Florida Senate - 2012 SENATOR AMENDMENT
Bill No. CS/CS/HB 119, 2nd Eng.
Barcode 918912
LEGISLATIVE ACTION
Senate . House
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Floor: 1/AD/3R . Floor: SENA1/CA
03/07/2012 11:19 AM . 03/09/2012 06:43 PM
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Senator Negron moved the following:
1 Senate Amendment (with title amendment)
2
3 Delete everything after the enacting clause
4 and insert:
5 Section 1. Subsection (1) of section 316.066, Florida
6 Statutes, is amended to read:
7 316.066 Written reports of crashes.—
8 (1)(a) A Florida Traffic Crash Report, Long Form must is
9 required to be completed and submitted to the department within
10 10 days after completing an investigation is completed by the
11 every law enforcement officer who in the regular course of duty
12 investigates a motor vehicle crash that:
13 1. Resulted in death or personal injury;.
14 2. Involved a violation of s. 316.061(1) or s. 316.193;.
15 3. Rendered a vehicle inoperable to a degree that required
16 a wrecker to remove it from the scene of the crash; or
17 4. Involved a commercial motor vehicle.
18 (b) In any every crash for which a Florida Traffic Crash
19 Report, Long Form is not required by this section and which
20 occurs on the public roadways of this state, the law enforcement
21 officer shall may complete a short-form crash report or provide
22 a driver exchange-of-information form, to be completed by all
23 drivers and passengers each party involved in the crash, which
24 requires the identification of each vehicle that the drivers and
25 passengers were in. The short-form report must include:
26 1. The date, time, and location of the crash.
27 2. A description of the vehicles involved.
28 3. The names and addresses of the parties involved,
29 including all drivers and passengers, and the identification of
30 the vehicle in which each was a passenger.
31 4. The names and addresses of witnesses.
32 5. The name, badge number, and law enforcement agency of
33 the officer investigating the crash.
34 6. The names of the insurance companies for the respective
35 parties involved in the crash.
36 (c) Each party to the crash must provide the law
37 enforcement officer with proof of insurance, which must be
38 documented in the crash report. If a law enforcement officer
39 submits a report on the crash, proof of insurance must be
40 provided to the officer by each party involved in the crash. Any
41 party who fails to provide the required information commits a
42 noncriminal traffic infraction, punishable as a nonmoving
43 violation as provided in chapter 318, unless the officer
44 determines that due to injuries or other special circumstances
45 such insurance information cannot be provided immediately. If
46 the person provides the law enforcement agency, within 24 hours
47 after the crash, proof of insurance that was valid at the time
48 of the crash, the law enforcement agency may void the citation.
49 (d) The driver of a vehicle that was in any manner involved
50 in a crash resulting in damage to a any vehicle or other
51 property which does not require a law enforcement report in an
52 amount of $500 or more which was not investigated by a law
53 enforcement agency, shall, within 10 days after the crash,
54 submit a written report of the crash to the department. The
55 report shall be submitted on a form approved by the department.
56 The entity receiving the report may require witnesses of the
57 crash to render reports and may require any driver of a vehicle
58 involved in a crash of which a written report must be made to
59 file supplemental written reports if the original report is
60 deemed insufficient by the receiving entity.
61 (e) Long-form and short-form crash reports prepared by law
62 enforcement must be submitted to the department and may shall be
63 maintained by the law enforcement officer’s agency.
64 Section 2. Subsection (4) of section 400.9905, Florida
65 Statutes, is amended to read:
66 400.9905 Definitions.—
67 (4) “Clinic” means an entity where at which health care
68 services are provided to individuals and which tenders charges
69 for reimbursement for such services, including a mobile clinic
70 and a portable equipment provider. As used in For purposes of
71 this part, the term does not include and the licensure
72 requirements of this part do not apply to:
73 (a) Entities licensed or registered by the state under
74 chapter 395; or entities licensed or registered by the state and
75 providing only health care services within the scope of services
76 authorized under their respective licenses granted under ss.
77 383.30-383.335, chapter 390, chapter 394, chapter 397, this
78 chapter except part X, chapter 429, chapter 463, chapter 465,
79 chapter 466, chapter 478, part I of chapter 483, chapter 484, or
80 chapter 651; end-stage renal disease providers authorized under
81 42 C.F.R. part 405, subpart U; or providers certified under 42
82 C.F.R. part 485, subpart B or subpart H; or any entity that
83 provides neonatal or pediatric hospital-based health care
84 services or other health care services by licensed practitioners
85 solely within a hospital licensed under chapter 395.
86 (b) Entities that own, directly or indirectly, entities
87 licensed or registered by the state pursuant to chapter 395; or
88 entities that own, directly or indirectly, entities licensed or
89 registered by the state and providing only health care services
90 within the scope of services authorized pursuant to their
91 respective licenses granted under ss. 383.30-383.335, chapter
92 390, chapter 394, chapter 397, this chapter except part X,
93 chapter 429, chapter 463, chapter 465, chapter 466, chapter 478,
94 part I of chapter 483, chapter 484, chapter 651; end-stage renal
95 disease providers authorized under 42 C.F.R. part 405, subpart
96 U; or providers certified under 42 C.F.R. part 485, subpart B or
97 subpart H; or any entity that provides neonatal or pediatric
98 hospital-based health care services by licensed practitioners
99 solely within a hospital licensed under chapter 395.
100 (c) Entities that are owned, directly or indirectly, by an
101 entity licensed or registered by the state pursuant to chapter
102 395; or entities that are owned, directly or indirectly, by an
103 entity licensed or registered by the state and providing only
104 health care services within the scope of services authorized
105 pursuant to their respective licenses granted under ss. 383.30
106 383.335, chapter 390, chapter 394, chapter 397, this chapter
107 except part X, chapter 429, chapter 463, chapter 465, chapter
108 466, chapter 478, part I of chapter 483, chapter 484, or chapter
109 651; end-stage renal disease providers authorized under 42
110 C.F.R. part 405, subpart U; or providers certified under 42
111 C.F.R. part 485, subpart B or subpart H; or any entity that
112 provides neonatal or pediatric hospital-based health care
113 services by licensed practitioners solely within a hospital
114 under chapter 395.
115 (d) Entities that are under common ownership, directly or
116 indirectly, with an entity licensed or registered by the state
117 pursuant to chapter 395; or entities that are under common
118 ownership, directly or indirectly, with an entity licensed or
119 registered by the state and providing only health care services
120 within the scope of services authorized pursuant to their
121 respective licenses granted under ss. 383.30-383.335, chapter
122 390, chapter 394, chapter 397, this chapter except part X,
123 chapter 429, chapter 463, chapter 465, chapter 466, chapter 478,
124 part I of chapter 483, chapter 484, or chapter 651; end-stage
125 renal disease providers authorized under 42 C.F.R. part 405,
126 subpart U; or providers certified under 42 C.F.R. part 485,
127 subpart B or subpart H; or any entity that provides neonatal or
128 pediatric hospital-based health care services by licensed
129 practitioners solely within a hospital licensed under chapter
130 395.
131 (e) An entity that is exempt from federal taxation under 26
132 U.S.C. s. 501(c)(3) or (4), an employee stock ownership plan
133 under 26 U.S.C. s. 409 that has a board of trustees at least not
134 less than two-thirds of which are Florida-licensed health care
135 practitioners and provides only physical therapy services under
136 physician orders, any community college or university clinic,
137 and any entity owned or operated by the federal or state
138 government, including agencies, subdivisions, or municipalities
139 thereof.
140 (f) A sole proprietorship, group practice, partnership, or
141 corporation that provides health care services by physicians
142 covered by s. 627.419, that is directly supervised by one or
143 more of such physicians, and that is wholly owned by one or more
144 of those physicians or by a physician and the spouse, parent,
145 child, or sibling of that physician.
146 (g) A sole proprietorship, group practice, partnership, or
147 corporation that provides health care services by licensed
148 health care practitioners under chapter 457, chapter 458,
149 chapter 459, chapter 460, chapter 461, chapter 462, chapter 463,
150 chapter 466, chapter 467, chapter 480, chapter 484, chapter 486,
151 chapter 490, chapter 491, or part I, part III, part X, part
152 XIII, or part XIV of chapter 468, or s. 464.012, and that is
153 which are wholly owned by one or more licensed health care
154 practitioners, or the licensed health care practitioners set
155 forth in this paragraph and the spouse, parent, child, or
156 sibling of a licensed health care practitioner if, so long as
157 one of the owners who is a licensed health care practitioner is
158 supervising the business activities and is legally responsible
159 for the entity’s compliance with all federal and state laws.
160 However, a health care practitioner may not supervise services
161 beyond the scope of the practitioner’s license, except that, for
162 the purposes of this part, a clinic owned by a licensee in s.
163 456.053(3)(b) which that provides only services authorized
164 pursuant to s. 456.053(3)(b) may be supervised by a licensee
165 specified in s. 456.053(3)(b).
166 (h) Clinical facilities affiliated with an accredited
167 medical school at which training is provided for medical
168 students, residents, or fellows.
169 (i) Entities that provide only oncology or radiation
170 therapy services by physicians licensed under chapter 458 or
171 chapter 459 or entities that provide oncology or radiation
172 therapy services by physicians licensed under chapter 458 or
173 chapter 459 which are owned by a corporation whose shares are
174 publicly traded on a recognized stock exchange.
175 (j) Clinical facilities affiliated with a college of
176 chiropractic accredited by the Council on Chiropractic Education
177 at which training is provided for chiropractic students.
178 (k) Entities that provide licensed practitioners to staff
179 emergency departments or to deliver anesthesia services in
180 facilities licensed under chapter 395 and that derive at least
181 90 percent of their gross annual revenues from the provision of
182 such services. Entities claiming an exemption from licensure
183 under this paragraph must provide documentation demonstrating
184 compliance.
185 (l) Orthotic or prosthetic clinical facilities that are a
186 publicly traded corporation or that are wholly owned, directly
187 or indirectly, by a publicly traded corporation. As used in this
188 paragraph, a publicly traded corporation is a corporation that
189 issues securities traded on an exchange registered with the
190 United States Securities and Exchange Commission as a national
191 securities exchange.
192
193 Notwithstanding this subsection, an entity shall be deemed a
194 clinic and must be licensed under this part in order to receive
195 reimbursement under the Florida Motor Vehicle No-Fault Law, ss.
196 627.730-627.7405, unless exempted under s. 627.736(5)(h). An
197 entity required to be licensed in order to receive reimbursement
198 under the Florida Motor Vehicle No-Fault Law is exempt from all
199 license fees under this part.
200 Section 3. Subsection (6) is added to section 400.991,
201 Florida Statutes, to read:
202 400.991 License requirements; background screenings;
203 prohibitions.—
204 (6) All agency forms for licensure application or exemption
205 from licensure under this part must contain the following
206 statement:
207
208 INSURANCE FRAUD NOTICE.—A person who knowingly submits
209 a false, misleading, or fraudulent application or
210 other document when applying for licensure as a health
211 care clinic, seeking an exemption from licensure as a
212 health care clinic, or demonstrating compliance with
213 part X of chapter 400, Florida Statutes, with the
214 intent to use the license, exemption from licensure,
215 or demonstration of compliance to provide services or
216 seek reimbursement under the Florida Motor Vehicle No
217 Fault Law, commits a fraudulent insurance act, as
218 defined in s. 626.989, Florida Statutes. A person who
219 presents a claim for personal injury protection
220 benefits knowing that the payee knowingly submitted
221 such health care clinic application or document,
222 commits insurance fraud, as defined in s. 817.234,
223 Florida Statutes.
224 Section 4. Subsection (1) of section 626.989, Florida
225 Statutes, is amended to read:
226 626.989 Investigation by department or Division of
227 Insurance Fraud; compliance; immunity; confidential information;
228 reports to division; division investigator’s power of arrest.—
229 (1) For the purposes of this section:,
230 (a) A person commits a “fraudulent insurance act” if the
231 person:
232 1. Knowingly and with intent to defraud presents, causes to
233 be presented, or prepares with knowledge or belief that it will
234 be presented, to or by an insurer, self-insurer, self-insurance
235 fund, servicing corporation, purported insurer, broker, or any
236 agent thereof, any written statement as part of, or in support
237 of, an application for the issuance of, or the rating of, any
238 insurance policy, or a claim for payment or other benefit
239 pursuant to any insurance policy, which the person knows to
240 contain materially false information concerning any fact
241 material thereto or if the person conceals, for the purpose of
242 misleading another, information concerning any fact material
243 thereto.
244 2. Knowingly submits:
245 a. A false, misleading, or fraudulent application or other
246 document when applying for licensure as a health care clinic,
247 seeking an exemption from licensure as a health care clinic, or
248 demonstrating compliance with part X of chapter 400 with an
249 intent to use the license, exemption from licensure, or
250 demonstration of compliance to provide services or seek
251 reimbursement under the Florida Motor Vehicle No-Fault Law.
252 b. A claim for payment or other benefit pursuant to a
253 personal injury protection insurance policy under the Florida
254 Motor Vehicle No-Fault Law if the person knows that the payee
255 knowingly submitted a false, misleading, or fraudulent
256 application or other document when applying for licensure as a
257 health care clinic, seeking an exemption from licensure as a
258 health care clinic, or demonstrating compliance with part X of
259 chapter 400. For the purposes of this section,
260 (b) The term “insurer” also includes a any health
261 maintenance organization, and the term “insurance policy” also
262 includes a health maintenance organization subscriber contract.
263 Section 5. Section 626.9581, Florida Statutes, is amended
264 to read:
265 626.9581 Cease and desist and penalty orders.—After the
266 hearing provided in s. 626.9571, the department or office shall
267 enter a final order in accordance with s. 120.569. If it is
268 determined that the person charged has engaged in an unfair or
269 deceptive act or practice or the unlawful transaction of
270 insurance, the department or office shall also issue an order
271 requiring the violator to cease and desist from engaging in such
272 method of competition, act, or practice or the unlawful
273 transaction of insurance. Further, if the act or practice is a
274 violation of s. 626.9541, or s. 626.9551, or s. 627.736(11), the
275 department or office may, at its discretion, order any one or
276 more of the following:
277 (1) Suspension or revocation of the person’s certificate of
278 authority, license, or eligibility for any certificate of
279 authority or license, if he or she knew, or reasonably should
280 have known, he or she was in violation of this act. However, the
281 office must revoke the certificate of authority of an insurer
282 that violates s. 627.736(11) for at least 5 years, and all board
283 members of such insurer are prohibited from serving on the board
284 of another insurer for 5 years.
285 (2) Such other relief as may be provided under in the
286 insurance code.
287 Section 6. Subsection (5) of section 626.9894, Florida
288 Statutes, is amended to read:
289 626.9894 Gifts and grants.—
290 (5) Notwithstanding the provisions of s. 216.301 and
291 pursuant to s. 216.351, any balance of moneys deposited into the
292 Insurance Regulatory Trust Fund pursuant to this section or s.
293 626.9895 remaining at the end of any fiscal year is shall be
294 available for carrying out the duties and responsibilities of
295 the division. The department may request annual appropriations
296 from the grants and donations received pursuant to this section
297 or s. 626.9895 and cash balances in the Insurance Regulatory
298 Trust Fund for the purpose of carrying out its duties and
299 responsibilities related to the division’s anti-fraud efforts,
300 including the funding of dedicated prosecutors and related
301 personnel.
302 Section 7. Section 626.9895, Florida Statutes, is created
303 to read:
304 626.9895 Motor vehicle insurance fraud direct-support
305 organization.—
306 (1) DEFINITIONS.—As used in this section, the term:
307 (a) “Division” means the Division of Insurance Fraud of the
308 Department of Financial Services.
309 (b) “Motor vehicle insurance fraud” means any act defined
310 as a “fraudulent insurance act” under s. 626.989, which relates
311 to the coverage of motor vehicle insurance as described in part
312 XI of chapter 627.
313 (c) “Organization” means the direct-support organization
314 established under this section.
315 (2) ORGANIZATION ESTABLISHED.—The division may establish a
316 direct-support organization, to be known as the “Automobile
317 Insurance Fraud Strike Force,” whose sole purpose is to support
318 the prosecution, investigation, and prevention of motor vehicle
319 insurance fraud. The organization shall:
320 (a) Be a not-for-profit corporation incorporated under
321 chapter 617 and approved by the Department of State.
322 (b) Be organized and operated to conduct programs and
323 activities; raise funds; request and receive grants, gifts, and
324 bequests of money; acquire, receive, hold, invest, and
325 administer, in its own name, securities, funds, objects of
326 value, or other property, real or personal; and make grants and
327 expenditures to or for the direct or indirect benefit of the
328 division, state attorneys’ offices, the statewide prosecutor,
329 the Agency for Health Care Administration, and the Department of
330 Health to the extent that such grants and expenditures are used
331 exclusively to advance the prosecution, investigation, or
332 prevention of motor vehicle insurance fraud. Grants and
333 expenditures may include the cost of salaries or benefits of
334 motor vehicle insurance fraud investigators, prosecutors, or
335 support personnel if such grants and expenditures do not
336 interfere with prosecutorial independence or otherwise create
337 conflicts of interest which threaten the success of
338 prosecutions.
339 (c) Be determined by the division to operate in a manner
340 that promotes the goals of laws relating to motor vehicle
341 insurance fraud, that is in the best interest of the state, and
342 that is in accordance with the adopted goals and mission of the
343 division.
344 (d) Use all of its grants and expenditures solely for the
345 purpose of preventing and decreasing motor vehicle insurance
346 fraud, and not for the purpose of lobbying as defined in s.
347 11.045.
348 (e) Be subject to an annual financial audit in accordance
349 with s. 215.981.
350 (3) CONTRACT.—The organization shall operate under written
351 contract with the division. The contract must provide for:
352 (a) Approval of the articles of incorporation and bylaws of
353 the organization by the division.
354 (b) Submission of an annual budget for approval of the
355 division. The budget must require the organization to minimize
356 costs to the division and its members at all times by using
357 existing personnel and property and allowing for telephonic
358 meetings if appropriate.
359 (c) Certification by the division that the organization is
360 complying with the terms of the contract and in a manner
361 consistent with the goals and purposes of the department and in
362 the best interest of the state. Such certification must be made
363 annually and reported in the official minutes of a meeting of
364 the organization.
365 (d) Allocation of funds to address motor vehicle insurance
366 fraud.
367 (e) Reversion of moneys and property held in trust by the
368 organization for motor vehicle insurance fraud prosecution,
369 investigation, and prevention to the division if the
370 organization is no longer approved to operate for the department
371 or if the organization ceases to exist, or to the state if the
372 division ceases to exist.
373 (f) Specific criteria to be used by the organization’s
374 board of directors to evaluate the effectiveness of funding used
375 to combat motor vehicle insurance fraud.
376 (g) The fiscal year of the organization, which begins July
377 1 of each year and ends June 30 of the following year.
378 (h) Disclosure of the material provisions of the contract,
379 and distinguishing between the department and the organization
380 to donors of gifts, contributions, or bequests, including
381 providing such disclosure on all promotional and fundraising
382 publications.
383 (4) BOARD OF DIRECTORS.—
384 (a) The board of directors of the organization shall
385 consist of the following eleven members:
386 1. The Chief Financial Officer, or designee, who shall
387 serve as chair.
388 2. Two state attorneys, one of whom shall be appointed by
389 the Chief Financial Officer and one of whom shall be appointed
390 by the Attorney General.
391 3. Two representatives of motor vehicle insurers appointed
392 by the Chief Financial Officer.
393 4. Two representatives of local law enforcement agencies,
394 one of whom shall be appointed by the Chief Financial Officer
395 and one of whom shall be appointed by the Attorney General.
396 5. Two representatives of the types of health care
397 providers who regularly make claims for benefits under ss.
398 627.730-627.7405, one of whom shall be appointed by the
399 President of the Senate and one of whom shall be appointed by
400 the Speaker of the House of Representatives. The appointees may
401 not represent the same type of health care provider.
402 6. A private attorney that has experience in representing
403 claimants in actions for benefits under ss. 627.730-627.7405,
404 who shall be appointed by the President of the Senate.
405 7. A private attorney who has experience in representing
406 insurers in actions for benefits under ss. 627.730-627.7405, who
407 shall be appointed by the Speaker of the House of
408 Representatives.
409 (b) The officer who appointed a member of the board may
410 remove that member for cause. The term of office of an appointed
411 member expires at the same time as the term of the officer who
412 appointed him or her or at such earlier time as the person
413 ceases to be qualified.
414 (5) USE OF PROPERTY.—The department may authorize, without
415 charge, appropriate use of fixed property and facilities of the
416 division by the organization, subject to this subsection.
417 (a) The department may prescribe any condition with which
418 the organization must comply in order to use the division’s
419 property or facilities.
420 (b) The department may not authorize the use of the
421 division’s property or facilities if the organization does not
422 provide equal membership and employment opportunities to all
423 persons regardless of race, religion, sex, age, or national
424 origin.
425 (c) The department shall adopt rules prescribing the
426 procedures by which the organization is governed and any
427 conditions with which the organization must comply to use the
428 division’s property or facilities.
429 (6) CONTRIBUTIONS FROM INSURERS.—Contributions from an
430 insurer to the organization shall be allowed as an appropriate
431 business expense of the insurer for all regulatory purposes.
432 (7) DEPOSITORY ACCOUNT.—Any moneys received by the
433 organization may be held in a separate depository account in the
434 name of the organization and subject to the contract with the
435 division.
436 (8) DIVISION’S RECEIPT OF PROCEEDS.—Proceeds received by
437 the division from the organization shall be deposited into the
438 Insurance Regulatory Trust Fund.
439 Section 8. Effective January 1, 2013, subsections (1), (4),
440 (5), (6), (8), (9), (10), and (11) of section 627.736, Florida
441 Statutes, are amended, and subsection (17) is added to that
442 section, to read:
443 627.736 Required personal injury protection benefits;
444 exclusions; priority; claims.—
445 (1) REQUIRED BENEFITS.—An Every insurance policy complying
446 with the security requirements of s. 627.733 must shall provide
447 personal injury protection to the named insured, relatives
448 residing in the same household, persons operating the insured
449 motor vehicle, passengers in the such motor vehicle, and other
450 persons struck by the such motor vehicle and suffering bodily
451 injury while not an occupant of a self-propelled vehicle,
452 subject to the provisions of subsection (2) and paragraph
453 (4)(e), to a limit of $10,000 in medical and disability benefits
454 and $5,000 in death benefits resulting from for loss sustained
455 by any such person as a result of bodily injury, sickness,
456 disease, or death arising out of the ownership, maintenance, or
457 use of a motor vehicle as follows:
458 (a) Medical benefits.—Eighty percent of all reasonable
459 expenses for medically necessary medical, surgical, X-ray,
460 dental, and rehabilitative services, including prosthetic
461 devices, and medically necessary ambulance, hospital, and
462 nursing services if the individual receives initial services and
463 care pursuant to subparagraph 1. within 14 days after the motor
464 vehicle accident. However, The medical benefits shall provide
465 reimbursement only for: such
466 1. Initial services and care that are lawfully provided,
467 supervised, ordered, or prescribed by a physician licensed under
468 chapter 458 or chapter 459, a dentist licensed under chapter
469 466, or a chiropractic physician licensed under chapter 460 or
470 that are provided in a hospital or in a facility that owns, or
471 is wholly owned by, a hospital. Initial services and care may
472 also be provided by a person or entity licensed under part III
473 of chapter 401 which provides emergency transportation and
474 treatment.
475 2. Followup services and care consistent with the
476 underlying medical diagnosis rendered pursuant to subparagraph
477 1. which may be provided, supervised, ordered, or prescribed
478 only by a physician licensed under chapter 458 or chapter 459, a
479 chiropractic physician licensed under chapter 460, a dentist
480 licensed under chapter 466, or, to the extent permitted by
481 applicable law and under the supervision of such physician,
482 osteopathic physician, chiropractic physician, or dentist, by a
483 physician assistant licensed under chapter 458 or chapter 459 or
484 an advanced registered nurse practitioner licensed under chapter
485 464. Followup services and care may also be provided by any of
486 the following persons or entities:
487 a.1. A hospital or ambulatory surgical center licensed
488 under chapter 395.
489 2. A person or entity licensed under ss. 401.2101-401.45
490 that provides emergency transportation and treatment.
491 b.3. An entity wholly owned by one or more physicians
492 licensed under chapter 458 or chapter 459, chiropractic
493 physicians licensed under chapter 460, or dentists licensed
494 under chapter 466 or by such practitioner or practitioners and
495 the spouse, parent, child, or sibling of such that practitioner
496 or those practitioners.
497 c.4. An entity that owns or is wholly owned, directly or
498 indirectly, by a hospital or hospitals.
499 d. A physical therapist licensed under chapter 486.
500 e.5. A health care clinic licensed under part X of chapter
501 400 which ss. 400.990-400.995 that is:
502 a. accredited by the Joint Commission on Accreditation of
503 Healthcare Organizations, the American Osteopathic Association,
504 the Commission on Accreditation of Rehabilitation Facilities, or
505 the Accreditation Association for Ambulatory Health Care, Inc.,;
506 or
507 b. A health care clinic that:
508 (I) Has a medical director licensed under chapter 458,
509 chapter 459, or chapter 460;
510 (II) Has been continuously licensed for more than 3 years
511 or is a publicly traded corporation that issues securities
512 traded on an exchange registered with the United States
513 Securities and Exchange Commission as a national securities
514 exchange; and
515 (III) Provides at least four of the following medical
516 specialties:
517 (A) General medicine.
518 (B) Radiography.
519 (C) Orthopedic medicine.
520 (D) Physical medicine.
521 (E) Physical therapy.
522 (F) Physical rehabilitation.
523 (G) Prescribing or dispensing outpatient prescription
524 medication.
525 (H) Laboratory services.
526 3. Reimbursement for services and care provided by each
527 type of licensed medical provider authorized to render such
528 services and care is limited to the lesser of 24 visits or to
529 services or care rendered within 12 weeks after the date of the
530 initial treatment, whichever comes first, unless the insurer
531 authorizes additional services or care.
532 4. Medical benefits do not include massage as defined in s.
533 480.033 or acupuncture as defined in s. 457.102, regardless of
534 the person, entity, or licensee providing massage or
535 acupuncture, and a licensed massage therapist or licensed
536 acupuncturist may not be reimbursed for medical benefits under
537 this section.
538 5. The Financial Services Commission shall adopt by rule
539 the form that must be used by an insurer and a health care
540 provider specified in sub-subparagraph 2.b., sub-subparagraph
541 2.c., or sub-subparagraph 2.e. subparagraph 3., subparagraph 4.,
542 or subparagraph 5. to document that the health care provider
543 meets the criteria of this paragraph, which rule must include a
544 requirement for a sworn statement or affidavit.
545 (b) Disability benefits.—Sixty percent of any loss of gross
546 income and loss of earning capacity per individual from
547 inability to work proximately caused by the injury sustained by
548 the injured person, plus all expenses reasonably incurred in
549 obtaining from others ordinary and necessary services in lieu of
550 those that, but for the injury, the injured person would have
551 performed without income for the benefit of his or her
552 household. All disability benefits payable under this provision
553 must shall be paid at least not less than every 2 weeks.
554 (c) Death benefits.—Death benefits equal to the lesser of
555 $5,000 or the remainder of unused personal injury protection
556 benefits per individual. Death benefits are in addition to the
557 medical and disability benefits provided under the insurance
558 policy. The insurer may pay death such benefits to the executor
559 or administrator of the deceased, to any of the deceased’s
560 relatives by blood, or legal adoption, or connection by
561 marriage, or to any person appearing to the insurer to be
562 equitably entitled to such benefits thereto.
563
564 Only insurers writing motor vehicle liability insurance in this
565 state may provide the required benefits of this section, and no
566 such insurer may not shall require the purchase of any other
567 motor vehicle coverage other than the purchase of property
568 damage liability coverage as required by s. 627.7275 as a
569 condition for providing such required benefits. Insurers may not
570 require that property damage liability insurance in an amount
571 greater than $10,000 be purchased in conjunction with personal
572 injury protection. Such insurers shall make benefits and
573 required property damage liability insurance coverage available
574 through normal marketing channels. An Any insurer writing motor
575 vehicle liability insurance in this state who fails to comply
576 with such availability requirement as a general business
577 practice violates shall be deemed to have violated part IX of
578 chapter 626, and such violation constitutes shall constitute an
579 unfair method of competition or an unfair or deceptive act or
580 practice involving the business of insurance. An; and any such
581 insurer committing such violation is shall be subject to the
582 penalties provided under that afforded in such part, as well as
583 those provided which may be afforded elsewhere in the insurance
584 code.
585 (4) PAYMENT OF BENEFITS; WHEN DUE.—Benefits due from an
586 insurer under ss. 627.730-627.7405 are shall be primary, except
587 that benefits received under any workers’ compensation law must
588 shall be credited against the benefits provided by subsection
589 (1) and are shall be due and payable as loss accrues, upon
590 receipt of reasonable proof of such loss and the amount of
591 expenses and loss incurred which are covered by the policy
592 issued under ss. 627.730-627.7405. If When the Agency for Health
593 Care Administration provides, pays, or becomes liable for
594 medical assistance under the Medicaid program related to injury,
595 sickness, disease, or death arising out of the ownership,
596 maintenance, or use of a motor vehicle, the benefits under ss.
597 627.730-627.7405 are shall be subject to the provisions of the
598 Medicaid program. However, within 30 days after receiving notice
599 that the Medicaid program paid such benefits, the insurer shall
600 repay the full amount of the benefits to the Medicaid program.
601 (a) An insurer may require written notice to be given as
602 soon as practicable after an accident involving a motor vehicle
603 with respect to which the policy affords the security required
604 by ss. 627.730-627.7405.
605 (b) Personal injury protection insurance benefits paid
606 pursuant to this section are shall be overdue if not paid within
607 30 days after the insurer is furnished written notice of the
608 fact of a covered loss and of the amount of same. However:
609 1. If such written notice of the entire claim is not
610 furnished to the insurer as to the entire claim, any partial
611 amount supported by written notice is overdue if not paid within
612 30 days after such written notice is furnished to the insurer.
613 Any part or all of the remainder of the claim that is
614 subsequently supported by written notice is overdue if not paid
615 within 30 days after such written notice is furnished to the
616 insurer.
617 2. If When an insurer pays only a portion of a claim or
618 rejects a claim, the insurer shall provide at the time of the
619 partial payment or rejection an itemized specification of each
620 item that the insurer had reduced, omitted, or declined to pay
621 and any information that the insurer desires the claimant to
622 consider related to the medical necessity of the denied
623 treatment or to explain the reasonableness of the reduced charge
624 if, provided that this does shall not limit the introduction of
625 evidence at trial.; and The insurer must also shall include the
626 name and address of the person to whom the claimant should
627 respond and a claim number to be referenced in future
628 correspondence.
629 3. If an insurer pays only a portion of a claim or rejects
630 a claim due to an alleged error in the claim, the insurer, at
631 the time of the partial payment or rejection, shall provide an
632 itemized specification or explanation of benefits due to the
633 specified error. Upon receiving the specification or
634 explanation, the person making the claim, at the person’s option
635 and without waiving any other legal remedy for payment, has 15
636 days to submit a revised claim, which shall be considered a
637 timely submission of written notice of a claim.
638 4. However, Notwithstanding the fact that written notice
639 has been furnished to the insurer, any payment is shall not be
640 deemed overdue if when the insurer has reasonable proof to
641 establish that the insurer is not responsible for the payment.
642 5. For the purpose of calculating the extent to which any
643 benefits are overdue, payment shall be treated as being made on
644 the date a draft or other valid instrument that which is
645 equivalent to payment was placed in the United States mail in a
646 properly addressed, postpaid envelope or, if not so posted, on
647 the date of delivery.
648 6. This paragraph does not preclude or limit the ability of
649 the insurer to assert that the claim was unrelated, was not
650 medically necessary, or was unreasonable or that the amount of
651 the charge was in excess of that permitted under, or in
652 violation of, subsection (5). Such assertion by the insurer may
653 be made at any time, including after payment of the claim or
654 after the 30-day time period for payment set forth in this
655 paragraph.
656 (c) Upon receiving notice of an accident that is
657 potentially covered by personal injury protection benefits, the
658 insurer must reserve $5,000 of personal injury protection
659 benefits for payment to physicians licensed under chapter 458 or
660 chapter 459 or dentists licensed under chapter 466 who provide
661 emergency services and care, as defined in s. 395.002(9), or who
662 provide hospital inpatient care. The amount required to be held
663 in reserve may be used only to pay claims from such physicians
664 or dentists until 30 days after the date the insurer receives
665 notice of the accident. After the 30-day period, any amount of
666 the reserve for which the insurer has not received notice of
667 such claims a claim from a physician or dentist who provided
668 emergency services and care or who provided hospital inpatient
669 care may then be used by the insurer to pay other claims. The
670 time periods specified in paragraph (b) for required payment of
671 personal injury protection benefits are shall be tolled for the
672 period of time that an insurer is required by this paragraph to
673 hold payment of a claim that is not from such a physician or
674 dentist who provided emergency services and care or who provided
675 hospital inpatient care to the extent that the personal injury
676 protection benefits not held in reserve are insufficient to pay
677 the claim. This paragraph does not require an insurer to
678 establish a claim reserve for insurance accounting purposes.
679 (d) All overdue payments shall bear simple interest at the
680 rate established under s. 55.03 or the rate established in the
681 insurance contract, whichever is greater, for the year in which
682 the payment became overdue, calculated from the date the insurer
683 was furnished with written notice of the amount of covered loss.
684 Interest is shall be due at the time payment of the overdue
685 claim is made.
686 (e) The insurer of the owner of a motor vehicle shall pay
687 personal injury protection benefits for:
688 1. Accidental bodily injury sustained in this state by the
689 owner while occupying a motor vehicle, or while not an occupant
690 of a self-propelled vehicle if the injury is caused by physical
691 contact with a motor vehicle.
692 2. Accidental bodily injury sustained outside this state,
693 but within the United States of America or its territories or
694 possessions or Canada, by the owner while occupying the owner’s
695 motor vehicle.
696 3. Accidental bodily injury sustained by a relative of the
697 owner residing in the same household, under the circumstances
698 described in subparagraph 1. or subparagraph 2., if provided the
699 relative at the time of the accident is domiciled in the owner’s
700 household and is not himself or herself the owner of a motor
701 vehicle with respect to which security is required under ss.
702 627.730-627.7405.
703 4. Accidental bodily injury sustained in this state by any
704 other person while occupying the owner’s motor vehicle or, if a
705 resident of this state, while not an occupant of a self
706 propelled vehicle, if the injury is caused by physical contact
707 with such motor vehicle, if provided the injured person is not
708 himself or herself:
709 a. The owner of a motor vehicle with respect to which
710 security is required under ss. 627.730-627.7405; or
711 b. Entitled to personal injury benefits from the insurer of
712 the owner or owners of such a motor vehicle.
713 (f) If two or more insurers are liable for paying to pay
714 personal injury protection benefits for the same injury to any
715 one person, the maximum payable is shall be as specified in
716 subsection (1), and the any insurer paying the benefits is shall
717 be entitled to recover from each of the other insurers an
718 equitable pro rata share of the benefits paid and expenses
719 incurred in processing the claim.
720 (g) It is a violation of the insurance code for an insurer
721 to fail to timely provide benefits as required by this section
722 with such frequency as to constitute a general business
723 practice.
724 (h) Benefits are shall not be due or payable to or on the
725 behalf of an insured person if that person has committed, by a
726 material act or omission, any insurance fraud relating to
727 personal injury protection coverage under his or her policy, if
728 the fraud is admitted to in a sworn statement by the insured or
729 if it is established in a court of competent jurisdiction. Any
730 insurance fraud voids shall void all coverage arising from the
731 claim related to such fraud under the personal injury protection
732 coverage of the insured person who committed the fraud,
733 irrespective of whether a portion of the insured person’s claim
734 may be legitimate, and any benefits paid before prior to the
735 discovery of the insured person’s insurance fraud is shall be
736 recoverable by the insurer in its entirety from the person who
737 committed insurance fraud in their entirety. The prevailing
738 party is entitled to its costs and attorney attorney’s fees in
739 any action in which it prevails in an insurer’s action to
740 enforce its right of recovery under this paragraph.
741 (i) If an insurer has a reasonable belief that a fraudulent
742 insurance act, as defined in s. 626.989 or s. 817.234, has been
743 committed, the insurer shall notify the claimant in writing
744 within 30 days after submission of the claim that the claim is
745 being investigated for suspected fraud and execute and provide
746 to the insured and the office an affidavit under oath stating
747 that there is a factual basis that there is a probability of
748 fraud. The insurer has an additional 60 days, beginning at the
749 end of the initial 30-day period, to conduct its fraud
750 investigation. Notwithstanding subsection (10), no later than
751 the 90th day after the submission of the claim, the insurer must
752 deny the claim or pay the claim along with simple interest as
753 provided in paragraph (d). All claims denied for suspected
754 fraudulent insurance acts shall be reported to the Division of
755 Insurance Fraud.
756 (j) An insurer shall create and maintain for each insured a
757 log of personal injury protection benefits paid by the insurer
758 on behalf of the insured. If litigation is commenced, the
759 insurer shall provide to the insured, or an assignee of the
760 insured, a copy of the log within 30 days after receiving a
761 request for the log from the insured or the assignee.
762 (5) CHARGES FOR TREATMENT OF INJURED PERSONS.—
763 (a)1. A Any physician, hospital, clinic, or other person or
764 institution lawfully rendering treatment to an injured person
765 for a bodily injury covered by personal injury protection
766 insurance may charge the insurer and injured party only a
767 reasonable amount pursuant to this section for the services and
768 supplies rendered, and the insurer providing such coverage may
769 pay for such charges directly to such person or institution
770 lawfully rendering such treatment, if the insured receiving such
771 treatment or his or her guardian has countersigned the properly
772 completed invoice, bill, or claim form approved by the office
773 upon which such charges are to be paid for as having actually
774 been rendered, to the best knowledge of the insured or his or
775 her guardian. In no event, However, may such a charge may not
776 exceed be in excess of the amount the person or institution
777 customarily charges for like services or supplies. In
778 determining With respect to a determination of whether a charge
779 for a particular service, treatment, or otherwise is reasonable,
780 consideration may be given to evidence of usual and customary
781 charges and payments accepted by the provider involved in the
782 dispute, and reimbursement levels in the community and various
783 federal and state medical fee schedules applicable to motor
784 vehicle automobile and other insurance coverages, and other
785 information relevant to the reasonableness of the reimbursement
786 for the service, treatment, or supply.
787 1.2. The insurer may limit reimbursement to 80 percent of
788 the following schedule of maximum charges:
789 a. For emergency transport and treatment by providers
790 licensed under chapter 401, 200 percent of Medicare.
791 b. For emergency services and care provided by a hospital
792 licensed under chapter 395, 75 percent of the hospital’s usual
793 and customary charges.
794 c. For emergency services and care as defined by s.
795 395.002(9) provided in a facility licensed under chapter 395
796 rendered by a physician or dentist, and related hospital
797 inpatient services rendered by a physician or dentist, the usual
798 and customary charges in the community.
799 d. For hospital inpatient services, other than emergency
800 services and care, 200 percent of the Medicare Part A
801 prospective payment applicable to the specific hospital
802 providing the inpatient services.
803 e. For hospital outpatient services, other than emergency
804 services and care, 200 percent of the Medicare Part A Ambulatory
805 Payment Classification for the specific hospital providing the
806 outpatient services.
807 f. For all other medical services, supplies, and care, 200
808 percent of the allowable amount under:
809 (I) The participating physicians fee schedule of Medicare
810 Part B, except as provided in sub-sub-subparagraphs (II) and
811 (III).
812 (II) Medicare Part B, in the case of services, supplies,
813 and care provided by ambulatory surgical centers and clinical
814 laboratories.
815 (III) The Durable Medical Equipment Prosthetics/Orthotics
816 and Supplies fee schedule of Medicare Part B, in the case of
817 durable medical equipment.
818
819 However, if such services, supplies, or care is not reimbursable
820 under Medicare Part B, as provided in this sub-subparagraph, the
821 insurer may limit reimbursement to 80 percent of the maximum
822 reimbursable allowance under workers’ compensation, as
823 determined under s. 440.13 and rules adopted thereunder which
824 are in effect at the time such services, supplies, or care is
825 provided. Services, supplies, or care that is not reimbursable
826 under Medicare or workers’ compensation is not required to be
827 reimbursed by the insurer.
828 2.3. For purposes of subparagraph 1. 2., the applicable fee
829 schedule or payment limitation under Medicare is the fee
830 schedule or payment limitation in effect on January 1 of the
831 year in which at the time the services, supplies, or care is was
832 rendered and for the area in which such services, supplies, or
833 care is were rendered, and the applicable fee schedule or
834 payment limitation applies throughout the remainder of that
835 year, notwithstanding any subsequent change made to the fee
836 schedule or payment limitation, except that it may not be less
837 than the allowable amount under the applicable participating
838 physicians schedule of Medicare Part B for 2007 for medical
839 services, supplies, and care subject to Medicare Part B.
840 3.4. Subparagraph 1. 2. does not allow the insurer to apply
841 any limitation on the number of treatments or other utilization
842 limits that apply under Medicare or workers’ compensation. An
843 insurer that applies the allowable payment limitations of
844 subparagraph 1. 2. must reimburse a provider who lawfully
845 provided care or treatment under the scope of his or her
846 license, regardless of whether such provider is would be
847 entitled to reimbursement under Medicare due to restrictions or
848 limitations on the types or discipline of health care providers
849 who may be reimbursed for particular procedures or procedure
850 codes.
851 4.5. If an insurer limits payment as authorized by
852 subparagraph 1. 2., the person providing such services,
853 supplies, or care may not bill or attempt to collect from the
854 insured any amount in excess of such limits, except for amounts
855 that are not covered by the insured’s personal injury protection
856 coverage due to the coinsurance amount or maximum policy limits.
857 5. Effective July 1, 2012, an insurer may limit payment as
858 authorized by this paragraph only if the insurance policy
859 includes a notice at the time of issuance or renewal that the
860 insurer may limit payment pursuant to the schedule of charges
861 specified in this paragraph. A policy form approved by the
862 office satisfies this requirement. If a provider submits a
863 charge for an amount less than the amount allowed under
864 subparagraph 1., the insurer may pay the amount of the charge
865 submitted.
866 (b)1. An insurer or insured is not required to pay a claim
867 or charges:
868 a. Made by a broker or by a person making a claim on behalf
869 of a broker;
870 b. For any service or treatment that was not lawful at the
871 time rendered;
872 c. To any person who knowingly submits a false or
873 misleading statement relating to the claim or charges;
874 d. With respect to a bill or statement that does not
875 substantially meet the applicable requirements of paragraph (d);
876 e. For any treatment or service that is upcoded, or that is
877 unbundled when such treatment or services should be bundled, in
878 accordance with paragraph (d). To facilitate prompt payment of
879 lawful services, an insurer may change codes that it determines
880 to have been improperly or incorrectly upcoded or unbundled, and
881 may make payment based on the changed codes, without affecting
882 the right of the provider to dispute the change by the insurer,
883 if, provided that before doing so, the insurer contacts must
884 contact the health care provider and discusses discuss the
885 reasons for the insurer’s change and the health care provider’s
886 reason for the coding, or makes make a reasonable good faith
887 effort to do so, as documented in the insurer’s file; and
888 f. For medical services or treatment billed by a physician
889 and not provided in a hospital unless such services are rendered
890 by the physician or are incident to his or her professional
891 services and are included on the physician’s bill, including
892 documentation verifying that the physician is responsible for
893 the medical services that were rendered and billed.
894 2. The Department of Health, in consultation with the
895 appropriate professional licensing boards, shall adopt, by rule,
896 a list of diagnostic tests deemed not to be medically necessary
897 for use in the treatment of persons sustaining bodily injury
898 covered by personal injury protection benefits under this
899 section. The initial list shall be adopted by January 1, 2004,
900 and shall be revised from time to time as determined by the
901 Department of Health, in consultation with the respective
902 professional licensing boards. Inclusion of a test on the list
903 of invalid diagnostic tests shall be based on lack of
904 demonstrated medical value and a level of general acceptance by
905 the relevant provider community and may shall not be dependent
906 for results entirely upon subjective patient response.
907 Notwithstanding its inclusion on a fee schedule in this
908 subsection, an insurer or insured is not required to pay any
909 charges or reimburse claims for an any invalid diagnostic test
910 as determined by the Department of Health.
911 (c)1. With respect to any treatment or service, other than
912 medical services billed by a hospital or other provider for
913 emergency services and care as defined in s. 395.002 or
914 inpatient services rendered at a hospital-owned facility, the
915 statement of charges must be furnished to the insurer by the
916 provider and may not include, and the insurer is not required to
917 pay, charges for treatment or services rendered more than 35
918 days before the postmark date or electronic transmission date of
919 the statement, except for past due amounts previously billed on
920 a timely basis under this paragraph, and except that, if the
921 provider submits to the insurer a notice of initiation of
922 treatment within 21 days after its first examination or
923 treatment of the claimant, the statement may include charges for
924 treatment or services rendered up to, but not more than, 75 days
925 before the postmark date of the statement. The injured party is
926 not liable for, and the provider may shall not bill the injured
927 party for, charges that are unpaid because of the provider’s
928 failure to comply with this paragraph. Any agreement requiring
929 the injured person or insured to pay for such charges is
930 unenforceable.
931 1.2. If, however, the insured fails to furnish the provider
932 with the correct name and address of the insured’s personal
933 injury protection insurer, the provider has 35 days from the
934 date the provider obtains the correct information to furnish the
935 insurer with a statement of the charges. The insurer is not
936 required to pay for such charges unless the provider includes
937 with the statement documentary evidence that was provided by the
938 insured during the 35-day period demonstrating that the provider
939 reasonably relied on erroneous information from the insured and
940 either:
941 a. A denial letter from the incorrect insurer; or
942 b. Proof of mailing, which may include an affidavit under
943 penalty of perjury, reflecting timely mailing to the incorrect
944 address or insurer.
945 2.3. For emergency services and care as defined in s.
946 395.002 rendered in a hospital emergency department or for
947 transport and treatment rendered by an ambulance provider
948 licensed pursuant to part III of chapter 401, the provider is
949 not required to furnish the statement of charges within the time
950 periods established by this paragraph,; and the insurer is shall
951 not be considered to have been furnished with notice of the
952 amount of covered loss for purposes of paragraph (4)(b) until it
953 receives a statement complying with paragraph (d), or copy
954 thereof, which specifically identifies the place of service to
955 be a hospital emergency department or an ambulance in accordance
956 with billing standards recognized by the federal Centers for
957 Medicare and Medicaid Services Health Care Finance
958 Administration.
959 3.4. Each notice of the insured’s rights under s. 627.7401
960 must include the following statement in at least 12-point type
961 in type no smaller than 12 points:
962
963 BILLING REQUIREMENTS.—Florida law provides
964 Statutes provide that with respect to any treatment or
965 services, other than certain hospital and emergency
966 services, the statement of charges furnished to the
967 insurer by the provider may not include, and the
968 insurer and the injured party are not required to pay,
969 charges for treatment or services rendered more than
970 35 days before the postmark date of the statement,
971 except for past due amounts previously billed on a
972 timely basis, and except that, if the provider submits
973 to the insurer a notice of initiation of treatment
974 within 21 days after its first examination or
975 treatment of the claimant, the statement may include
976 charges for treatment or services rendered up to, but
977 not more than, 75 days before the postmark date of the
978 statement.
979
980 (d) All statements and bills for medical services rendered
981 by a any physician, hospital, clinic, or other person or
982 institution shall be submitted to the insurer on a properly
983 completed Centers for Medicare and Medicaid Services (CMS) 1500
984 form, UB 92 forms, or any other standard form approved by the
985 office or adopted by the commission for purposes of this
986 paragraph. All billings for such services rendered by providers
987 must shall, to the extent applicable, follow the Physicians’
988 Current Procedural Terminology (CPT) or Healthcare Correct
989 Procedural Coding System (HCPCS), or ICD-9 in effect for the
990 year in which services are rendered and comply with the Centers
991 for Medicare and Medicaid Services (CMS) 1500 form instructions,
992 and the American Medical Association Current Procedural
993 Terminology (CPT) Editorial Panel, and the Healthcare Correct
994 Procedural Coding System (HCPCS). All providers, other than
995 hospitals, must shall include on the applicable claim form the
996 professional license number of the provider in the line or space
997 provided for “Signature of Physician or Supplier, Including
998 Degrees or Credentials.” In determining compliance with
999 applicable CPT and HCPCS coding, guidance shall be provided by
1000 the Physicians’ Current Procedural Terminology (CPT) or the
1001 Healthcare Correct Procedural Coding System (HCPCS) in effect
1002 for the year in which services were rendered, the Office of the
1003 Inspector General (OIG), Physicians Compliance Guidelines, and
1004 other authoritative treatises designated by rule by the Agency
1005 for Health Care Administration. A No statement of medical
1006 services may not include charges for medical services of a
1007 person or entity that performed such services without possessing
1008 the valid licenses required to perform such services. For
1009 purposes of paragraph (4)(b), an insurer is shall not be
1010 considered to have been furnished with notice of the amount of
1011 covered loss or medical bills due unless the statements or bills
1012 comply with this paragraph, and unless the statements or bills
1013 are properly completed in their entirety as to all material
1014 provisions, with all relevant information being provided
1015 therein.
1016 (e)1. At the initial treatment or service provided, each
1017 physician, other licensed professional, clinic, or other medical
1018 institution providing medical services upon which a claim for
1019 personal injury protection benefits is based shall require an
1020 insured person, or his or her guardian, to execute a disclosure
1021 and acknowledgment form, which reflects at a minimum that:
1022 a. The insured, or his or her guardian, must countersign
1023 the form attesting to the fact that the services set forth
1024 therein were actually rendered;
1025 b. The insured, or his or her guardian, has both the right
1026 and affirmative duty to confirm that the services were actually
1027 rendered;
1028 c. The insured, or his or her guardian, was not solicited
1029 by any person to seek any services from the medical provider;
1030 d. The physician, other licensed professional, clinic, or
1031 other medical institution rendering services for which payment
1032 is being claimed explained the services to the insured or his or
1033 her guardian; and
1034 e. If the insured notifies the insurer in writing of a
1035 billing error, the insured may be entitled to a certain
1036 percentage of a reduction in the amounts paid by the insured’s
1037 motor vehicle insurer.
1038 2. The physician, other licensed professional, clinic, or
1039 other medical institution rendering services for which payment
1040 is being claimed has the affirmative duty to explain the
1041 services rendered to the insured, or his or her guardian, so
1042 that the insured, or his or her guardian, countersigns the form
1043 with informed consent.
1044 3. Countersignature by the insured, or his or her guardian,
1045 is not required for the reading of diagnostic tests or other
1046 services that are of such a nature that they are not required to
1047 be performed in the presence of the insured.
1048 4. The licensed medical professional rendering treatment
1049 for which payment is being claimed must sign, by his or her own
1050 hand, the form complying with this paragraph.
1051 5. The original completed disclosure and acknowledgment
1052 form shall be furnished to the insurer pursuant to paragraph
1053 (4)(b) and may not be electronically furnished.
1054 6. The This disclosure and acknowledgment form is not
1055 required for services billed by a provider for emergency
1056 services as defined in s. 395.002, for emergency services and
1057 care as defined in s. 395.002 rendered in a hospital emergency
1058 department, or for transport and treatment rendered by an
1059 ambulance provider licensed pursuant to part III of chapter 401.
1060 7. The Financial Services Commission shall adopt, by rule,
1061 a standard disclosure and acknowledgment form to that shall be
1062 used to fulfill the requirements of this paragraph, effective 90
1063 days after such form is adopted and becomes final. The
1064 commission shall adopt a proposed rule by October 1, 2003. Until
1065 the rule is final, the provider may use a form of its own which
1066 otherwise complies with the requirements of this paragraph.
1067 8. As used in this paragraph, the term “countersign” or
1068 “countersignature” “countersigned” means a second or verifying
1069 signature, as on a previously signed document, and is not
1070 satisfied by the statement “signature on file” or any similar
1071 statement.
1072 9. The requirements of this paragraph apply only with
1073 respect to the initial treatment or service of the insured by a
1074 provider. For subsequent treatments or service, the provider
1075 must maintain a patient log signed by the patient, in
1076 chronological order by date of service, which that is consistent
1077 with the services being rendered to the patient as claimed. The
1078 requirement to maintain requirements of this subparagraph for
1079 maintaining a patient log signed by the patient may be met by a
1080 hospital that maintains medical records as required by s.
1081 395.3025 and applicable rules and makes such records available
1082 to the insurer upon request.
1083 (f) Upon written notification by any person, an insurer
1084 shall investigate any claim of improper billing by a physician
1085 or other medical provider. The insurer shall determine if the
1086 insured was properly billed for only those services and
1087 treatments that the insured actually received. If the insurer
1088 determines that the insured has been improperly billed, the
1089 insurer shall notify the insured, the person making the written
1090 notification, and the provider of its findings and shall reduce
1091 the amount of payment to the provider by the amount determined
1092 to be improperly billed. If a reduction is made due to a such
1093 written notification by any person, the insurer shall pay to the
1094 person 20 percent of the amount of the reduction, up to $500. If
1095 the provider is arrested due to the improper billing, then the
1096 insurer shall pay to the person 40 percent of the amount of the
1097 reduction, up to $500.
1098 (g) An insurer may not systematically downcode with the
1099 intent to deny reimbursement otherwise due. Such action
1100 constitutes a material misrepresentation under s.
1101 626.9541(1)(i)2.
1102 (h) As provided in s. 400.9905, an entity excluded from the
1103 definition of a clinic shall be deemed a clinic and must be
1104 licensed under part X of chapter 400 in order to receive
1105 reimbursement under ss. 627.730-627.7405. However, this
1106 licensing requirement does not apply to:
1107 1. An entity wholly owned by a physician licensed under
1108 chapter 458 or chapter 459, or by the physician and the spouse,
1109 parent, child, or sibling of the physician;
1110 2. An entity wholly owned by a dentist licensed under
1111 chapter 466, or by the dentist and the spouse, parent, child, or
1112 sibling of the dentist;
1113 3. An entity wholly owned by a chiropractic physician
1114 licensed under chapter 460, or by the chiropractic physician and
1115 the spouse, parent, child, or sibling of the chiropractic
1116 physician;
1117 4. A hospital or ambulatory surgical center licensed under
1118 chapter 395;
1119 5. An entity that wholly owns or is wholly owned, directly
1120 or indirectly, by a hospital or hospitals licensed under chapter
1121 395; or
1122 6. An entity that is a clinical facility affiliated with an
1123 accredited medical school at which training is provided for
1124 medical students, residents, or fellows.
1125 (6) DISCOVERY OF FACTS ABOUT AN INJURED PERSON; DISPUTES.—
1126 (a) Every employer shall, If a request is made by an
1127 insurer providing personal injury protection benefits under ss.
1128 627.730-627.7405 against whom a claim has been made, an employer
1129 must furnish forthwith, in a form approved by the office, a
1130 sworn statement of the earnings, since the time of the bodily
1131 injury and for a reasonable period before the injury, of the
1132 person upon whose injury the claim is based.
1133 (b) Every physician, hospital, clinic, or other medical
1134 institution providing, before or after bodily injury upon which
1135 a claim for personal injury protection insurance benefits is
1136 based, any products, services, or accommodations in relation to
1137 that or any other injury, or in relation to a condition claimed
1138 to be connected with that or any other injury, shall, if
1139 requested to do so by the insurer against whom the claim has
1140 been made, furnish forthwith a written report of the history,
1141 condition, treatment, dates, and costs of such treatment of the
1142 injured person and why the items identified by the insurer were
1143 reasonable in amount and medically necessary, together with a
1144 sworn statement that the treatment or services rendered were
1145 reasonable and necessary with respect to the bodily injury
1146 sustained and identifying which portion of the expenses for such
1147 treatment or services was incurred as a result of such bodily
1148 injury, and produce forthwith, and allow permit the inspection
1149 and copying of, his or her or its records regarding such
1150 history, condition, treatment, dates, and costs of treatment if;
1151 provided that this does shall not limit the introduction of
1152 evidence at trial. Such sworn statement must shall read as
1153 follows: “Under penalty of perjury, I declare that I have read
1154 the foregoing, and the facts alleged are true, to the best of my
1155 knowledge and belief.” A No cause of action for violation of the
1156 physician-patient privilege or invasion of the right of privacy
1157 may not be brought shall be permitted against any physician,
1158 hospital, clinic, or other medical institution complying with
1159 the provisions of this section. The person requesting such
1160 records and such sworn statement shall pay all reasonable costs
1161 connected therewith. If an insurer makes a written request for
1162 documentation or information under this paragraph within 30 days
1163 after having received notice of the amount of a covered loss
1164 under paragraph (4)(a), the amount or the partial amount that
1165 which is the subject of the insurer’s inquiry is shall become
1166 overdue if the insurer does not pay in accordance with paragraph
1167 (4)(b) or within 10 days after the insurer’s receipt of the
1168 requested documentation or information, whichever occurs later.
1169 As used in For purposes of this paragraph, the term “receipt”
1170 includes, but is not limited to, inspection and copying pursuant
1171 to this paragraph. An Any insurer that requests documentation or
1172 information pertaining to reasonableness of charges or medical
1173 necessity under this paragraph without a reasonable basis for
1174 such requests as a general business practice is engaging in an
1175 unfair trade practice under the insurance code.
1176 (c) In the event of a any dispute regarding an insurer’s
1177 right to discovery of facts under this section, the insurer may
1178 petition a court of competent jurisdiction to enter an order
1179 permitting such discovery. The order may be made only on motion
1180 for good cause shown and upon notice to all persons having an
1181 interest, and must it shall specify the time, place, manner,
1182 conditions, and scope of the discovery. Such court may, In order
1183 to protect against annoyance, embarrassment, or oppression, as
1184 justice requires, the court may enter an order refusing
1185 discovery or specifying conditions of discovery and may order
1186 payments of costs and expenses of the proceeding, including
1187 reasonable fees for the appearance of attorneys at the
1188 proceedings, as justice requires.
1189 (d) The injured person shall be furnished, upon request, a
1190 copy of all information obtained by the insurer under the
1191 provisions of this section, and shall pay a reasonable charge,
1192 if required by the insurer.
1193 (e) Notice to an insurer of the existence of a claim may
1194 shall not be unreasonably withheld by an insured.
1195 (f) In a dispute between the insured and the insurer, or
1196 between an assignee of the insured’s rights and the insurer, the
1197 insurer must notify the insured or the assignee that the policy
1198 limits under this section have been reached within 15 days after
1199 the limits have been reached.
1200 (8) APPLICABILITY OF PROVISION REGULATING ATTORNEY
1201 ATTORNEY’S FEES.—
1202 (a) With respect to any dispute under the provisions of ss.
1203 627.730-627.7405 between the insured and the insurer, or between
1204 an assignee of an insured’s rights and the insurer, the
1205 provisions of ss. s. 627.428 and 768.79 shall apply, except as
1206 provided in subsections (10) and (15), and except that any
1207 attorney fees recovered must:
1208 1. Comply with prevailing professional standards;
1209 2. Ensure that the attorney fees for work performed by an
1210 attorney does not duplicate work performed by a paralegal or
1211 legal assistant; and
1212 3. Not overstate or inflate the number of hours reasonably
1213 necessary for a case of comparable skill or complexity.
1214 (b) Notwithstanding s. 627.428 and this subsection, it
1215 shall be presumed that any attorney fees awarded under ss.
1216 627.730-627.7405 are calculated without regard to a contingency
1217 risk multiplier. This presumption may be overcome only if the
1218 court makes findings of fact based upon competent evidence in
1219 the record which establishes that:
1220 1. The party requesting the multiplier would have faced
1221 substantial difficulties finding competent counsel to pursue the
1222 case in the relevant market but for the consideration of a fee
1223 multiplier;
1224 2. Consideration of a fee multiplier was a necessary
1225 incentive to obtain competent counsel to pursue the case;
1226 3. The claim would not be economically feasible to hire an
1227 attorney on a noncontingent, fixed-fee basis;
1228 4. The attorney was unable to mitigate the risk of
1229 nonpayment of attorney fees in any other way; and
1230 5. The use of a multiplier is justified based on factors
1231 such as the amount of risk undertaken by the attorney at the
1232 outset of the case, the results obtained, and the type of fee
1233 arrangement between the attorney and client.
1234 (c) Paragraph (b) does not apply to a case where class
1235 action status has been sought or granted, and a contingency risk
1236 multiplier may be applied in such cases notwithstanding
1237 paragraph (b).
1238 (d) Upon the request of either party, a judge must make
1239 written findings, substantiated by evidence presented at trial
1240 or any hearings associated with the trial, that an award of
1241 attorney fees complies with this subsection.
1242 (9) PREFERRED PROVIDERS.—An insurer may negotiate and
1243 contract enter into contracts with preferred licensed health
1244 care providers for the benefits described in this section,
1245 referred to in this section as “preferred providers,” which
1246 shall include health care providers licensed under chapter
1247 chapters 458, chapter 459, chapter 460, chapter 461, or chapter
1248 and 463. The insurer may provide an option to an insured to use
1249 a preferred provider at the time of purchasing purchase of the
1250 policy for personal injury protection benefits, if the
1251 requirements of this subsection are met. If the insured elects
1252 to use a provider who is not a preferred provider, whether the
1253 insured purchased a preferred provider policy or a nonpreferred
1254 provider policy, the medical benefits provided by the insurer
1255 shall be as required by this section. If the insured elects to
1256 use a provider who is a preferred provider, the insurer may pay
1257 medical benefits in excess of the benefits required by this
1258 section and may waive or lower the amount of any deductible that
1259 applies to such medical benefits. If the insurer offers a
1260 preferred provider policy to a policyholder or applicant, it
1261 must also offer a nonpreferred provider policy. The insurer
1262 shall provide each insured policyholder with a current roster of
1263 preferred providers in the county in which the insured resides
1264 at the time of purchase of such policy, and shall make such list
1265 available for public inspection during regular business hours at
1266 the insurer’s principal office of the insurer within the state.
1267 (10) DEMAND LETTER.—
1268 (a) As a condition precedent to filing any action for
1269 benefits under this section, the insurer must be provided with
1270 written notice of an intent to initiate litigation must be
1271 provided to the insurer. Such notice may not be sent until the
1272 claim is overdue, including any additional time the insurer has
1273 to pay the claim pursuant to paragraph (4)(b).
1274 (b) The notice must required shall state that it is a
1275 “demand letter under s. 627.736(10)” and shall state with
1276 specificity:
1277 1. The name of the insured upon which such benefits are
1278 being sought, including a copy of the assignment giving rights
1279 to the claimant if the claimant is not the insured.
1280 2. The claim number or policy number upon which such claim
1281 was originally submitted to the insurer.
1282 3. To the extent applicable, the name of any medical
1283 provider who rendered to an insured the treatment, services,
1284 accommodations, or supplies that form the basis of such claim;
1285 and an itemized statement specifying each exact amount, the date
1286 of treatment, service, or accommodation, and the type of benefit
1287 claimed to be due. A completed form satisfying the requirements
1288 of paragraph (5)(d) or the lost-wage statement previously
1289 submitted may be used as the itemized statement. To the extent
1290 that the demand involves an insurer’s withdrawal of payment
1291 under paragraph (7)(a) for future treatment not yet rendered,
1292 the claimant shall attach a copy of the insurer’s notice
1293 withdrawing such payment and an itemized statement of the type,
1294 frequency, and duration of future treatment claimed to be
1295 reasonable and medically necessary.
1296 (c) Each notice required by this subsection must be
1297 delivered to the insurer by United States certified or
1298 registered mail, return receipt requested, or by electronic
1299 mail. Such postal costs shall be reimbursed by the insurer if so
1300 requested by the claimant in the notice, when the insurer pays
1301 the claim. Such notice must be sent to the person and address
1302 specified by the insurer for the purposes of receiving notices
1303 under this subsection. Each licensed insurer, whether domestic,
1304 foreign, or alien, shall file with the office designation of the
1305 name and physical and e-mail address of the designated person to
1306 whom notices must pursuant to this subsection shall be sent
1307 which the office shall make available on its Internet website.
1308 The name and address on file with the office pursuant to s.
1309 624.422 are shall be deemed the authorized representative to
1310 accept notice pursuant to this subsection if in the event no
1311 other designation has been made.
1312 (d) If, within 30 days after receipt of notice by the
1313 insurer, the overdue claim specified in the notice is paid by
1314 the insurer together with applicable interest and a penalty of
1315 10 percent of the overdue amount paid by the insurer, subject to
1316 a maximum penalty of $250, no action may be brought against the
1317 insurer. If the demand involves an insurer’s withdrawal of
1318 payment under paragraph (7)(a) for future treatment not yet
1319 rendered, no action may be brought against the insurer if,
1320 within 30 days after its receipt of the notice, the insurer
1321 mails to the person filing the notice a written statement of the
1322 insurer’s agreement to pay for such treatment in accordance with
1323 the notice and to pay a penalty of 10 percent, subject to a
1324 maximum penalty of $250, when it pays for such future treatment
1325 in accordance with the requirements of this section. To the
1326 extent the insurer determines not to pay any amount demanded,
1327 the penalty is shall not be payable in any subsequent action.
1328 For purposes of this subsection, payment or the insurer’s
1329 agreement shall be treated as being made on the date a draft or
1330 other valid instrument that is equivalent to payment, or the
1331 insurer’s written statement of agreement, is placed in the
1332 United States mail in a properly addressed, postpaid envelope,
1333 or if not so posted, on the date of delivery. The insurer is not
1334 obligated to pay any attorney attorney’s fees if the insurer
1335 pays the claim or mails its agreement to pay for future
1336 treatment within the time prescribed by this subsection.
1337 (e) The applicable statute of limitation for an action
1338 under this section shall be tolled for a period of 30 business
1339 days by the mailing of the notice required by this subsection.
1340 (f) Any insurer making a general business practice of not
1341 paying valid claims until receipt of the notice required by this
1342 subsection is engaging in an unfair trade practice under the
1343 insurance code.
1344 (11) FAILURE TO PAY VALID CLAIMS; UNFAIR OR DECEPTIVE
1345 PRACTICE.—
1346 (a) If An insurer fails to pay valid claims for personal
1347 injury protection with such frequency so as to indicate a
1348 general business practice, the insurer is engaging in a
1349 prohibited unfair or deceptive practice that is subject to the
1350 penalties provided in s. 626.9521 and the office has the powers
1351 and duties specified in ss. 626.9561-626.9601 if the insurer,
1352 with such frequency so as to indicate a general business
1353 practice: with respect thereto
1354 1. Fails to pay valid claims for personal injury
1355 protection; or
1356 2. Fails to pay valid claims until receipt of the notice
1357 required by subsection (10).
1358 (b) Notwithstanding s. 501.212, the Department of Legal
1359 Affairs may investigate and initiate actions for a violation of
1360 this subsection, including, but not limited to, the powers and
1361 duties specified in part II of chapter 501.
1362 (17) REFERRAL FEES.—A person, entity, or licensee may not
1363 accept a fee for the referral of the insured to a person,
1364 entity, or licensee for medical benefits under paragraph (1)(a)
1365 unless the person, entity, or licensee making the referral
1366 discloses in writing to the insured and the insurer that he or
1367 she has received a referral fee, the amount of the referral fee,
1368 and the name and business address of the person or entity that
1369 provided the referral fee. Reimbursement under the Florida Motor
1370 Vehicle No-Fault Law to a person, entity, or licensee who
1371 receives and fails to disclose a referral fee to the insured and
1372 insurer as required by this subsection must be reduced by the
1373 amount of the undisclosed referral fee.
1374 Section 9. Effective December 1, 2012, subsection (16) of
1375 section 627.736, Florida Statutes, is amended to read:
1376 627.736 Required personal injury protection benefits;
1377 exclusions; priority; claims.—
1378 (16) SECURE ELECTRONIC DATA TRANSFER.—If all parties
1379 mutually and expressly agree, A notice, documentation,
1380 transmission, or communication of any kind required or
1381 authorized under ss. 627.730-627.7405 may be transmitted
1382 electronically if it is transmitted by secure electronic data
1383 transfer that is consistent with state and federal privacy and
1384 security laws.
1385 Section 10. Section 627.7405, Florida Statutes, is amended
1386 to read:
1387 627.7405 Insurers’ right of reimbursement.—
1388 (1) Notwithstanding any other provisions of ss. 627.730
1389 627.7405, an any insurer providing personal injury protection
1390 benefits on a private passenger motor vehicle shall have, to the
1391 extent of any personal injury protection benefits paid to any
1392 person as a benefit arising out of such private passenger motor
1393 vehicle insurance, a right of reimbursement against the owner or
1394 the insurer of the owner of a commercial motor vehicle, if the
1395 benefits paid result from such person having been an occupant of
1396 the commercial motor vehicle or having been struck by the
1397 commercial motor vehicle while not an occupant of any self
1398 propelled vehicle.
1399 (2) The insurer’s right of reimbursement under this section
1400 does not apply to an owner or registrant as identified in s.
1401 627.733(1)(b).
1402 Section 11. Subsections (1), (10), and (13) of section
1403 817.234, Florida Statutes, are amended to read:
1404 817.234 False and fraudulent insurance claims.—
1405 (1)(a) A person commits insurance fraud punishable as
1406 provided in subsection (11) if that person, with the intent to
1407 injure, defraud, or deceive any insurer:
1408 1. Presents or causes to be presented any written or oral
1409 statement as part of, or in support of, a claim for payment or
1410 other benefit pursuant to an insurance policy or a health
1411 maintenance organization subscriber or provider contract,
1412 knowing that such statement contains any false, incomplete, or
1413 misleading information concerning any fact or thing material to
1414 such claim;
1415 2. Prepares or makes any written or oral statement that is
1416 intended to be presented to any insurer in connection with, or
1417 in support of, any claim for payment or other benefit pursuant
1418 to an insurance policy or a health maintenance organization
1419 subscriber or provider contract, knowing that such statement
1420 contains any false, incomplete, or misleading information
1421 concerning any fact or thing material to such claim; or
1422 3.a. Knowingly presents, causes to be presented, or
1423 prepares or makes with knowledge or belief that it will be
1424 presented to any insurer, purported insurer, servicing
1425 corporation, insurance broker, or insurance agent, or any
1426 employee or agent thereof, any false, incomplete, or misleading
1427 information or written or oral statement as part of, or in
1428 support of, an application for the issuance of, or the rating
1429 of, any insurance policy, or a health maintenance organization
1430 subscriber or provider contract; or
1431 b. Who Knowingly conceals information concerning any fact
1432 material to such application; or.
1433 4. Knowingly presents, causes to be presented, or prepares
1434 or makes with knowledge or belief that it will be presented to
1435 any insurer a claim for payment or other benefit under a
1436 personal injury protection insurance policy if the person knows
1437 that the payee knowingly submitted a false, misleading, or
1438 fraudulent application or other document when applying for
1439 licensure as a health care clinic, seeking an exemption from
1440 licensure as a health care clinic, or demonstrating compliance
1441 with part X of chapter 400.
1442 (b) All claims and application forms must shall contain a
1443 statement that is approved by the Office of Insurance Regulation
1444 of the Financial Services Commission which clearly states in
1445 substance the following: “Any person who knowingly and with
1446 intent to injure, defraud, or deceive any insurer files a
1447 statement of claim or an application containing any false,
1448 incomplete, or misleading information is guilty of a felony of
1449 the third degree.” This paragraph does shall not apply to
1450 reinsurance contracts, reinsurance agreements, or reinsurance
1451 claims transactions.
1452 (10) A licensed health care practitioner who is found
1453 guilty of insurance fraud under this section for an act relating
1454 to a personal injury protection insurance policy loses his or
1455 her license to practice for 5 years and may not receive
1456 reimbursement for personal injury protection benefits for 10
1457 years. As used in this section, the term “insurer” means any
1458 insurer, health maintenance organization, self-insurer, self
1459 insurance fund, or other similar entity or person regulated
1460 under chapter 440 or chapter 641 or by the Office of Insurance
1461 Regulation under the Florida Insurance Code.
1462 (13) As used in this section, the term:
1463 (a) “Insurer” means any insurer, health maintenance
1464 organization, self-insurer, self-insurance fund, or similar
1465 entity or person regulated under chapter 440 or chapter 641 or
1466 by the Office of Insurance Regulation under the Florida
1467 Insurance Code.
1468 (b)(a) “Property” means property as defined in s. 812.012.
1469 (c)(b) “Value” means value as defined in s. 812.012.
1470 Section 12. Subsection (4) of section 316.065, Florida
1471 Statutes, is amended to read:
1472 316.065 Crashes; reports; penalties.—
1473 (4) Any person who knowingly repairs a motor vehicle
1474 without having made a report as required by subsection (3) is
1475 guilty of a misdemeanor of the first degree, punishable as
1476 provided in s. 775.082 or s. 775.083. The owner and driver of a
1477 vehicle involved in a crash who makes a report thereof in
1478 accordance with subsection (1) or s. 316.066(1) is not liable
1479 under this section.
1480 Section 13. Motor vehicle insurance rate rollback.—
1481 (1) The Office of Insurance Regulation shall order insurers
1482 writing personal injury protection insurance in this state to
1483 make a rate filing before October 1, 2012, and effective January
1484 1, 2013, which reduces rates for such insurance by a factor that
1485 reflects the expected effect of the changes contained in this
1486 act. In the absence of clear and convincing evidence to the
1487 contrary, it shall be presumed that the expected impact of the
1488 act will result in at least a 25 percent reduction in the rates
1489 in effect for such insurance on December 31, 2012. In lieu of
1490 making the rate filing required in this subsection, an insurer
1491 may, upon notification to the office, implement a 25 percent
1492 reduction of its rates, effective January 1, 2013.
1493 (2) An insurer or rating organization that contends in the
1494 January 1, 2013, rate filing or any subsequent rate filing made
1495 on or before December 31, 2018, that the presumed reduced rate
1496 provided for in subsection (1) is excessive, inadequate, or
1497 unfairly discriminatory shall separately state in its filing the
1498 rate it contends is appropriate and shall state with specificity
1499 the factors or data that it contends should be considered in
1500 order to produce such appropriate rate. The insurer or rating
1501 organization shall be permitted to use all of the generally
1502 accepted actuarial techniques, as provided in s. 627.062,
1503 Florida Statutes, in making any filing pursuant to this
1504 subsection. The Office of Insurance Regulation shall review each
1505 exception and approve or disapprove it prior to use. It shall be
1506 the insurer’s burden to actuarially justify by clear and
1507 convincing evidence any deviation that results in a rate that is
1508 higher than the presumed reduced rate as provided in subsection
1509 (1).
1510 (3) If any provision of this act is held invalid by a court
1511 of competent jurisdiction, the Office of Insurance Regulation
1512 shall permit an adjustment of all rates filed under this section
1513 to reflect the impact of such holding on such rates so as to
1514 ensure that the rates are not excessive, inadequate, or unfairly
1515 discriminatory.
1516 Section 14. The Office of Insurance Regulation shall
1517 perform a comprehensive personal injury protection data call and
1518 publish the results by January 1, 2015. It is the intent of the
1519 Legislature that the office design the data call with the
1520 expectation that the Legislature will use the data to help
1521 evaluate market conditions relating to the Florida Motor Vehicle
1522 No-Fault Law and the impact on the market of reforms to the law
1523 made by this act. The elements of the data call must address,
1524 but need not be limited to, the following components of the
1525 Florida Motor Vehicle No-Fault Law:
1526 (1) Quantity of personal injury protection claims.
1527 (2) Type or nature of claimants.
1528 (3) Amount and type of personal injury protection benefits
1529 paid and expenses incurred.
1530 (4) Type and quantity of, and charges for, medical
1531 benefits.
1532 (5) Attorney fees related to bringing and defending actions
1533 for benefits.
1534 (6) Direct earned premiums for personal injury protection
1535 coverage, pure loss ratios, pure premiums, and other information
1536 related to premiums and losses.
1537 (7) Licensed drivers and accidents.
1538 (8) Fraud and enforcement.
1539 Section 15. If any provision of this act or its application
1540 to any person or circumstance is held invalid, the invalidity
1541 does not affect other provisions or applications of the act
1542 which can be given effect without the invalid provision or
1543 application, and to this end the provisions of this act are
1544 severable.
1545 Section 16. Except as otherwise expressly provided in this
1546 act, this act shall take effect July 1, 2012.
1547
1548 ================= T I T L E A M E N D M E N T ================
1549 And the title is amended as follows:
1550 Delete everything before the enacting clause
1551 and insert:
1552 A bill to be entitled
1553 An act relating to motor vehicle personal injury
1554 protection insurance; amending s. 316.066, F.S.;
1555 revising the conditions for completing the long-form
1556 traffic crash report; revising the information
1557 contained in the short-form report; revising the
1558 requirements relating to the driver’s responsibility
1559 for submitting a report for crashes not requiring a
1560 law enforcement report; amending s. 400.9905, F.S.;
1561 providing that certain entities exempt from licensure
1562 as a health care clinic must nonetheless be licensed
1563 in order to receive reimbursement for the provision of
1564 personal injury protection benefits; amending s.
1565 400.991, F.S.; requiring that an application for
1566 licensure, or exemption from licensure, as a health
1567 care clinic include a statement regarding insurance
1568 fraud; amending s. 626.989, F.S.; providing that
1569 knowingly submitting false, misleading, or fraudulent
1570 documents relating to licensure as a health care
1571 clinic, or submitting a claim for personal injury
1572 protection relating to clinic licensure documents, is
1573 a fraudulent insurance act under certain conditions;
1574 amending s. 626.9581, F.S.; requiring the Department
1575 of Financial Services or the Office of Insurance
1576 Regulation to revoke the certificate of authority of
1577 an insurer that engages in unfair trade practices
1578 while providing motor vehicle personal injury
1579 protection insurance; amending s. 626.9894, F.S.;
1580 conforming provisions to changes made by act; creating
1581 s. 626.9895, F.S.; providing definitions; authorizing
1582 the Division of Insurance Fraud of the Department of
1583 Financial Services to establish a direct-support
1584 organization for the purpose of prosecuting,
1585 investigating, and preventing motor vehicle insurance
1586 fraud; providing requirements for, and duties of, the
1587 organization; requiring that the organization operate
1588 pursuant to a contract with the division; providing
1589 for the requirements of the contract; providing for a
1590 board of directors; authorizing the organization to
1591 use the division’s property and facilities subject to
1592 certain requirements; requiring that the department
1593 adopt rules relating to procedures for the
1594 organization’s governance and relating to conditions
1595 for the use of the division’s property or facilities;
1596 authorizing contributions from insurers; authorizing
1597 any moneys received by the organization to be held in
1598 a separate depository account in the name of the
1599 organization; requiring that the division deposit
1600 certain proceeds into the Insurance Regulatory Trust
1601 Fund; amending s. 627.736, F.S.; revising the cap on
1602 benefits to provide that death benefits are in
1603 addition to medical and disability benefits; revising
1604 medical benefits; distinguishing between initial and
1605 followup services; excluding massage and acupuncture
1606 from medical benefits that may be reimbursed under the
1607 Florida Motor Vehicle No-Fault Law; adding physical
1608 therapists to the list of providers that may provide
1609 services; requiring that an insurer repay any benefits
1610 covered by the Medicaid program; requiring that an
1611 insurer provide a claimant an opportunity to revise
1612 claims that contain errors; authorizing an insurer to
1613 provide notice to the claimant and conduct an
1614 investigation if fraud is suspected; requiring that an
1615 insurer create and maintain a log of personal injury
1616 protection benefits paid and that the insurer provide
1617 to the insured or an assignee of the insured, upon
1618 request, a copy of the log if litigation is commenced;
1619 revising the Medicare fee schedules that an insurer
1620 may use as a basis for limiting reimbursement of
1621 personal injury protection benefits; providing that
1622 the Medicare fee schedule in effect on a specific date
1623 applies for purposes of limiting reimbursement;
1624 requiring that an insurer that limits payments based
1625 on the statutory fee schedule include a notice in
1626 insurance policies at the time of issuance or renewal;
1627 deleting obsolete provisions; providing that certain
1628 entities exempt from licensure as a clinic must
1629 nonetheless be licensed to receive reimbursement for
1630 the provision of personal injury protection benefits;
1631 providing exceptions; requiring that an insurer notify
1632 parties in disputes over personal injury protection
1633 claims when policy limits are reached; providing
1634 criteria for the award of attorney fees; providing a
1635 presumption regarding the use of a contingency risk
1636 multiplier; consolidating provisions relating to
1637 unfair or deceptive practices under certain
1638 conditions; providing for demand notices to be
1639 submitted electronically; requiring that a person,
1640 entity, or licensee that makes a referral for medical
1641 benefits disclose referral fees in writing to the
1642 insured and insurer; eliminating a requirement that
1643 all parties mutually and expressly agree to the use of
1644 electronic transmission of data; amending s. 627.7405,
1645 F.S.; providing an exception from an insurer’s right
1646 of reimbursement for certain owners or registrants;
1647 amending s. 817.234, F.S.; providing that it is
1648 insurance fraud to present a claim for personal injury
1649 protection benefits payable to a person or entity that
1650 knowingly submitted false, misleading, or fraudulent
1651 documents relating to licensure as a health care
1652 clinic; providing that a licensed health care
1653 practitioner guilty of certain insurance fraud loses
1654 his or her license and may not receive reimbursement
1655 for personal injury protection benefits for a
1656 specified period; defining the term “insurer”;
1657 amending s. 316.065, F.S.; conforming a cross
1658 reference; requiring personal injury protection motor
1659 vehicle insurers to file rates with the Office of
1660 Insurance Regulation for review under certain
1661 circumstances; specifying a presumption with regard to
1662 rates for personal injury protection motor vehicle
1663 insurance; requiring that the Office of Insurance
1664 Regulation perform a data call relating to personal
1665 injury protection; prescribing required elements of
1666 the data call; providing for severability; providing
1667 effective dates.