Florida Senate - 2012                          SENATOR AMENDMENT
       Bill No. CS for CS for SB 1860
                                Barcode 435312                          
                              LEGISLATIVE ACTION                        
                    Senate             .             House              
                Floor: 5/AD/2R         .                                
             03/06/2012 05:28 PM       .                                

       Senator Negron moved the following:
    1         Senate Amendment (with title amendment)
    3         Delete lines 507 - 1390
    4  and insert:
    5         Section 7. Subsections (1), (4), (5), (6), (8), (9), (10),
    6  and (11) of section 627.736, Florida Statutes, are amended to
    7  read:
    8         627.736 Required personal injury protection benefits;
    9  exclusions; priority; claims.—
   10         (1) REQUIRED BENEFITS.—An Every insurance policy complying
   11  with the security requirements of s. 627.733 must shall provide
   12  personal injury protection to the named insured, relatives
   13  residing in the same household, persons operating the insured
   14  motor vehicle, passengers in the such motor vehicle, and other
   15  persons struck by the such motor vehicle and suffering bodily
   16  injury while not an occupant of a self-propelled vehicle,
   17  subject to the provisions of subsection (2) and paragraph
   18  (4)(e), to a limit of $10,000 in medical and disability benefits
   19  and $5,000 in death benefits resulting from for loss sustained
   20  by any such person as a result of bodily injury, sickness,
   21  disease, or death arising out of the ownership, maintenance, or
   22  use of a motor vehicle as follows:
   23         (a) Medical benefits.—Eighty percent of all reasonable
   24  expenses for medically necessary medical, surgical, X-ray,
   25  dental, and rehabilitative services, including prosthetic
   26  devices, and medically necessary ambulance, hospital, and
   27  nursing services if the individual receives initial services and
   28  care pursuant to subparagraph 1. within 14 days after the motor
   29  vehicle accident. However, The medical benefits shall provide
   30  reimbursement only for: such
   31         1. Initial services and care that are lawfully provided,
   32  supervised, ordered, or prescribed by a physician licensed under
   33  chapter 458 or chapter 459, by a dentist licensed under chapter
   34  466, or a chiropractic physician licensed under chapter 460 or
   35  that are provided in a hospital or in a facility that owns, or
   36  is wholly owned by, a hospital. Initial services and care may
   37  also be provided by a person or entity licensed under part III
   38  of chapter 401 which provides emergency transportation and
   39  treatment.
   40         2. Followup services and care consistent with the
   41  underlying medical diagnosis rendered pursuant to subparagraph
   42  1. which may be provided, supervised, ordered, or prescribed
   43  only by a physician licensed under chapter 458 or chapter 459, a
   44  chiropractic physician licensed under chapter 460, a dentist
   45  licensed under chapter 466, or, to the extent permitted by
   46  applicable law and under the supervision of such physician,
   47  osteopathic physician, chiropractic physician, or dentist, by a
   48  physician assistant licensed under chapter 458 or chapter 459 or
   49  an advanced registered nurse practitioner licensed under chapter
   50  464. Followup services and care may also be provided by any of
   51  the following persons or entities:
   52         a.1. A hospital or ambulatory surgical center licensed
   53  under chapter 395.
   54         2. A person or entity licensed under ss. 401.2101-401.45
   55  that provides emergency transportation and treatment.
   56         b.3. An entity wholly owned by one or more physicians
   57  licensed under chapter 458 or chapter 459, chiropractic
   58  physicians licensed under chapter 460, or dentists licensed
   59  under chapter 466 or by such practitioner or practitioners and
   60  the spouse, parent, child, or sibling of such that practitioner
   61  or those practitioners.
   62         c.4. An entity that owns or is wholly owned, directly or
   63  indirectly, by a hospital or hospitals.
   64         d. A physical therapist licensed under chapter 486.
   65         e.5. A health care clinic licensed under part X of chapter
   66  400 which ss. 400.990-400.995 that is:
   67         a. accredited by the Joint Commission on Accreditation of
   68  Healthcare Organizations, the American Osteopathic Association,
   69  the Commission on Accreditation of Rehabilitation Facilities, or
   70  the Accreditation Association for Ambulatory Health Care, Inc.;
   71  or
   72         b. A health care clinic that:
   73         (I) Has a medical director licensed under chapter 458,
   74  chapter 459, or chapter 460;
   75         (II) Has been continuously licensed for more than 3 years
   76  or is a publicly traded corporation that issues securities
   77  traded on an exchange registered with the United States
   78  Securities and Exchange Commission as a national securities
   79  exchange; and
   80         (III) Provides at least four of the following medical
   81  specialties:
   82         (A) General medicine.
   83         (B) Radiography.
   84         (C) Orthopedic medicine.
   85         (D) Physical medicine.
   86         (E) Physical therapy.
   87         (F) Physical rehabilitation.
   88         (G) Prescribing or dispensing outpatient prescription
   89  medication.
   90         (H) Laboratory services.
   91         3. Reimbursement for services and care provided by each
   92  type of licensed medical provider authorized to render such
   93  services and care is limited to the lesser of 24 treatments or
   94  to services or care rendered within 12 weeks after the date of
   95  the initial treatment, whichever comes first, unless the insurer
   96  authorizes additional services or care.
   97         4. Medical benefits do not include massage as defined in s.
   98  480.033 or acupuncture as defined in s. 457.102, regardless of
   99  the person, entity, or licensee providing massage or
  100  acupuncture, and a licensed massage therapist or licensed
  101  acupuncturist may not be reimbursed for medical benefits under
  102  this section.
  103         5. The Financial Services Commission shall adopt by rule
  104  the form that must be used by an insurer and a health care
  105  provider specified in sub-subparagraph 3.b., sub-subparagraph
  106  3.c., or sub-subparagraph 3.e. subparagraph 3., subparagraph 4.,
  107  or subparagraph 5. to document that the health care provider
  108  meets the criteria of this paragraph, which rule must include a
  109  requirement for a sworn statement or affidavit.
  110         (b) Disability benefits.—Sixty percent of any loss of gross
  111  income and loss of earning capacity per individual from
  112  inability to work proximately caused by the injury sustained by
  113  the injured person, plus all expenses reasonably incurred in
  114  obtaining from others ordinary and necessary services in lieu of
  115  those that, but for the injury, the injured person would have
  116  performed without income for the benefit of his or her
  117  household. All disability benefits payable under this provision
  118  must shall be paid at least not less than every 2 weeks.
  119         (c) Death benefits.—Death benefits equal to the lesser of
  120  $5,000 or the remainder of unused personal injury protection
  121  benefits per individual. Death benefits are in addition to the
  122  medical and disability benefits provided under the insurance
  123  policy. The insurer may pay death such benefits to the executor
  124  or administrator of the deceased, to any of the deceased’s
  125  relatives by blood, or legal adoption, or connection by
  126  marriage, or to any person appearing to the insurer to be
  127  equitably entitled to such benefits thereto.
  129  Only insurers writing motor vehicle liability insurance in this
  130  state may provide the required benefits of this section, and no
  131  such insurer may not shall require the purchase of any other
  132  motor vehicle coverage other than the purchase of property
  133  damage liability coverage as required by s. 627.7275 as a
  134  condition for providing such required benefits. Insurers may not
  135  require that property damage liability insurance in an amount
  136  greater than $10,000 be purchased in conjunction with personal
  137  injury protection. Such insurers shall make benefits and
  138  required property damage liability insurance coverage available
  139  through normal marketing channels. An Any insurer writing motor
  140  vehicle liability insurance in this state who fails to comply
  141  with such availability requirement as a general business
  142  practice violates shall be deemed to have violated part IX of
  143  chapter 626, and such violation constitutes shall constitute an
  144  unfair method of competition or an unfair or deceptive act or
  145  practice involving the business of insurance. An; and any such
  146  insurer committing such violation is shall be subject to the
  147  penalties provided under that afforded in such part, as well as
  148  those provided which may be afforded elsewhere in the insurance
  149  code.
  150         (4) PAYMENT OF BENEFITS; WHEN DUE.—Benefits due from an
  151  insurer under ss. 627.730-627.7405 are shall be primary, except
  152  that benefits received under any workers’ compensation law must
  153  shall be credited against the benefits provided by subsection
  154  (1) and are shall be due and payable as loss accrues, upon
  155  receipt of reasonable proof of such loss and the amount of
  156  expenses and loss incurred which are covered by the policy
  157  issued under ss. 627.730-627.7405. If When the Agency for Health
  158  Care Administration provides, pays, or becomes liable for
  159  medical assistance under the Medicaid program related to injury,
  160  sickness, disease, or death arising out of the ownership,
  161  maintenance, or use of a motor vehicle, the benefits under ss.
  162  627.730-627.7405 are shall be subject to the provisions of the
  163  Medicaid program. However, within 30 days after receiving notice
  164  that the Medicaid program paid such benefits, the insurer shall
  165  repay the full amount of the benefits to the Medicaid program.
  166         (a) An insurer may require written notice to be given as
  167  soon as practicable after an accident involving a motor vehicle
  168  with respect to which the policy affords the security required
  169  by ss. 627.730-627.7405.
  170         (b) Personal injury protection insurance benefits paid
  171  pursuant to this section are shall be overdue if not paid within
  172  30 days after the insurer is furnished written notice of the
  173  fact of a covered loss and of the amount of same. However:
  174         1. If such written notice of the entire claim is not
  175  furnished to the insurer as to the entire claim, any partial
  176  amount supported by written notice is overdue if not paid within
  177  30 days after such written notice is furnished to the insurer.
  178  Any part or all of the remainder of the claim that is
  179  subsequently supported by written notice is overdue if not paid
  180  within 30 days after such written notice is furnished to the
  181  insurer.
  182         2. If When an insurer pays only a portion of a claim or
  183  rejects a claim, the insurer shall provide at the time of the
  184  partial payment or rejection an itemized specification of each
  185  item that the insurer had reduced, omitted, or declined to pay
  186  and any information that the insurer desires the claimant to
  187  consider related to the medical necessity of the denied
  188  treatment or to explain the reasonableness of the reduced charge
  189  if, provided that this does shall not limit the introduction of
  190  evidence at trial.; and The insurer must also shall include the
  191  name and address of the person to whom the claimant should
  192  respond and a claim number to be referenced in future
  193  correspondence.
  194         3. If an insurer pays only a portion of a claim or rejects
  195  a claim due to an alleged error in the claim, the insurer, at
  196  the time of the partial payment or rejection, shall provide an
  197  itemized specification or explanation of benefits due to the
  198  specified error. Upon receiving the specification or
  199  explanation, the person making the claim, at the person’s option
  200  and without waiving any other legal remedy for payment, has 15
  201  days to submit a revised claim, which shall be considered a
  202  timely submission of written notice of a claim.
  203         4.However, Notwithstanding the fact that written notice
  204  has been furnished to the insurer, any payment is shall not be
  205  deemed overdue if when the insurer has reasonable proof to
  206  establish that the insurer is not responsible for the payment.
  207         5. For the purpose of calculating the extent to which any
  208  benefits are overdue, payment shall be treated as being made on
  209  the date a draft or other valid instrument that which is
  210  equivalent to payment was placed in the United States mail in a
  211  properly addressed, postpaid envelope or, if not so posted, on
  212  the date of delivery.
  213         6. This paragraph does not preclude or limit the ability of
  214  the insurer to assert that the claim was unrelated, was not
  215  medically necessary, or was unreasonable or that the amount of
  216  the charge was in excess of that permitted under, or in
  217  violation of, subsection (5). Such assertion by the insurer may
  218  be made at any time, including after payment of the claim or
  219  after the 30-day time period for payment set forth in this
  220  paragraph.
  221         (c) Upon receiving notice of an accident that is
  222  potentially covered by personal injury protection benefits, the
  223  insurer must reserve $5,000 of personal injury protection
  224  benefits for payment to physicians licensed under chapter 458 or
  225  chapter 459 or dentists licensed under chapter 466 who provide
  226  emergency services and care, as defined in s. 395.002(9), or who
  227  provide hospital inpatient care. The amount required to be held
  228  in reserve may be used only to pay claims from such physicians
  229  or dentists until 30 days after the date the insurer receives
  230  notice of the accident. After the 30-day period, any amount of
  231  the reserve for which the insurer has not received notice of
  232  such claims a claim from a physician or dentist who provided
  233  emergency services and care or who provided hospital inpatient
  234  care may then be used by the insurer to pay other claims. The
  235  time periods specified in paragraph (b) for required payment of
  236  personal injury protection benefits are shall be tolled for the
  237  period of time that an insurer is required by this paragraph to
  238  hold payment of a claim that is not from such a physician or
  239  dentist who provided emergency services and care or who provided
  240  hospital inpatient care to the extent that the personal injury
  241  protection benefits not held in reserve are insufficient to pay
  242  the claim. This paragraph does not require an insurer to
  243  establish a claim reserve for insurance accounting purposes.
  244         (d) All overdue payments shall bear simple interest at the
  245  rate established under s. 55.03 or the rate established in the
  246  insurance contract, whichever is greater, for the year in which
  247  the payment became overdue, calculated from the date the insurer
  248  was furnished with written notice of the amount of covered loss.
  249  Interest is shall be due at the time payment of the overdue
  250  claim is made.
  251         (e) The insurer of the owner of a motor vehicle shall pay
  252  personal injury protection benefits for:
  253         1. Accidental bodily injury sustained in this state by the
  254  owner while occupying a motor vehicle, or while not an occupant
  255  of a self-propelled vehicle if the injury is caused by physical
  256  contact with a motor vehicle.
  257         2. Accidental bodily injury sustained outside this state,
  258  but within the United States of America or its territories or
  259  possessions or Canada, by the owner while occupying the owner’s
  260  motor vehicle.
  261         3. Accidental bodily injury sustained by a relative of the
  262  owner residing in the same household, under the circumstances
  263  described in subparagraph 1. or subparagraph 2., if provided the
  264  relative at the time of the accident is domiciled in the owner’s
  265  household and is not himself or herself the owner of a motor
  266  vehicle with respect to which security is required under ss.
  267  627.730-627.7405.
  268         4. Accidental bodily injury sustained in this state by any
  269  other person while occupying the owner’s motor vehicle or, if a
  270  resident of this state, while not an occupant of a self
  271  propelled vehicle, if the injury is caused by physical contact
  272  with such motor vehicle, if provided the injured person is not
  273  himself or herself:
  274         a. The owner of a motor vehicle with respect to which
  275  security is required under ss. 627.730-627.7405; or
  276         b. Entitled to personal injury benefits from the insurer of
  277  the owner or owners of such a motor vehicle.
  278         (f) If two or more insurers are liable for paying to pay
  279  personal injury protection benefits for the same injury to any
  280  one person, the maximum payable is shall be as specified in
  281  subsection (1), and the any insurer paying the benefits is shall
  282  be entitled to recover from each of the other insurers an
  283  equitable pro rata share of the benefits paid and expenses
  284  incurred in processing the claim.
  285         (g) It is a violation of the insurance code for an insurer
  286  to fail to timely provide benefits as required by this section
  287  with such frequency as to constitute a general business
  288  practice.
  289         (h) Benefits are shall not be due or payable to or on the
  290  behalf of an insured person if that person has committed, by a
  291  material act or omission, any insurance fraud relating to
  292  personal injury protection coverage under his or her policy, if
  293  the fraud is admitted to in a sworn statement by the insured or
  294  if it is established in a court of competent jurisdiction. Any
  295  insurance fraud voids shall void all coverage arising from the
  296  claim related to such fraud under the personal injury protection
  297  coverage of the insured person who committed the fraud,
  298  irrespective of whether a portion of the insured person’s claim
  299  may be legitimate, and any benefits paid before prior to the
  300  discovery of the insured person’s insurance fraud is shall be
  301  recoverable by the insurer in its entirety from the person who
  302  committed insurance fraud in their entirety. The prevailing
  303  party is entitled to its costs and attorney attorney’s fees in
  304  any action in which it prevails in an insurer’s action to
  305  enforce its right of recovery under this paragraph.
  306         (i) If an insurer has a reasonable belief that a fraudulent
  307  insurance act, as defined in s. 626.989 or s. 817.234, has been
  308  committed, the insurer shall notify the claimant in writing
  309  within 30 days after submission of the claim that the claim is
  310  being investigated for suspected fraud and execute and provide
  311  to the insured and the office an affidavit under oath stating
  312  that there is a factual basis that there is a probability of
  313  fraud. The insurer has an additional 60 days, beginning at the
  314  end of the initial 30-day period, to conduct its fraud
  315  investigation. Notwithstanding subsection (10), no later than
  316  the 90th day after the submission of the claim, the insurer must
  317  deny the claim or pay the claim along with simple interest as
  318  provided in paragraph (d). All claims denied for suspected
  319  fraudulent insurance acts shall be reported to the Division of
  320  Insurance Fraud.
  321         (j) An insurer shall create and maintain for each insured a
  322  log of personal injury protection benefits paid by the insurer
  323  on behalf of the insured. If litigation is commenced, the
  324  insurer shall provide to the insured, or an assignee of the
  325  insured, a copy of the log within 30 days after receiving a
  326  request for the log from the insured or the assignee.
  328         (a)1.A Any physician, hospital, clinic, or other person or
  329  institution lawfully rendering treatment to an injured person
  330  for a bodily injury covered by personal injury protection
  331  insurance may charge the insurer and injured party only a
  332  reasonable amount pursuant to this section for the services and
  333  supplies rendered, and the insurer providing such coverage may
  334  pay for such charges directly to such person or institution
  335  lawfully rendering such treatment, if the insured receiving such
  336  treatment or his or her guardian has countersigned the properly
  337  completed invoice, bill, or claim form approved by the office
  338  upon which such charges are to be paid for as having actually
  339  been rendered, to the best knowledge of the insured or his or
  340  her guardian. In no event, However, may such a charge may not
  341  exceed be in excess of the amount the person or institution
  342  customarily charges for like services or supplies. In
  343  determining With respect to a determination of whether a charge
  344  for a particular service, treatment, or otherwise is reasonable,
  345  consideration may be given to evidence of usual and customary
  346  charges and payments accepted by the provider involved in the
  347  dispute, and reimbursement levels in the community and various
  348  federal and state medical fee schedules applicable to motor
  349  vehicle automobile and other insurance coverages, and other
  350  information relevant to the reasonableness of the reimbursement
  351  for the service, treatment, or supply.
  352         1.2. The insurer may limit reimbursement to 80 percent of
  353  the following schedule of maximum charges:
  354         a. For emergency transport and treatment by providers
  355  licensed under chapter 401, 200 percent of Medicare.
  356         b. For emergency services and care provided by a hospital
  357  licensed under chapter 395, 75 percent of the hospital’s usual
  358  and customary charges.
  359         c. For emergency services and care as defined by s.
  360  395.002(9) provided in a facility licensed under chapter 395
  361  rendered by a physician or dentist, and related hospital
  362  inpatient services rendered by a physician or dentist, the usual
  363  and customary charges in the community.
  364         d. For hospital inpatient services, other than emergency
  365  services and care, 200 percent of the Medicare Part A
  366  prospective payment applicable to the specific hospital
  367  providing the inpatient services.
  368         e. For hospital outpatient services, other than emergency
  369  services and care, 200 percent of the Medicare Part A Ambulatory
  370  Payment Classification for the specific hospital providing the
  371  outpatient services.
  372         f. For all other medical services, supplies, and care, 200
  373  percent of the allowable amount under:
  374         (I) The participating physicians fee schedule of Medicare
  375  Part B, except as provided in sub-sub-subparagraphs (II) and
  376  (III).
  377         (II) Medicare Part B, in the case of services, supplies,
  378  and care provided by ambulatory surgical centers and clinical
  379  laboratories.
  380         (III) The Durable Medical Equipment Prosthetics/Orthotics
  381  and Supplies fee schedule of Medicare Part B, in the case of
  382  durable medical equipment.
  384  However, if such services, supplies, or care is not reimbursable
  385  under Medicare Part B, as provided in this sub-subparagraph, the
  386  insurer may limit reimbursement to 80 percent of the maximum
  387  reimbursable allowance under workers’ compensation, as
  388  determined under s. 440.13 and rules adopted thereunder which
  389  are in effect at the time such services, supplies, or care is
  390  provided. Services, supplies, or care that is not reimbursable
  391  under Medicare or workers’ compensation is not required to be
  392  reimbursed by the insurer.
  393         2.3. For purposes of subparagraph 1. 2., the applicable fee
  394  schedule or payment limitation under Medicare is the fee
  395  schedule or payment limitation in effect on January 1 of the
  396  year in which at the time the services, supplies, or care is was
  397  rendered and for the area in which such services, supplies, or
  398  care is were rendered, and the applicable fee schedule or
  399  payment limitation applies throughout the remainder of that
  400  year, notwithstanding any subsequent change made to the fee
  401  schedule or payment limitation, except that it may not be less
  402  than the allowable amount under the applicable participating
  403  physicians schedule of Medicare Part B for 2007 for medical
  404  services, supplies, and care subject to Medicare Part B.
  405         3.4. Subparagraph 1. 2. does not allow the insurer to apply
  406  any limitation on the number of treatments or other utilization
  407  limits that apply under Medicare or workers’ compensation. An
  408  insurer that applies the allowable payment limitations of
  409  subparagraph 1. 2. must reimburse a provider who lawfully
  410  provided care or treatment under the scope of his or her
  411  license, regardless of whether such provider is would be
  412  entitled to reimbursement under Medicare due to restrictions or
  413  limitations on the types or discipline of health care providers
  414  who may be reimbursed for particular procedures or procedure
  415  codes. However, subparagraph 1. does not prohibit an insurer
  416  from using the Medicare coding policies and payment
  417  methodologies of the federal Centers for Medicare and Medicaid
  418  Services, including applicable modifiers, to determine the
  419  appropriate amount of reimbursement for medical services,
  420  supplies, or care if the coding policy or payment methodology
  421  does not constitute a utilization limit.
  422         4.5. If an insurer limits payment as authorized by
  423  subparagraph 1. 2., the person providing such services,
  424  supplies, or care may not bill or attempt to collect from the
  425  insured any amount in excess of such limits, except for amounts
  426  that are not covered by the insured’s personal injury protection
  427  coverage due to the coinsurance amount or maximum policy limits.
  428         5. Effective July 1, 2012, an insurer may limit payment as
  429  authorized by this paragraph only if the insurance policy
  430  includes a notice at the time of issuance or renewal that the
  431  insurer may limit payment pursuant to the schedule of charges
  432  specified in this paragraph. A policy form approved by the
  433  office satisfies this requirement. If a provider submits a
  434  charge for an amount less than the amount allowed under
  435  subparagraph 1., the insurer may pay the amount of the charge
  436  submitted.
  437         (b)1. An insurer or insured is not required to pay a claim
  438  or charges:
  439         a. Made by a broker or by a person making a claim on behalf
  440  of a broker;
  441         b. For any service or treatment that was not lawful at the
  442  time rendered;
  443         c. To any person who knowingly submits a false or
  444  misleading statement relating to the claim or charges;
  445         d. With respect to a bill or statement that does not
  446  substantially meet the applicable requirements of paragraph (d);
  447         e. For any treatment or service that is upcoded, or that is
  448  unbundled when such treatment or services should be bundled, in
  449  accordance with paragraph (d). To facilitate prompt payment of
  450  lawful services, an insurer may change codes that it determines
  451  to have been improperly or incorrectly upcoded or unbundled, and
  452  may make payment based on the changed codes, without affecting
  453  the right of the provider to dispute the change by the insurer,
  454  if, provided that before doing so, the insurer contacts must
  455  contact the health care provider and discusses discuss the
  456  reasons for the insurer’s change and the health care provider’s
  457  reason for the coding, or makes make a reasonable good faith
  458  effort to do so, as documented in the insurer’s file; and
  459         f. For medical services or treatment billed by a physician
  460  and not provided in a hospital unless such services are rendered
  461  by the physician or are incident to his or her professional
  462  services and are included on the physician’s bill, including
  463  documentation verifying that the physician is responsible for
  464  the medical services that were rendered and billed.
  465         2. The Department of Health, in consultation with the
  466  appropriate professional licensing boards, shall adopt, by rule,
  467  a list of diagnostic tests deemed not to be medically necessary
  468  for use in the treatment of persons sustaining bodily injury
  469  covered by personal injury protection benefits under this
  470  section. The initial list shall be adopted by January 1, 2004,
  471  and shall be revised from time to time as determined by the
  472  Department of Health, in consultation with the respective
  473  professional licensing boards. Inclusion of a test on the list
  474  of invalid diagnostic tests shall be based on lack of
  475  demonstrated medical value and a level of general acceptance by
  476  the relevant provider community and may shall not be dependent
  477  for results entirely upon subjective patient response.
  478  Notwithstanding its inclusion on a fee schedule in this
  479  subsection, an insurer or insured is not required to pay any
  480  charges or reimburse claims for an any invalid diagnostic test
  481  as determined by the Department of Health.
  482         (c)1. With respect to any treatment or service, other than
  483  medical services billed by a hospital or other provider for
  484  emergency services and care as defined in s. 395.002 or
  485  inpatient services rendered at a hospital-owned facility, the
  486  statement of charges must be furnished to the insurer by the
  487  provider and may not include, and the insurer is not required to
  488  pay, charges for treatment or services rendered more than 35
  489  days before the postmark date or electronic transmission date of
  490  the statement, except for past due amounts previously billed on
  491  a timely basis under this paragraph, and except that, if the
  492  provider submits to the insurer a notice of initiation of
  493  treatment within 21 days after its first examination or
  494  treatment of the claimant, the statement may include charges for
  495  treatment or services rendered up to, but not more than, 75 days
  496  before the postmark date of the statement. The injured party is
  497  not liable for, and the provider may shall not bill the injured
  498  party for, charges that are unpaid because of the provider’s
  499  failure to comply with this paragraph. Any agreement requiring
  500  the injured person or insured to pay for such charges is
  501  unenforceable.
  502         1.2. If, however, the insured fails to furnish the provider
  503  with the correct name and address of the insured’s personal
  504  injury protection insurer, the provider has 35 days from the
  505  date the provider obtains the correct information to furnish the
  506  insurer with a statement of the charges. The insurer is not
  507  required to pay for such charges unless the provider includes
  508  with the statement documentary evidence that was provided by the
  509  insured during the 35-day period demonstrating that the provider
  510  reasonably relied on erroneous information from the insured and
  511  either:
  512         a. A denial letter from the incorrect insurer; or
  513         b. Proof of mailing, which may include an affidavit under
  514  penalty of perjury, reflecting timely mailing to the incorrect
  515  address or insurer.
  516         2.3. For emergency services and care as defined in s.
  517  395.002 rendered in a hospital emergency department or for
  518  transport and treatment rendered by an ambulance provider
  519  licensed pursuant to part III of chapter 401, the provider is
  520  not required to furnish the statement of charges within the time
  521  periods established by this paragraph,; and the insurer is shall
  522  not be considered to have been furnished with notice of the
  523  amount of covered loss for purposes of paragraph (4)(b) until it
  524  receives a statement complying with paragraph (d), or copy
  525  thereof, which specifically identifies the place of service to
  526  be a hospital emergency department or an ambulance in accordance
  527  with billing standards recognized by the federal Centers for
  528  Medicare and Medicaid Services Health Care Finance
  529  Administration.
  530         3.4. Each notice of the insured’s rights under s. 627.7401
  531  must include the following statement in at least 12-point type
  532  in type no smaller than 12 points:
  534         BILLING REQUIREMENTS.—Florida law provides
  535         Statutes provide that with respect to any treatment or
  536         services, other than certain hospital and emergency
  537         services, the statement of charges furnished to the
  538         insurer by the provider may not include, and the
  539         insurer and the injured party are not required to pay,
  540         charges for treatment or services rendered more than
  541         35 days before the postmark date of the statement,
  542         except for past due amounts previously billed on a
  543         timely basis, and except that, if the provider submits
  544         to the insurer a notice of initiation of treatment
  545         within 21 days after its first examination or
  546         treatment of the claimant, the statement may include
  547         charges for treatment or services rendered up to, but
  548         not more than, 75 days before the postmark date of the
  549         statement.
  551         (d) All statements and bills for medical services rendered
  552  by a any physician, hospital, clinic, or other person or
  553  institution shall be submitted to the insurer on a properly
  554  completed Centers for Medicare and Medicaid Services (CMS) 1500
  555  form, UB 92 forms, or any other standard form approved by the
  556  office or adopted by the commission for purposes of this
  557  paragraph. All billings for such services rendered by providers
  558  must shall, to the extent applicable, follow the Physicians’
  559  Current Procedural Terminology (CPT) or Healthcare Correct
  560  Procedural Coding System (HCPCS), or ICD-9 in effect for the
  561  year in which services are rendered and comply with the Centers
  562  for Medicare and Medicaid Services (CMS) 1500 form instructions,
  563  and the American Medical Association Current Procedural
  564  Terminology (CPT) Editorial Panel, and the Healthcare Correct
  565  Procedural Coding System (HCPCS). All providers, other than
  566  hospitals, must shall include on the applicable claim form the
  567  professional license number of the provider in the line or space
  568  provided for “Signature of Physician or Supplier, Including
  569  Degrees or Credentials.” In determining compliance with
  570  applicable CPT and HCPCS coding, guidance shall be provided by
  571  the Physicians’ Current Procedural Terminology (CPT) or the
  572  Healthcare Correct Procedural Coding System (HCPCS) in effect
  573  for the year in which services were rendered, the Office of the
  574  Inspector General (OIG), Physicians Compliance Guidelines, and
  575  other authoritative treatises designated by rule by the Agency
  576  for Health Care Administration. A No statement of medical
  577  services may not include charges for medical services of a
  578  person or entity that performed such services without possessing
  579  the valid licenses required to perform such services. For
  580  purposes of paragraph (4)(b), an insurer is shall not be
  581  considered to have been furnished with notice of the amount of
  582  covered loss or medical bills due unless the statements or bills
  583  comply with this paragraph, and unless the statements or bills
  584  are properly completed in their entirety as to all material
  585  provisions, with all relevant information being provided
  586  therein.
  587         (e)1. At the initial treatment or service provided, each
  588  physician, other licensed professional, clinic, or other medical
  589  institution providing medical services upon which a claim for
  590  personal injury protection benefits is based shall require an
  591  insured person, or his or her guardian, to execute a disclosure
  592  and acknowledgment form, which reflects at a minimum that:
  593         a. The insured, or his or her guardian, must countersign
  594  the form attesting to the fact that the services set forth
  595  therein were actually rendered;
  596         b. The insured, or his or her guardian, has both the right
  597  and affirmative duty to confirm that the services were actually
  598  rendered;
  599         c. The insured, or his or her guardian, was not solicited
  600  by any person to seek any services from the medical provider;
  601         d. The physician, other licensed professional, clinic, or
  602  other medical institution rendering services for which payment
  603  is being claimed explained the services to the insured or his or
  604  her guardian; and
  605         e. If the insured notifies the insurer in writing of a
  606  billing error, the insured may be entitled to a certain
  607  percentage of a reduction in the amounts paid by the insured’s
  608  motor vehicle insurer.
  609         2. The physician, other licensed professional, clinic, or
  610  other medical institution rendering services for which payment
  611  is being claimed has the affirmative duty to explain the
  612  services rendered to the insured, or his or her guardian, so
  613  that the insured, or his or her guardian, countersigns the form
  614  with informed consent.
  615         3. Countersignature by the insured, or his or her guardian,
  616  is not required for the reading of diagnostic tests or other
  617  services that are of such a nature that they are not required to
  618  be performed in the presence of the insured.
  619         4. The licensed medical professional rendering treatment
  620  for which payment is being claimed must sign, by his or her own
  621  hand, the form complying with this paragraph.
  622         5. The original completed disclosure and acknowledgment
  623  form shall be furnished to the insurer pursuant to paragraph
  624  (4)(b) and may not be electronically furnished.
  625         6. The This disclosure and acknowledgment form is not
  626  required for services billed by a provider for emergency
  627  services as defined in s. 395.002, for emergency services and
  628  care as defined in s. 395.002 rendered in a hospital emergency
  629  department, or for transport and treatment rendered by an
  630  ambulance provider licensed pursuant to part III of chapter 401.
  631         7. The Financial Services Commission shall adopt, by rule,
  632  a standard disclosure and acknowledgment form to that shall be
  633  used to fulfill the requirements of this paragraph, effective 90
  634  days after such form is adopted and becomes final. The
  635  commission shall adopt a proposed rule by October 1, 2003. Until
  636  the rule is final, the provider may use a form of its own which
  637  otherwise complies with the requirements of this paragraph.
  638         8. As used in this paragraph, the term “countersign” or
  639  “countersignature” “countersigned” means a second or verifying
  640  signature, as on a previously signed document, and is not
  641  satisfied by the statement “signature on file” or any similar
  642  statement.
  643         9. The requirements of this paragraph apply only with
  644  respect to the initial treatment or service of the insured by a
  645  provider. For subsequent treatments or service, the provider
  646  must maintain a patient log signed by the patient, in
  647  chronological order by date of service, which that is consistent
  648  with the services being rendered to the patient as claimed. The
  649  requirement to maintain requirements of this subparagraph for
  650  maintaining a patient log signed by the patient may be met by a
  651  hospital that maintains medical records as required by s.
  652  395.3025 and applicable rules and makes such records available
  653  to the insurer upon request.
  654         (f) Upon written notification by any person, an insurer
  655  shall investigate any claim of improper billing by a physician
  656  or other medical provider. The insurer shall determine if the
  657  insured was properly billed for only those services and
  658  treatments that the insured actually received. If the insurer
  659  determines that the insured has been improperly billed, the
  660  insurer shall notify the insured, the person making the written
  661  notification, and the provider of its findings and shall reduce
  662  the amount of payment to the provider by the amount determined
  663  to be improperly billed. If a reduction is made due to a such
  664  written notification by any person, the insurer shall pay to the
  665  person 20 percent of the amount of the reduction, up to $500. If
  666  the provider is arrested due to the improper billing, then the
  667  insurer shall pay to the person 40 percent of the amount of the
  668  reduction, up to $500.
  669         (g) An insurer may not systematically downcode with the
  670  intent to deny reimbursement otherwise due. Such action
  671  constitutes a material misrepresentation under s.
  672  626.9541(1)(i)2.
  673         (h) As provided in s. 400.9905, an entity excluded from the
  674  definition of a clinic shall be deemed a clinic and must be
  675  licensed under part X of chapter 400 in order to receive
  676  reimbursement under ss. 627.730-627.7405. However, this
  677  licensing requirement does not apply to:
  678         1. An entity wholly owned by a physician licensed under
  679  chapter 458 or chapter 459, or by the physician and the spouse,
  680  parent, child, or sibling of the physician;
  681         2. An entity wholly owned by a dentist licensed under
  682  chapter 466, or by the dentist and the spouse, parent, child, or
  683  sibling of the dentist;
  684         3. An entity wholly owned by a chiropractic physician
  685  licensed under chapter 460, or by the chiropractic physician and
  686  the spouse, parent, child, or sibling of the chiropractic
  687  physician;
  688         4. A hospital or ambulatory surgical center licensed under
  689  chapter 395;
  690         5. An entity that wholly owns or is wholly owned, directly
  691  or indirectly, by a hospital or hospitals licensed under chapter
  692  395; or
  693         6. An entity that is a clinical facility affiliated with an
  694  accredited medical school at which training is provided for
  695  medical students, residents, or fellows.
  697         (a) Every employer shall, If a request is made by an
  698  insurer providing personal injury protection benefits under ss.
  699  627.730-627.7405 against whom a claim has been made, an employer
  700  must furnish forthwith, in a form approved by the office, a
  701  sworn statement of the earnings, since the time of the bodily
  702  injury and for a reasonable period before the injury, of the
  703  person upon whose injury the claim is based.
  704         (b) Every physician, hospital, clinic, or other medical
  705  institution providing, before or after bodily injury upon which
  706  a claim for personal injury protection insurance benefits is
  707  based, any products, services, or accommodations in relation to
  708  that or any other injury, or in relation to a condition claimed
  709  to be connected with that or any other injury, shall, if
  710  requested to do so by the insurer against whom the claim has
  711  been made, furnish forthwith a written report of the history,
  712  condition, treatment, dates, and costs of such treatment of the
  713  injured person and why the items identified by the insurer were
  714  reasonable in amount and medically necessary, together with a
  715  sworn statement that the treatment or services rendered were
  716  reasonable and necessary with respect to the bodily injury
  717  sustained and identifying which portion of the expenses for such
  718  treatment or services was incurred as a result of such bodily
  719  injury, and produce forthwith, and allow permit the inspection
  720  and copying of, his or her or its records regarding such
  721  history, condition, treatment, dates, and costs of treatment if;
  722  provided that this does shall not limit the introduction of
  723  evidence at trial. Such sworn statement must shall read as
  724  follows: “Under penalty of perjury, I declare that I have read
  725  the foregoing, and the facts alleged are true, to the best of my
  726  knowledge and belief.” A No cause of action for violation of the
  727  physician-patient privilege or invasion of the right of privacy
  728  may not be brought shall be permitted against any physician,
  729  hospital, clinic, or other medical institution complying with
  730  the provisions of this section. The person requesting such
  731  records and such sworn statement shall pay all reasonable costs
  732  connected therewith. If an insurer makes a written request for
  733  documentation or information under this paragraph within 30 days
  734  after having received notice of the amount of a covered loss
  735  under paragraph (4)(a), the amount or the partial amount that
  736  which is the subject of the insurer’s inquiry is shall become
  737  overdue if the insurer does not pay in accordance with paragraph
  738  (4)(b) or within 10 days after the insurer’s receipt of the
  739  requested documentation or information, whichever occurs later.
  740  As used in For purposes of this paragraph, the term “receipt”
  741  includes, but is not limited to, inspection and copying pursuant
  742  to this paragraph. An Any insurer that requests documentation or
  743  information pertaining to reasonableness of charges or medical
  744  necessity under this paragraph without a reasonable basis for
  745  such requests as a general business practice is engaging in an
  746  unfair trade practice under the insurance code.
  747         (c) In the event of a any dispute regarding an insurer’s
  748  right to discovery of facts under this section, the insurer may
  749  petition a court of competent jurisdiction to enter an order
  750  permitting such discovery. The order may be made only on motion
  751  for good cause shown and upon notice to all persons having an
  752  interest, and must it shall specify the time, place, manner,
  753  conditions, and scope of the discovery. Such court may, In order
  754  to protect against annoyance, embarrassment, or oppression, as
  755  justice requires, the court may enter an order refusing
  756  discovery or specifying conditions of discovery and may order
  757  payments of costs and expenses of the proceeding, including
  758  reasonable fees for the appearance of attorneys at the
  759  proceedings, as justice requires.
  760         (d) The injured person shall be furnished, upon request, a
  761  copy of all information obtained by the insurer under the
  762  provisions of this section, and shall pay a reasonable charge,
  763  if required by the insurer.
  764         (e) Notice to an insurer of the existence of a claim may
  765  shall not be unreasonably withheld by an insured.
  766         (f) In a dispute between the insured and the insurer, or
  767  between an assignee of the insured’s rights and the insurer, the
  768  insurer must notify the insured or the assignee that the policy
  769  limits under this section have been reached within 15 days after
  770  the limits have been reached.
  772  ATTORNEY’S FEES.—With respect to any dispute under the
  773  provisions of ss. 627.730-627.7405 between the insured and the
  774  insurer, or between an assignee of an insured’s rights and the
  775  insurer, the provisions of ss. s. 627.428 and 768.79 shall
  776  apply, except as provided in subsections (10) and (15).
  777         (9) PREFERRED PROVIDERS.—An insurer may negotiate and
  778  contract enter into contracts with preferred licensed health
  779  care providers for the benefits described in this section,
  780  referred to in this section as “preferred providers,” which
  781  shall include health care providers licensed under chapter
  782  chapters 458, chapter 459, chapter 460, chapter 461, or chapter
  783  and 463. The insurer may provide an option to an insured to use
  784  a preferred provider at the time of purchasing purchase of the
  785  policy for personal injury protection benefits, if the
  786  requirements of this subsection are met. If the insured elects
  787  to use a provider who is not a preferred provider, whether the
  788  insured purchased a preferred provider policy or a nonpreferred
  789  provider policy, the medical benefits provided by the insurer
  790  shall be as required by this section. If the insured elects to
  791  use a provider who is a preferred provider, the insurer may pay
  792  medical benefits in excess of the benefits required by this
  793  section and may waive or lower the amount of any deductible that
  794  applies to such medical benefits. If the insurer offers a
  795  preferred provider policy to a policyholder or applicant, it
  796  must also offer a nonpreferred provider policy. The insurer
  797  shall provide each insured policyholder with a current roster of
  798  preferred providers in the county in which the insured resides
  799  at the time of purchase of such policy, and shall make such list
  800  available for public inspection during regular business hours at
  801  the insurer’s principal office of the insurer within the state.
  802         (10) DEMAND LETTER.—
  803         (a) As a condition precedent to filing any action for
  804  benefits under this section, the insurer must be provided with
  805  written notice of an intent to initiate litigation must be
  806  provided to the insurer. Such notice may not be sent until the
  807  claim is overdue, including any additional time the insurer has
  808  to pay the claim pursuant to paragraph (4)(b).
  809         (b) The notice must required shall state that it is a
  810  “demand letter under s. 627.736(10)” and shall state with
  811  specificity:
  812         1. The name of the insured upon which such benefits are
  813  being sought, including a copy of the assignment giving rights
  814  to the claimant if the claimant is not the insured.
  815         2. The claim number or policy number upon which such claim
  816  was originally submitted to the insurer.
  817         3. To the extent applicable, the name of any medical
  818  provider who rendered to an insured the treatment, services,
  819  accommodations, or supplies that form the basis of such claim;
  820  and an itemized statement specifying each exact amount, the date
  821  of treatment, service, or accommodation, and the type of benefit
  822  claimed to be due. A completed form satisfying the requirements
  823  of paragraph (5)(d) or the lost-wage statement previously
  824  submitted may be used as the itemized statement. To the extent
  825  that the demand involves an insurer’s withdrawal of payment
  826  under paragraph (7)(a) for future treatment not yet rendered,
  827  the claimant shall attach a copy of the insurer’s notice
  828  withdrawing such payment and an itemized statement of the type,
  829  frequency, and duration of future treatment claimed to be
  830  reasonable and medically necessary.
  831         (c) Each notice required by this subsection must be
  832  delivered to the insurer by United States certified or
  833  registered mail, return receipt requested. Such postal costs
  834  shall be reimbursed by the insurer if so requested by the
  835  claimant in the notice, when the insurer pays the claim. Such
  836  notice must be sent to the person and address specified by the
  837  insurer for the purposes of receiving notices under this
  838  subsection. Each licensed insurer, whether domestic, foreign, or
  839  alien, shall file with the office designation of the name and
  840  address of the person to whom notices must pursuant to this
  841  subsection shall be sent which the office shall make available
  842  on its Internet website. The name and address on file with the
  843  office pursuant to s. 624.422 are shall be deemed the authorized
  844  representative to accept notice pursuant to this subsection if
  845  in the event no other designation has been made.
  846         (d) If, within 30 days after receipt of notice by the
  847  insurer, the overdue claim specified in the notice is paid by
  848  the insurer together with applicable interest and a penalty of
  849  10 percent of the overdue amount paid by the insurer, subject to
  850  a maximum penalty of $250, no action may be brought against the
  851  insurer. If the demand involves an insurer’s withdrawal of
  852  payment under paragraph (7)(a) for future treatment not yet
  853  rendered, no action may be brought against the insurer if,
  854  within 30 days after its receipt of the notice, the insurer
  855  mails to the person filing the notice a written statement of the
  856  insurer’s agreement to pay for such treatment in accordance with
  857  the notice and to pay a penalty of 10 percent, subject to a
  858  maximum penalty of $250, when it pays for such future treatment
  859  in accordance with the requirements of this section. To the
  860  extent the insurer determines not to pay any amount demanded,
  861  the penalty is shall not be payable in any subsequent action.
  862  For purposes of this subsection, payment or the insurer’s
  863  agreement shall be treated as being made on the date a draft or
  864  other valid instrument that is equivalent to payment, or the
  865  insurer’s written statement of agreement, is placed in the
  866  United States mail in a properly addressed, postpaid envelope,
  867  or if not so posted, on the date of delivery. The insurer is not
  868  obligated to pay any attorney attorney’s fees if the insurer
  869  pays the claim or mails its agreement to pay for future
  870  treatment within the time prescribed by this subsection.
  871         (e) The applicable statute of limitation for an action
  872  under this section shall be tolled for a period of 30 business
  873  days by the mailing of the notice required by this subsection.
  874         (f) Any insurer making a general business practice of not
  875  paying valid claims until receipt of the notice required by this
  876  subsection is engaging in an unfair trade practice under the
  877  insurance code.
  879  PRACTICE.—
  880         (a) If An insurer fails to pay valid claims for personal
  881  injury protection with such frequency so as to indicate a
  882  general business practice, the insurer is engaging in a
  883  prohibited unfair or deceptive practice that is subject to the
  884  penalties provided in s. 626.9521 and the office has the powers
  885  and duties specified in ss. 626.9561-626.9601 if the insurer,
  886  with such frequency so as to indicate a general business
  887  practice: with respect thereto
  888         1. Fails to pay valid claims for personal injury
  889  protection; or
  890         2. Fails to pay valid claims until receipt of the notice
  891  required by subsection (10).
  892         (b) Notwithstanding s. 501.212, the Department of Legal
  893  Affairs may investigate and initiate actions for a violation of
  894  this subsection, including, but not limited to, the powers and
  895  duties specified in part II of chapter 501.
  896         Section 8. Effective December 1, 2012, subsection (16) of
  897  section 627.736, Florida Statutes, is amended to read:
  898         627.736 Required personal injury protection benefits;
  899  exclusions; priority; claims.—
  900         (16) SECURE ELECTRONIC DATA TRANSFER.—If all parties
  901  mutually and expressly agree, A notice, documentation,
  902  transmission, or communication of any kind required or
  903  authorized under ss. 627.730-627.7405 may be transmitted
  904  electronically if it is transmitted by secure electronic data
  905  transfer that is consistent with state and federal privacy and
  906  security laws.
  908  ================= T I T L E  A M E N D M E N T ================
  909         And the title is amended as follows:
  910         Delete lines 45 - 81
  911  and insert:
  912         627.736, F.S.; revising the cap on benefits to provide
  913         that death benefits are in addition to medical and
  914         disability benefits; revising medical benefits;
  915         distinguishing between initial and followup services;
  916         excluding massage and acupuncture from medical
  917         benefits that may be reimbursed under the Florida
  918         Motor Vehicle No-Fault Law; adding physical therapists
  919         to the list of providers that may provide services;
  920         requiring that an insurer repay any benefits covered
  921         by the Medicaid program; requiring that an insurer
  922         provide a claimant an opportunity to revise claims
  923         that contain errors; authorizing an insurer to provide
  924         notice to the claimant and conduct an investigation if
  925         fraud is suspected; requiring that an insurer create
  926         and maintain a log of personal injury protection
  927         benefits paid and that the insurer provide to the
  928         insured or an assignee of the insured, upon request, a
  929         copy of the log if litigation is commenced; revising
  930         the Medicare fee schedules that an insurer may use as
  931         a basis for limiting reimbursement of personal injury
  932         protection benefits; providing that the Medicare fee
  933         schedule in effect on a specific date applies for
  934         purposes of limiting such reimbursement; authorizing
  935         insurers to apply certain Medicare coding policies and
  936         payment methodologies; requiring that an insurer that
  937         limits payments based on the statutory fee schedule
  938         include a notice in insurance policies at the time of
  939         issuance or renewal; deleting obsolete provisions;
  940         providing that certain entities exempt from licensure
  941         as a clinic must nonetheless be licensed to receive
  942         reimbursement for the provision of personal injury
  943         protection benefits; providing exceptions; requiring
  944         that an insurer notify parties in disputes over
  945         personal injury protection claims when policy limits
  946         are reached; consolidating provisions relating to
  947         unfair or deceptive practices under certain
  948         conditions; eliminating a requirement that all parties
  949         mutually and expressly agree to the use of electronic
  950         transmission of data; amending s. 817.234, F.S.;