188 includes, but is not limited to, inspection and copying pursuant
1189 to this paragraph. An Any insurer that requests documentation or
1190 information pertaining to reasonableness of charges or medical
1191 necessity under this paragraph without a reasonable basis for
1192 such requests as a general business practice is engaging in an
1193 unfair trade practice under the insurance code.
1194 2. If an insured seeking to recover benefits pursuant to
1195 the no-fault law assigns the contractual right to those benefits
1196 or payment of those benefits to any person or entity, the
1197 assignee must comply with the terms of the policy. In all
1198 circumstances, the assignee is obligated to cooperate under the
1199 policy, which includes, but is not limited to, participating in
1200 an examination under oath. Examinations under oath may be
1201 recorded by audio, video, court reporter, or any combination
1202 thereof. Compliance with this paragraph is a condition precedent
1203 to recovery of benefits pursuant to the no-fault law.
1204 a. If an insurer requests an examination under oath of a
1205 medical provider, the provider must produce the persons having
1206 the most knowledge of the issues identified by the insurer in
1207 the request for examination under oath. All claimants must
1208 produce and provide for inspection all documents requested by
1209 the insurer which are reasonably obtainable by the claimant.
1210 b. Before requesting that an assignee participate in an
1211 examination under oath, the insurer must send a written request
1212 to the assignee requesting all information that the insurer
1213 believes is necessary to process the claim, including the
1214 information contemplated under this subparagraph.
1215 c. An insurer that, as a general practice, requests
1216 examinations under oath of an assignee without a reasonable
1217 basis is engaging in an unfair and deceptive trade practice.
1218 (8)(7) MENTAL AND PHYSICAL EXAMINATION OF INJURED PERSON;
1219 REPORTS.—
1220 (b) If requested by the person examined, a party causing an
1221 examination to be made shall deliver to him or her a copy of
1222 every written report concerning the examination rendered by an
1223 examining physician, at least one of which reports must set out
1224 the examining physician’s findings and conclusions in detail.
1225 After such request and delivery, the party causing the
1226 examination to be made is entitled, upon request, to receive
1227 from the person examined every written report available to him
1228 or her or his or her representative concerning any examination,
1229 previously or thereafter made, of the same mental or physical
1230 condition. By requesting and obtaining a report of the
1231 examination so ordered, or by taking the deposition of the
1232 examiner, the person examined waives any privilege he or she may
1233 have, in relation to the claim for benefits, regarding the
1234 testimony of every other person who has examined, or may
1235 thereafter examine, him or her in respect to the same mental or
1236 physical condition. If a person fails to appear for unreasonably
1237 refuses to submit to an examination, the personal injury
1238 protection carrier is not required to pay no longer liable for
1239 subsequent personal injury protection benefits incurred after
1240 the date of the first requested examination until the insured
1241 appears for the examination. Failure to appear for two scheduled
1242 examinations raises a rebuttable presumption that such failure
1243 was unreasonable. Submission to an examination is a condition
1244 precedent to the recovery of benefits.
1245 (9)(8) APPLICABILITY OF PROVISION REGULATING ATTORNEY’S
1246 FEES.—With respect to any dispute under the provisions of ss.
1247 627.730-627.7405 between the insured and the insurer under the
1248 no-fault law, or between an assignee of an insured’s rights and
1249 the insurer, the provisions of s. 627.428 shall apply, except as
1250 provided in subsections (11) and (16) (10) and (15).
1251 (10)(9) PREFERRED PROVIDERS.—An insurer may negotiate and
1252 enter into contracts with preferred licensed health care
1253 providers for the benefits described in this section, referred
1254 to in this section as “preferred providers,” which include shall
1255 include health care providers licensed under chapter 457,
1256 chapter chapters 458, chapter 459, chapter 460, chapter 461, or
1257 chapter and 463.
1258 (a) The insurer may provide an option to an insured to use
1259 a preferred provider at the time of purchase of the policy for
1260 personal injury protection benefits, if the requirements of this
1261 subsection are met. However, if the insurer offers a preferred
1262 provider option, it must also offer a nonpreferred provider
1263 policy. If the insured elects to use a provider who is not a
1264 preferred provider, whether the insured purchased a preferred
1265 provider policy or a nonpreferred provider policy, the medical
1266 benefits provided by the insurer shall be as required by this
1267 section.
1268 (b) If the insured elects the to use a provider who is a
1269 preferred provider option, the insurer may pay medical benefits
1270 in excess of the benefits required by this section and may waive
1271 or lower the amount of any deductible that applies to such
1272 medical benefits. As an alternative, or in addition to such
1273 benefits, waiver, or reduction, the insurer may provide an
1274 actuarially appropriate premium discount as specified in an
1275 approved rate filing to an insured who selects the preferred
1276 provider option. If the preferred provider option provides a
1277 premium discount, the policy may provide that charges for
1278 nonemergency services provided within this state are payable
1279 only if performed by members of the preferred provider network
1280 unless there is no member of the preferred provider network
1281 located within 15 miles of the insured’s place of residence
1282 whose scope of practice includes the required services, or
1283 unless the nonemergency services are rendered in the emergency
1284 room of a hospital licensed under chapter 395. If the insurer
1285 offers a preferred provider policy to a policyholder or
1286 applicant, it must also offer a nonpreferred provider policy.
1287 (c) The insurer shall provide each insured policyholder
1288 with a current roster of preferred providers in the county in
1289 which the insured resides at the time of purchasing purchase of
1290 such policy, and shall make such list available for public
1291 inspection during regular business hours at the insurer’s
1292 principal office of the insurer within the state. The insurer
1293 may contract with a health insurer for the right to use an
1294 existing preferred provider network to implement the preferred
1295 provider option. Any other arrangement is subject to the
1296 approval of the Office of Insurance Regulation.
1297 (11)(10) DEMAND LETTER.—
1298 (a) As a condition precedent to filing any action for
1299 benefits under this section, the claimant filing suit must
1300 provide the insurer must be provided with written notice of an
1301 intent to initiate litigation. Such notice may not be sent until
1302 the claim is overdue, including any additional time the insurer
1303 has to pay the claim pursuant to paragraph (4)(b). A premature
1304 demand letter is defective and cannot be cured unless the court
1305 first abates the action or the claimant first voluntarily
1306 dismisses the action.
1307 (b) The notice required notice must shall state that it is
1308 a “demand letter under s. 627.736(10)” and shall state with
1309 specificity:
1310 1. The name of the insured upon which such benefits are
1311 being sought, including a copy of the assignment giving rights
1312 to the claimant if the claimant is not the insured.
1313 2. The claim number or policy number upon which such claim
1314 was originally submitted to the insurer.
1315 3. To the extent applicable, the name of any medical
1316 provider who rendered to an insured the treatment, services,
1317 accommodations, or supplies that form the basis of such claim;
1318 and an itemized statement specifying each exact amount, the date
1319 of treatment, service, or accommodation, and the type of benefit
1320 claimed to be due. A completed form satisfying the requirements
1321 of paragraph (6)(5)(d) or the lost-wage statement previously
1322 submitted may be used as the itemized statement. To the extent
1323 that the demand involves an insurer’s withdrawal of payment
1324 under paragraph (7)(a) for future treatment not yet rendered,
1325 the claimant shall attach a copy of the insurer’s notice
1326 withdrawing such payment and an itemized statement of the type,
1327 frequency, and duration of future treatment claimed to be
1328 reasonable and medically necessary.
1329 (c) Each notice required by this subsection must be
1330 delivered to the insurer by United States certified or
1331 registered mail, return receipt requested. Such postal costs
1332 shall be reimbursed by the insurer if so requested by the
1333 claimant in the notice, when the insurer pays the claim. Such
1334 notice must be sent to the person and address specified by the
1335 insurer for the purposes of receiving notices under this
1336 subsection. Each licensed insurer, whether domestic, foreign, or
1337 alien, shall file with the office designation of the name and
1338 address of the person to whom notices must pursuant to this
1339 subsection shall be sent which the office shall make available
1340 on its Internet website. The name and address on file with the
1341 office pursuant to s. 624.422 shall be deemed the authorized
1342 representative to accept notice pursuant to this subsection if
1343 in the event no other designation has been made.
1344 (d) If, within 30 days after receipt of notice by the
1345 insurer, the overdue claim specified in the notice is paid by
1346 the insurer together with applicable interest and a penalty of
1347 10 percent of the overdue amount paid by the insurer, subject to
1348 a maximum penalty of $250, no action may be brought against the
1349 insurer. If the demand involves an insurer’s withdrawal of
1350 payment under paragraph (7)(a) for future treatment not yet
1351 rendered, no action may be brought against the insurer if,
1352 within 30 days after its receipt of the notice, the insurer
1353 mails to the person filing the notice a written statement of the
1354 insurer’s agreement to pay for such treatment in accordance with
1355 the notice and to pay a penalty of 10 percent, subject to a
1356 maximum penalty of $250, when it pays for such future treatment
1357 in accordance with the requirements of this section. To the
1358 extent the insurer determines not to pay any amount demanded,
1359 the penalty is shall not be payable in any subsequent action.
1360 For purposes of this subsection, payment or the insurer’s
1361 agreement is shall be treated as being made on the date a draft
1362 or other valid instrument that is equivalent to payment, or the
1363 insurer’s written statement of agreement, is placed in the
1364 United States mail in a properly addressed, postpaid envelope,
1365 or if not so posted, on the date of delivery. The insurer is not
1366 obligated to pay any attorney’s fees if the insurer pays the
1367 claim or mails its agreement to pay for future treatment within
1368 the time prescribed by this subsection.
1369 (e) The applicable statute of limitation for an action
1370 under this section shall be tolled for a period of 30 business
1371 days by the mailing of the notice required by this subsection.
1372 (f) A demand letter that does not meet the minimum
1373 requirements set forth in this subsection or that is sent during
1374 the pendency of the lawsuit is defective. A defective demand
1375 letter cannot be cured unless the court first abates the action
1376 or the claimant first voluntarily dismisses the action.
1377 (g)(f) An Any insurer making a general business practice of
1378 not paying valid claims until receipt of the notice required by
1379 this subsection is engaging in an unfair trade practice under
1380 the insurance code.
1381 (h) If the insurer pays in response to a demand letter and
1382 the claimant disputes the amount paid, the claimant must send a
1383 second demand letter by certified or registered mail stating the
1384 exact amount that the claimant believes the insurer owes and why
1385 the claimant believes the amount paid is incorrect. The insurer
1386 has an additional 10 days after receipt of the second letter to
1387 issue any additional payment that is owed. The purpose of this
1388 provision is to avoid unnecessary litigation over miscalculated
1389 payments.
1390 (i) Demand letters may not be used to request the
1391 production of claim documents or other records from the insurer.
1392 Section 10. Paragraph (c) of subsection (7), and
1393 subsections (10) through (12) of section 817.234, Florida
1394 Statutes, are amended to read:
1395 817.234 False and fraudulent insurance claims.—
1396 (7)
1397 (c) An insurer, or any person acting at the direction of or
1398 on behalf of an insurer, may not change an opinion in a mental
1399 or physical report prepared under s. 627.736(8) 627.736(7) or
1400 direct the physician preparing the report to change such
1401 opinion; however, this provision does not preclude the insurer
1402 from calling to the attention of the physician errors of fact in
1403 the report based upon information in the claim file. Any person
1404 who violates this paragraph commits a felony of the third
1405 degree, punishable as provided in s. 775.082, s. 775.083, or s.
1406 775.084.
1407 (10) As used in this section, the term “insurer” means any
1408 insurer, health maintenance organization, self-insurer, self
1409 insurance fund, or other similar entity or person regulated
1410 under chapter 440 or chapter 641 or by the Office of Insurance
1411 Regulation under the Florida Insurance Code.
1412 (10)(11) If the value of any property involved in a
1413 violation of this section:
1414 (a) Is less than $20,000, the offender commits a felony of
1415 the third degree, punishable as provided in s. 775.082, s.
1416 775.083, or s. 775.084.
1417 (b) Is $20,000 or more, but less than $100,000, the
1418 offender commits a felony of the second degree, punishable as
1419 provided in s. 775.082, s. 775.083, or s. 775.084.
1420 (c) Is $100,000 or more, the offender commits a felony of
1421 the first degree, punishable as provided in s. 775.082, s.
1422 775.083, or s. 775.084.
1423 (11) In addition to any criminal liability, a person
1424 convicted of violating any provision of this section for the
1425 purpose of receiving insurance proceeds from a motor vehicle
1426 insurance contract is subject to a civil penalty.
1427 (a) Except for a violation of subsection (9), the civil
1428 penalty shall be:
1429 1. A fine up to $5,000 for a first offense.
1430 2. A fine greater than $5,000, but not to exceed $10,000,
1431 for a second offense.
1432 3. A fine greater than $10,000, but not to exceed $15,000,
1433 for a third or subsequent offense.
1434 (b) The civil penalty for a violation of subsection (9)
1435 must be at least $15,000, but may not exceed $50,000.
1436 (c) The civil penalty shall be paid to the Insurance
1437 Regulatory Trust Fund within the Department of Financial
1438 Services and used by the department for the investigation and
1439 prosecution of insurance fraud.
1440 (d) This subsection does not prohibit a state attorney from
1441 entering into a written agreement in which the person charged
1442 with the violation does not admit to or deny the charges but
1443 consents to payment of the civil penalty.
1444 (12) As used in this section, the term:
1445 (a) “Insurer” means any insurer, health maintenance
1446 organization, self-insurer, self-insurance fund, or similar
1447 entity or person regulated under chapter 440 or chapter 641 or
1448 by the Office of Insurance Regulation under the Florida
1449 Insurance Code.
1450 (b)(a) “Property” means property as defined in s. 812.012.
1451 (c)(b) “Value” has the same meaning means value as defined
1452 in s. 812.012.
1453 Section 11. Subsection (1) of section 324.021, Florida
1454 Statutes, is amended to read:
1455 324.021 Definitions; minimum insurance required.—The
1456 following words and phrases when used in this chapter shall, for
1457 the purpose of this chapter, have the meanings respectively
1458 ascribed to them in this section, except in those instances
1459 where the context clearly indicates a different meaning:
1460 (1) MOTOR VEHICLE.—Every self-propelled vehicle that which
1461 is designed and required to be licensed for use upon a highway,
1462 including trailers and semitrailers designed for use with such
1463 vehicles, except traction engines, road rollers, farm tractors,
1464 power shovels, and well drillers, and every vehicle that which
1465 is propelled by electric power obtained from overhead wires but
1466 not operated upon rails, but not including any bicycle or moped.
1467 However, the term does “motor vehicle” shall not include a any
1468 motor vehicle as defined in s. 627.732(3) if when the owner of
1469 such vehicle has complied with the no-fault law requirements of
1470 ss. 627.730-627.7405, inclusive, unless the provisions of s.
1471 324.051 apply; and, in such case, the applicable proof of
1472 insurance provisions of s. 320.02 apply.
1473 Section 12. Paragraph (k) of subsection (2) of section
1474 456.057, Florida Statutes, is amended to read:
1475 456.057 Ownership and control of patient records; report or
1476 copies of records to be furnished.—
1477 (2) As used in this section, the terms “records owner,”
1478 “health care practitioner,” and “health care practitioner’s
1479 employer” do not include any of the following persons or
1480 entities; furthermore, the following persons or entities are not
1481 authorized to acquire or own medical records, but are authorized
1482 under the confidentiality and disclosure requirements of this
1483 section to maintain those documents required by the part or
1484 chapter under which they are licensed or regulated:
1485 (k) Persons or entities practicing under s. 627.736(8)
1486 627.736(7).
1487 Section 13. Paragraph (b) of subsection (1) of section
1488 627.7401, Florida Statutes, is amended to read:
1489 627.7401 Notification of insured’s rights.—
1490 (1) The commission, by rule, shall adopt a form for the
1491 notification of insureds of their right to receive personal
1492 injury protection benefits under the Florida Motor Vehicle no
1493 fault law. Such notice shall include:
1494 (b) An advisory informing insureds that:
1495 1. Pursuant to s. 626.9892, the Department of Financial
1496 Services may pay rewards of up to $25,000 to persons providing
1497 information leading to the arrest and conviction of persons
1498 committing crimes investigated by the Division of Insurance
1499 Fraud arising from violations of s. 440.105, s. 624.15, s.
1500 626.9541, s. 626.989, or s. 817.234.
1501 2. Pursuant to s. 627.736(6)(e)1. 627.736(5)(e)1., if the
1502 insured notifies the insurer of a billing error, the insured may
1503 be entitled to a certain percentage of a reduction in the amount
1504 paid by the insured’s motor vehicle insurer.
1505 Section 14. This act shall take effect July 1, 2011.
1506
1507 ================= T I T L E A M E N D M E N T ================
1508 And the title is amended as follows:
1509 Delete lines 34 - 39
1510 and insert:
1511 Delete everything before the enacting clause
1512 and insert:
1513 A bill to be entitled
1514 An act relating to motor vehicle personal injury
1515 protection insurance; amending s. 316.066, F.S.;
1516 revising provisions relating to the contents of
1517 written reports of motor vehicle crashes; requiring
1518 short-form crash reports by a law enforcement officer
1519 to be maintained by the officer’s agency; authorizing
1520 the investigation officer to testify at trial or
1521 provide an affidavit concerning the content of the
1522 reports; amending s. 400.991, F.S.; requiring that an
1523 application for licensure as a mobile clinic include a
1524 statement regarding insurance fraud; creating s.
1525 626.9894, F.S.; providing definitions; authorizing the
1526 Division of Insurance Fraud to establish a direct
1527 support organization for the purpose of prosecuting,
1528 investigating, and preventing motor vehicle insurance
1529 fraud; providing requirements for the organization and
1530 the organization’s contract with the division;
1531 providing for a board of directors; authorizing the
1532 organization to use the division’s property and
1533 facilities subject to certain requirements;
1534 authorizing contributions from insurers; providing
1535 that any moneys received by the organization may be
1536 held in a separate depository account in the name of
1537 the organization; requiring the division to deposit
1538 certain proceeds into the Insurance Regulatory Trust
1539 Fund; amending s. 627.4137, F.S.; requiring a
1540 claimant’s request about insurance coverage to be
1541 appropriately served upon the disclosing entity;
1542 amending s. 627.730, F.S.; conforming a cross
1543 reference; amending s. 627.731, F.S.; providing
1544 legislative intent with respect to the Florida Motor
1545 Vehicle No-Fault Law; creating s. 627.7311, F.S.;
1546 requiring the provisions, schedules, and procedures of
1547 the no-fault law to be implemented by insurers
1548 regardless of whether they are expressly stated in the
1549 policy; amending s. 627.732, F.S.; defining the terms
1550 “claimant” and “no-fault law”; amending s. 627.736,
1551 F.S.; conforming a cross-reference; adding
1552 acupuncturists to the list of authorized
1553 practitioners; requiring certain entities providing
1554 medical services to document that they meet required
1555 criteria; revising requirements relating to the form
1556 that must be submitted by providers; requiring an
1557 entity or clinic to file a new form within a specified
1558 period after the date of a change of ownership;
1559 revising provisions relating to when payment for a
1560 benefit is due; providing that an insurer’s failure to
1561 send certain specification or explanation does not
1562 waive other grounds for rejecting an invalid claim;
1563 authorizing an insurer to obtain evidence and assert
1564 any ground for adjusting or rejecting a claim;
1565 providing that the time period for paying a claim is
1566 tolled during the investigation of a fraudulent
1567 insurance act; specifying when benefits are not
1568 payable; preempting local lien laws with respect to
1569 payment of benefits to medical providers; providing
1570 that a claimant that violates certain provisions is
1571 not entitled to any payment, regardless of whether a
1572 portion of the claim may be legitimate; authorizing an
1573 insurer to recover payments and bring a cause of
1574 action to recover payments; providing that an insurer
1575 may deny any claim based on other evidence of fraud;
1576 forbidding a physician, hospital, clinic, or other
1577 medical institution that fails to comply with certain
1578 provisions from billing the injured person or the
1579 insured; providing that an insurer has a right to
1580 conduct reasonable investigations of claims;
1581 authorizing an insurer to require a claimant to
1582 provide certain records; requiring a records review to
1583 be conducted by the same type of practitioner as the
1584 medical provider whose records are being reviewed or
1585 by a physician; specifying when the period for payment
1586 is tolled; authorizing an insurer to deny benefits if
1587 an insured, claimant, or medical provider fails to
1588 comply with certain provisions; forbidding the
1589 claimant from filing suit unless the claimant complies
1590 with the act; revising the insurer’s reimbursement
1591 limitation; providing a limit on the amount of
1592 reimbursement; creating a rebuttable presumption that
1593 the insured did not receive the alleged treatment if
1594 the insured does not countersign the patient log;
1595 authorizing the insurer to deny a claim if the
1596 provider does not properly complete the required form
1597 within a certain time; requiring the provider to
1598 ensure that the insured understands the services being
1599 provided; specifying requirements for furnishing the
1600 insured with notice of the amount of covered loss;
1601 deleting an obsolete provision; requiring the provider
1602 to provide copies of the patient log within a certain
1603 time if requested by the insurer; providing that
1604 failure to maintain a patient log renders the
1605 treatment unlawful and noncompensable; revising
1606 requirements relating to discovery; authorizing the
1607 insurer to conduct a physical review of the treatment
1608 location; requiring the insured and assignee to comply
1609 with certain provisions to recover benefits; requiring
1610 the provider to produce persons having the most
1611 knowledge in specified circumstances; requiring the
1612 insurer to request certain information before
1613 requesting an assignee to participate in an
1614 examination under oath; providing that an insurer that
1615 requests an examination under oath without a
1616 reasonable basis is engaging in an unfair and
1617 deceptive trade practice; providing that failure to
1618 appear for scheduled examinations establishes a
1619 rebuttable presumption that such failure was
1620 unreasonable; authorizing an insurer to contract with
1621 a preferred provider network; authorizing an insurer
1622 to provide a premium discount to an insured who
1623 selects a preferred provider; authorizing an insurance
1624 policy to not pay for nonemergency services performed
1625 by a nonpreferred provider in specified circumstances;
1626 authorizing an insurer to contract with a health
1627 insurer in specified circumstances; revising
1628 requirements relating to demand letters in an action
1629 for benefits; specifying when a demand letter is
1630 defective; requiring a second demand letter under
1631 certain circumstances; deleting obsolete provisions;
1632 providing that a demand letter may not be used to
1633 request the production of claim documents or records
1634 from the insurer; amending s. 817.234, F.S.;
1635 conforming a cross-reference; providing civil
1636 penalties for fraudulent insurance claims; amending
1637 ss. 324.021, 456.057, and 627.7401, F.S.; conforming
1638 cross-references; providing an effective date.