Florida Senate - 2012 COMMITTEE AMENDMENT
Bill No. CS for SB 1860
Barcode 616172
LEGISLATIVE ACTION
Senate . House
Comm: UNFAV .
02/29/2012 .
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The Committee on Budget (Negron and Richter) recommended the
following:
1 Senate Amendment (with title amendment)
2
3 Delete lines 515 - 1373
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. However, the medical benefits shall provide
28 reimbursement only for: such
29 1. Initial services and care that are lawfully provided,
30 supervised, ordered, or prescribed within 14 days of the motor
31 vehicle accident by a physician licensed under chapter 458 or
32 chapter 459, by a dentist licensed under chapter 466, or, to the
33 extent permitted by applicable law and under the supervision of
34 such physician, osteopathic physician, or dentist, by a
35 physician assistant licensed under chapter 458 or chapter 459 or
36 an advanced registered nurse practitioner licensed under chapter
37 464, a chiropractic physician licensed under chapter 460 or that
38 are provided in a hospital or in a facility that owns, or is
39 wholly owned by, a hospital. Initial services and care may also
40 be provided by a person or entity licensed under part III of
41 chapter 401 which provides emergency transportation and
42 treatment.
43 2. Followup services and care consistent with the
44 underlying medical diagnosis rendered pursuant to subparagraph
45 1. Such follow up services and care may be rendered by a
46 physician licensed under chapter 458 or chapter 459, a
47 chiropractic physician licensed under chapter 460, a dentist
48 licensed under chapter 466, or, to the extent permitted by
49 applicable law and under the supervision of such physician,
50 osteopathic physician, chiropractic physician, or dentist, by a
51 physician assistant licensed under chapter 458 or chapter 459 or
52 an advanced registered nurse practitioner licensed under chapter
53 464. Followup services and care may also be provided by any of
54 the following persons or entities:
55 a.1. A hospital or ambulatory surgical center licensed
56 under chapter 395.
57 2. A person or entity licensed under ss. 401.2101-401.45
58 that provides emergency transportation and treatment.
59 b.3. An entity wholly owned by one or more physicians
60 licensed under chapter 458 or chapter 459, chiropractic
61 physicians licensed under chapter 460, or dentists licensed
62 under chapter 466 or by such practitioner or practitioners and
63 the spouse, parent, child, or sibling of such that practitioner
64 or those practitioners.
65 c.4. An entity that owns or is wholly owned, directly or
66 indirectly, by a hospital or hospitals.
67 d.5. A health care clinic licensed under part X of chapter
68 400 which ss. 400.990-400.995 that is:
69 a. accredited by the Joint Commission on Accreditation of
70 Healthcare Organizations, the American Osteopathic Association,
71 the Commission on Accreditation of Rehabilitation Facilities, or
72 the Accreditation Association for Ambulatory Health Care, Inc.;
73 or
74 b. A health care clinic that:
75 (I) Has a medical director licensed under chapter 458,
76 chapter 459, or chapter 460;
77 (II) Has been continuously licensed for more than 3 years
78 or is a publicly traded corporation that issues securities
79 traded on an exchange registered with the United States
80 Securities and Exchange Commission as a national securities
81 exchange; and
82 (III) Provides at least four of the following medical
83 specialties:
84 (A) General medicine.
85 (B) Radiography.
86 (C) Orthopedic medicine.
87 (D) Physical medicine.
88 (E) Physical therapy.
89 (F) Physical rehabilitation.
90 (G) Prescribing or dispensing outpatient prescription
91 medication.
92 (H) Laboratory services.
93 3. Reimbursement for services provided by each type of
94 licensed medical provider authorized to render such services
95 under subparagraph 2. is limited to the lesser of 24 treatments
96 or to services rendered within 12 weeks after the date of the
97 initial treatment, whichever comes first, unless the insurer
98 authorizes additional services.
99 4. Medical benefits do not include massage as defined in s.
100 480.033 or acupuncture as defined in s. 457.102, regardless of
101 the person, entity, or licensee providing massage or
102 acupuncture, and a licensed massage therapist or licensed
103 acupuncturist may not be reimbursed for medical benefits under
104 this section.
105
106 The Financial Services Commission shall adopt by rule the form
107 that must be used by an insurer and a health care provider
108 specified in subparagraph 3., subparagraph 4., or subparagraph
109 5. to document that the health care provider meets the criteria
110 of this paragraph, which rule must include a requirement for a
111 sworn statement or affidavit.
112 (b) Disability benefits.—Sixty percent of any loss of gross
113 income and loss of earning capacity per individual from
114 inability to work proximately caused by the injury sustained by
115 the injured person, plus all expenses reasonably incurred in
116 obtaining from others ordinary and necessary services in lieu of
117 those that, but for the injury, the injured person would have
118 performed without income for the benefit of his or her
119 household. All disability benefits payable under this provision
120 must shall be paid at least not less than every 2 weeks.
121 (c) Death benefits.—Death benefits equal to the lesser of
122 $5,000 or the remainder of unused personal injury protection
123 benefits per individual. Death benefits are in addition to the
124 medical and disability benefits provided under the insurance
125 policy. The insurer may pay death such benefits to the executor
126 or administrator of the deceased, to any of the deceased’s
127 relatives by blood, or legal adoption, or connection by
128 marriage, or to any person appearing to the insurer to be
129 equitably entitled to such benefits thereto.
130
131 Only insurers writing motor vehicle liability insurance in this
132 state may provide the required benefits of this section, and no
133 such insurer may not shall require the purchase of any other
134 motor vehicle coverage other than the purchase of property
135 damage liability coverage as required by s. 627.7275 as a
136 condition for providing such required benefits. Insurers may not
137 require that property damage liability insurance in an amount
138 greater than $10,000 be purchased in conjunction with personal
139 injury protection. Such insurers shall make benefits and
140 required property damage liability insurance coverage available
141 through normal marketing channels. An Any insurer writing motor
142 vehicle liability insurance in this state who fails to comply
143 with such availability requirement as a general business
144 practice violates shall be deemed to have violated part IX of
145 chapter 626, and such violation constitutes shall constitute an
146 unfair method of competition or an unfair or deceptive act or
147 practice involving the business of insurance. An; and any such
148 insurer committing such violation is shall be subject to the
149 penalties provided under that afforded in such part, as well as
150 those provided which may be afforded elsewhere in the insurance
151 code.
152 (4) PAYMENT OF BENEFITS; WHEN DUE.—Benefits due from an
153 insurer under ss. 627.730-627.7405 are shall be primary, except
154 that benefits received under any workers’ compensation law must
155 shall be credited against the benefits provided by subsection
156 (1) and are shall be due and payable as loss accrues, upon
157 receipt of reasonable proof of such loss and the amount of
158 expenses and loss incurred which are covered by the policy
159 issued under ss. 627.730-627.7405. If When the Agency for Health
160 Care Administration provides, pays, or becomes liable for
161 medical assistance under the Medicaid program related to injury,
162 sickness, disease, or death arising out of the ownership,
163 maintenance, or use of a motor vehicle, the benefits under ss.
164 627.730-627.7405 are shall be subject to the provisions of the
165 Medicaid program. However, within 30 days after receiving notice
166 that the Medicaid program paid such benefits, the insurer shall
167 repay the full amount of the benefits to the Medicaid program.
168 (a) An insurer may require written notice to be given as
169 soon as practicable after an accident involving a motor vehicle
170 with respect to which the policy affords the security required
171 by ss. 627.730-627.7405.
172 (b) Personal injury protection insurance benefits paid
173 pursuant to this section are shall be overdue if not paid within
174 30 days after the insurer is furnished written notice of the
175 fact of a covered loss and of the amount of same. However:
176 1. If such written notice of the entire claim is not
177 furnished to the insurer as to the entire claim, any partial
178 amount supported by written notice is overdue if not paid within
179 30 days after such written notice is furnished to the insurer.
180 Any part or all of the remainder of the claim that is
181 subsequently supported by written notice is overdue if not paid
182 within 30 days after such written notice is furnished to the
183 insurer.
184 2. If When an insurer pays only a portion of a claim or
185 rejects a claim, the insurer shall provide at the time of the
186 partial payment or rejection an itemized specification of each
187 item that the insurer had reduced, omitted, or declined to pay
188 and any information that the insurer desires the claimant to
189 consider related to the medical necessity of the denied
190 treatment or to explain the reasonableness of the reduced charge
191 if, provided that this does shall not limit the introduction of
192 evidence at trial.; and The insurer must also shall include the
193 name and address of the person to whom the claimant should
194 respond and a claim number to be referenced in future
195 correspondence.
196 3. If an insurer pays only a portion of a claim or rejects
197 a claim due to an alleged error in the claim, the insurer shall
198 provide at the time of the partial payment or rejection an
199 itemized specification or explanation of benefits of the
200 specified error. Upon receiving the specification or
201 explanation, the person making the claim has, at the person’s
202 option and without waiving any other legal remedy for payment,
203 15 days to submit a revised claim, and the revised claim shall
204 be considered a timely submission of written notice of a claim.
205 4. However, Notwithstanding the fact that written notice
206 has been furnished to the insurer, any payment is shall not be
207 deemed overdue if when the insurer has reasonable proof to
208 establish that the insurer is not responsible for the payment.
209 5. For the purpose of calculating the extent to which any
210 benefits are overdue, payment shall be treated as being made on
211 the date a draft or other valid instrument that which is
212 equivalent to payment was placed in the United States mail in a
213 properly addressed, postpaid envelope or, if not so posted, on
214 the date of delivery.
215 6. This paragraph does not preclude or limit the ability of
216 the insurer to assert that the claim was unrelated, was not
217 medically necessary, or was unreasonable or that the amount of
218 the charge was in excess of that permitted under, or in
219 violation of, subsection (5). Such assertion by the insurer may
220 be made at any time, including after payment of the claim or
221 after the 30-day time period for payment set forth in this
222 paragraph.
223 (c) Upon receiving notice of an accident that is
224 potentially covered by personal injury protection benefits, the
225 insurer must reserve $5,000 of personal injury protection
226 benefits for payment to physicians licensed under chapter 458 or
227 chapter 459 or dentists licensed under chapter 466 who provide
228 emergency services and care, as defined in s. 395.002(9), or who
229 provide hospital inpatient care. The amount required to be held
230 in reserve may be used only to pay claims from such physicians
231 or dentists until 30 days after the date the insurer receives
232 notice of the accident. After the 30-day period, any amount of
233 the reserve for which the insurer has not received notice of
234 such claims a claim from a physician or dentist who provided
235 emergency services and care or who provided hospital inpatient
236 care may then be used by the insurer to pay other claims. The
237 time periods specified in paragraph (b) for required payment of
238 personal injury protection benefits are shall be tolled for the
239 period of time that an insurer is required by this paragraph to
240 hold payment of a claim that is not from such a physician or
241 dentist who provided emergency services and care or who provided
242 hospital inpatient care to the extent that the personal injury
243 protection benefits not held in reserve are insufficient to pay
244 the claim. This paragraph does not require an insurer to
245 establish a claim reserve for insurance accounting purposes.
246 (d) All overdue payments shall bear simple interest at the
247 rate established under s. 55.03 or the rate established in the
248 insurance contract, whichever is greater, for the year in which
249 the payment became overdue, calculated from the date the insurer
250 was furnished with written notice of the amount of covered loss.
251 Interest is shall be due at the time payment of the overdue
252 claim is made.
253 (e) The insurer of the owner of a motor vehicle shall pay
254 personal injury protection benefits for:
255 1. Accidental bodily injury sustained in this state by the
256 owner while occupying a motor vehicle, or while not an occupant
257 of a self-propelled vehicle if the injury is caused by physical
258 contact with a motor vehicle.
259 2. Accidental bodily injury sustained outside this state,
260 but within the United States of America or its territories or
261 possessions or Canada, by the owner while occupying the owner’s
262 motor vehicle.
263 3. Accidental bodily injury sustained by a relative of the
264 owner residing in the same household, under the circumstances
265 described in subparagraph 1. or subparagraph 2., if provided the
266 relative at the time of the accident is domiciled in the owner’s
267 household and is not himself or herself the owner of a motor
268 vehicle with respect to which security is required under ss.
269 627.730-627.7405.
270 4. Accidental bodily injury sustained in this state by any
271 other person while occupying the owner’s motor vehicle or, if a
272 resident of this state, while not an occupant of a self
273 propelled vehicle, if the injury is caused by physical contact
274 with such motor vehicle, if provided the injured person is not
275 himself or herself:
276 a. The owner of a motor vehicle with respect to which
277 security is required under ss. 627.730-627.7405; or
278 b. Entitled to personal injury benefits from the insurer of
279 the owner or owners of such a motor vehicle.
280 (f) If two or more insurers are liable for paying to pay
281 personal injury protection benefits for the same injury to any
282 one person, the maximum payable is shall be as specified in
283 subsection (1), and the any insurer paying the benefits is shall
284 be entitled to recover from each of the other insurers an
285 equitable pro rata share of the benefits paid and expenses
286 incurred in processing the claim.
287 (g) It is a violation of the insurance code for an insurer
288 to fail to timely provide benefits as required by this section
289 with such frequency as to constitute a general business
290 practice.
291 (h) Benefits are shall not be due or payable to or on the
292 behalf of an insured person if that person has committed, by a
293 material act or omission, any insurance fraud relating to
294 personal injury protection coverage under his or her policy, if
295 the fraud is admitted to in a sworn statement by the insured or
296 if it is established in a court of competent jurisdiction. Any
297 insurance fraud voids shall void all coverage arising from the
298 claim related to such fraud under the personal injury protection
299 coverage of the insured person who committed the fraud,
300 irrespective of whether a portion of the insured person’s claim
301 may be legitimate, and any benefits paid before prior to the
302 discovery of the insured person’s insurance fraud is shall be
303 recoverable by the insurer in its entirety from the person who
304 committed insurance fraud in their entirety. The prevailing
305 party is entitled to its costs and attorney attorney’s fees in
306 any action in which it prevails in an insurer’s action to
307 enforce its right of recovery under this paragraph.
308 (i) If an insurer has a reasonable belief that a fraudulent
309 insurance act, as defined in s. 626.989 or s. 817.234, has been
310 committed, the insurer shall notify the claimant in writing
311 within 30 days after submission of the claim that the claim is
312 being investigated for suspected fraud and execute and provide
313 to the insured an affidavit under oath stating that there is a
314 factual basis that there is a probability of fraud. The insurer
315 has an additional 30 days, beginning at the end of the initial
316 30-day period, to conduct its fraud investigation.
317 Notwithstanding subsection (10), no later than the 60th day
318 after the submission of the claim, the insurer must deny the
319 claim or pay the claim along with simple interest as provided in
320 paragraph (d). All claims denied for suspected fraudulent
321 insurance acts shall be reported to the Division of Insurance
322 Fraud.
323 (j) An insurer shall create and maintain for each insured a
324 log of personal injury protection benefits paid by the insurer
325 on behalf of the insured. The insurer shall provide to the
326 insured, or an assignee of the insured, a copy of the log within
327 30 days after receiving a request for the log from the insured
328 or the assignee.
329 (5) CHARGES FOR TREATMENT OF INJURED PERSONS.—
330 (a)1. A Any physician, hospital, clinic, or other person or
331 institution lawfully rendering treatment to an injured person
332 for a bodily injury covered by personal injury protection
333 insurance may charge the insurer and injured party only a
334 reasonable amount pursuant to this section for the services and
335 supplies rendered, and the insurer providing such coverage may
336 pay for such charges directly to such person or institution
337 lawfully rendering such treatment, if the insured receiving such
338 treatment or his or her guardian has countersigned the properly
339 completed invoice, bill, or claim form approved by the office
340 upon which such charges are to be paid for as having actually
341 been rendered, to the best knowledge of the insured or his or
342 her guardian. In no event, However, may such a charge may not
343 exceed be in excess of the amount the person or institution
344 customarily charges for like services or supplies. In
345 determining With respect to a determination of whether a charge
346 for a particular service, treatment, or otherwise is reasonable,
347 consideration may be given to evidence of usual and customary
348 charges and payments accepted by the provider involved in the
349 dispute, and reimbursement levels in the community and various
350 federal and state medical fee schedules applicable to motor
351 vehicle automobile and other insurance coverages, and other
352 information relevant to the reasonableness of the reimbursement
353 for the service, treatment, or supply.
354 1.2. The insurer may limit reimbursement to 80 percent of
355 the following schedule of maximum charges:
356 a. For emergency transport and treatment by providers
357 licensed under chapter 401, 200 percent of Medicare.
358 b. For emergency services and care provided by a hospital
359 licensed under chapter 395, 75 percent of the hospital’s usual
360 and customary charges.
361 c. For emergency services and care as defined by s.
362 395.002(9) provided in a facility licensed under chapter 395
363 rendered by a physician or dentist, and related hospital
364 inpatient services rendered by a physician or dentist, the usual
365 and customary charges in the community.
366 d. For hospital inpatient services, other than emergency
367 services and care, 200 percent of the Medicare Part A
368 prospective payment applicable to the specific hospital
369 providing the inpatient services.
370 e. For hospital outpatient services, other than emergency
371 services and care, 200 percent of the Medicare Part A Ambulatory
372 Payment Classification for the specific hospital providing the
373 outpatient services.
374 f. For all other medical services, supplies, and care, 200
375 percent of the allowable amount under:
376 (I) The participating physicians fee schedule of Medicare
377 Part B, except as provided in sub-sub-subparagraphs (II) and
378 (III).
379 (II) Medicare Part B, in the case of services, supplies,
380 and care provided by ambulatory surgical centers and clinical
381 laboratories.
382 (III) The Durable Medical Equipment Prosthetics/Orthotics
383 and Supplies fee schedule of Medicare Part B, in the case of
384 durable medical equipment.
385
386 However, if such services, supplies, or care is not reimbursable
387 under Medicare Part B, as provided in this sub-subparagraph, the
388 insurer may limit reimbursement to 80 percent of the maximum
389 reimbursable allowance under workers’ compensation, as
390 determined under s. 440.13 and rules adopted thereunder which
391 are in effect at the time such services, supplies, or care is
392 provided. Services, supplies, or care that is not reimbursable
393 under Medicare or workers’ compensation is not required to be
394 reimbursed by the insurer.
395 2.3. For purposes of subparagraph 1. 2., the applicable fee
396 schedule or payment limitation under Medicare is the fee
397 schedule or payment limitation in effect on January 1 of the
398 year in which at the time the services, supplies, or care is was
399 rendered and for the area in which such services, supplies, or
400 care is were rendered, and the applicable fee schedule or
401 payment limitation applies throughout the remainder of that
402 year, notwithstanding any subsequent change made to the fee
403 schedule or payment limitation, except that it may not be less
404 than the allowable amount under the applicable participating
405 physicians schedule of Medicare Part B for 2007 for medical
406 services, supplies, and care subject to Medicare Part B.
407 3.4. Subparagraph 1. 2. does not allow the insurer to apply
408 any limitation on the number of treatments or other utilization
409 limits that apply under Medicare or workers’ compensation. An
410 insurer that applies the allowable payment limitations of
411 subparagraph 1. 2. must reimburse a provider who lawfully
412 provided care or treatment under the scope of his or her
413 license, regardless of whether such provider is would be
414 entitled to reimbursement under Medicare due to restrictions or
415 limitations on the types or discipline of health care providers
416 who may be reimbursed for particular procedures or procedure
417 codes. However, subparagraph 1. does not prohibit an insurer
418 from using the Medicare coding policies and payment
419 methodologies of the federal Centers for Medicare and Medicaid
420 Services, including applicable modifiers, to determine the
421 appropriate amount of reimbursement for medical services,
422 supplies, or care if the coding policy or payment methodology
423 does not constitute a utilization limit.
424 4.5. If an insurer limits payment as authorized by
425 subparagraph 1. 2., the person providing such services,
426 supplies, or care may not bill or attempt to collect from the
427 insured any amount in excess of such limits, except for amounts
428 that are not covered by the insured’s personal injury protection
429 coverage due to the coinsurance amount or maximum policy limits.
430 5. Effective July 1, 2012, an insurer may limit payment as
431 authorized by this paragraph only if the insurance policy
432 includes a notice at the time of issuance or renewal that the
433 insurer may limit payment pursuant to the schedule of charges
434 specified in this paragraph. A policy form approved by the
435 office satisfies this requirement. If a provider submits a
436 charge for an amount less than the amount allowed under
437 subparagraph 1., the insurer may pay the amount of the charge
438 submitted.
439 (b)1. An insurer or insured is not required to pay a claim
440 or charges:
441 a. Made by a broker or by a person making a claim on behalf
442 of a broker;
443 b. For any service or treatment that was not lawful at the
444 time rendered;
445 c. To any person who knowingly submits a false or
446 misleading statement relating to the claim or charges;
447 d. With respect to a bill or statement that does not
448 substantially meet the applicable requirements of paragraph (d);
449 e. For any treatment or service that is upcoded, or that is
450 unbundled when such treatment or services should be bundled, in
451 accordance with paragraph (d). To facilitate prompt payment of
452 lawful services, an insurer may change codes that it determines
453 to have been improperly or incorrectly upcoded or unbundled, and
454 may make payment based on the changed codes, without affecting
455 the right of the provider to dispute the change by the insurer,
456 if, provided that before doing so, the insurer contacts must
457 contact the health care provider and discusses discuss the
458 reasons for the insurer’s change and the health care provider’s
459 reason for the coding, or makes make a reasonable good faith
460 effort to do so, as documented in the insurer’s file; and
461 f. For medical services or treatment billed by a physician
462 and not provided in a hospital unless such services are rendered
463 by the physician or are incident to his or her professional
464 services and are included on the physician’s bill, including
465 documentation verifying that the physician is responsible for
466 the medical services that were rendered and billed.
467 2. The Department of Health, in consultation with the
468 appropriate professional licensing boards, shall adopt, by rule,
469 a list of diagnostic tests deemed not to be medically necessary
470 for use in the treatment of persons sustaining bodily injury
471 covered by personal injury protection benefits under this
472 section. The initial list shall be adopted by January 1, 2004,
473 and shall be revised from time to time as determined by the
474 Department of Health, in consultation with the respective
475 professional licensing boards. Inclusion of a test on the list
476 of invalid diagnostic tests shall be based on lack of
477 demonstrated medical value and a level of general acceptance by
478 the relevant provider community and may shall not be dependent
479 for results entirely upon subjective patient response.
480 Notwithstanding its inclusion on a fee schedule in this
481 subsection, an insurer or insured is not required to pay any
482 charges or reimburse claims for an any invalid diagnostic test
483 as determined by the Department of Health.
484 (c)1. With respect to any treatment or service, other than
485 medical services billed by a hospital or other provider for
486 emergency services and care as defined in s. 395.002 or
487 inpatient services rendered at a hospital-owned facility, the
488 statement of charges must be furnished to the insurer by the
489 provider and may not include, and the insurer is not required to
490 pay, charges for treatment or services rendered more than 35
491 days before the postmark date or electronic transmission date of
492 the statement, except for past due amounts previously billed on
493 a timely basis under this paragraph, and except that, if the
494 provider submits to the insurer a notice of initiation of
495 treatment within 21 days after its first examination or
496 treatment of the claimant, the statement may include charges for
497 treatment or services rendered up to, but not more than, 75 days
498 before the postmark date of the statement. The injured party is
499 not liable for, and the provider may shall not bill the injured
500 party for, charges that are unpaid because of the provider’s
501 failure to comply with this paragraph. Any agreement requiring
502 the injured person or insured to pay for such charges is
503 unenforceable.
504 1.2. If, however, the insured fails to furnish the provider
505 with the correct name and address of the insured’s personal
506 injury protection insurer, the provider has 35 days from the
507 date the provider obtains the correct information to furnish the
508 insurer with a statement of the charges. The insurer is not
509 required to pay for such charges unless the provider includes
510 with the statement documentary evidence that was provided by the
511 insured during the 35-day period demonstrating that the provider
512 reasonably relied on erroneous information from the insured and
513 either:
514 a. A denial letter from the incorrect insurer; or
515 b. Proof of mailing, which may include an affidavit under
516 penalty of perjury, reflecting timely mailing to the incorrect
517 address or insurer.
518 2.3. For emergency services and care as defined in s.
519 395.002 rendered in a hospital emergency department or for
520 transport and treatment rendered by an ambulance provider
521 licensed pursuant to part III of chapter 401, the provider is
522 not required to furnish the statement of charges within the time
523 periods established by this paragraph,; and the insurer is shall
524 not be considered to have been furnished with notice of the
525 amount of covered loss for purposes of paragraph (4)(b) until it
526 receives a statement complying with paragraph (d), or copy
527 thereof, which specifically identifies the place of service to
528 be a hospital emergency department or an ambulance in accordance
529 with billing standards recognized by the federal Centers for
530 Medicare and Medicaid Services Health Care Finance
531 Administration.
532 3.4. Each notice of the insured’s rights under s. 627.7401
533 must include the following statement in at least 12-point type
534 in type no smaller than 12 points:
535
536 BILLING REQUIREMENTS.—Florida law provides
537 Statutes provide that with respect to any treatment or
538 services, other than certain hospital and emergency
539 services, the statement of charges furnished to the
540 insurer by the provider may not include, and the
541 insurer and the injured party are not required to pay,
542 charges for treatment or services rendered more than
543 35 days before the postmark date of the statement,
544 except for past due amounts previously billed on a
545 timely basis, and except that, if the provider submits
546 to the insurer a notice of initiation of treatment
547 within 21 days after its first examination or
548 treatment of the claimant, the statement may include
549 charges for treatment or services rendered up to, but
550 not more than, 75 days before the postmark date of the
551 statement.
552
553 (d) All statements and bills for medical services rendered
554 by a any physician, hospital, clinic, or other person or
555 institution shall be submitted to the insurer on a properly
556 completed Centers for Medicare and Medicaid Services (CMS) 1500
557 form, UB 92 forms, or any other standard form approved by the
558 office or adopted by the commission for purposes of this
559 paragraph. All billings for such services rendered by providers
560 must shall, to the extent applicable, follow the Physicians’
561 Current Procedural Terminology (CPT) or Healthcare Correct
562 Procedural Coding System (HCPCS), or ICD-9 in effect for the
563 year in which services are rendered and comply with the Centers
564 for Medicare and Medicaid Services (CMS) 1500 form instructions,
565 and the American Medical Association Current Procedural
566 Terminology (CPT) Editorial Panel, and the Healthcare Correct
567 Procedural Coding System (HCPCS). All providers, other than
568 hospitals, must shall include on the applicable claim form the
569 professional license number of the provider in the line or space
570 provided for “Signature of Physician or Supplier, Including
571 Degrees or Credentials.” In determining compliance with
572 applicable CPT and HCPCS coding, guidance shall be provided by
573 the Physicians’ Current Procedural Terminology (CPT) or the
574 Healthcare Correct Procedural Coding System (HCPCS) in effect
575 for the year in which services were rendered, the Office of the
576 Inspector General (OIG), Physicians Compliance Guidelines, and
577 other authoritative treatises designated by rule by the Agency
578 for Health Care Administration. A No statement of medical
579 services may not include charges for medical services of a
580 person or entity that performed such services without possessing
581 the valid licenses required to perform such services. For
582 purposes of paragraph (4)(b), an insurer is shall not be
583 considered to have been furnished with notice of the amount of
584 covered loss or medical bills due unless the statements or bills
585 comply with this paragraph, and unless the statements or bills
586 are properly completed in their entirety as to all material
587 provisions, with all relevant information being provided
588 therein.
589 (e)1. At the initial treatment or service provided, each
590 physician, other licensed professional, clinic, or other medical
591 institution providing medical services upon which a claim for
592 personal injury protection benefits is based shall require an
593 insured person, or his or her guardian, to execute a disclosure
594 and acknowledgment form, which reflects at a minimum that:
595 a. The insured, or his or her guardian, must countersign
596 the form attesting to the fact that the services set forth
597 therein were actually rendered;
598 b. The insured, or his or her guardian, has both the right
599 and affirmative duty to confirm that the services were actually
600 rendered;
601 c. The insured, or his or her guardian, was not solicited
602 by any person to seek any services from the medical provider;
603 d. The physician, other licensed professional, clinic, or
604 other medical institution rendering services for which payment
605 is being claimed explained the services to the insured or his or
606 her guardian; and
607 e. If the insured notifies the insurer in writing of a
608 billing error, the insured may be entitled to a certain
609 percentage of a reduction in the amounts paid by the insured’s
610 motor vehicle insurer.
611 2. The physician, other licensed professional, clinic, or
612 other medical institution rendering services for which payment
613 is being claimed has the affirmative duty to explain the
614 services rendered to the insured, or his or her guardian, so
615 that the insured, or his or her guardian, countersigns the form
616 with informed consent.
617 3. Countersignature by the insured, or his or her guardian,
618 is not required for the reading of diagnostic tests or other
619 services that are of such a nature that they are not required to
620 be performed in the presence of the insured.
621 4. The licensed medical professional rendering treatment
622 for which payment is being claimed must sign, by his or her own
623 hand, the form complying with this paragraph.
624 5. The original completed disclosure and acknowledgment
625 form shall be furnished to the insurer pursuant to paragraph
626 (4)(b) and may not be electronically furnished.
627 6. The This disclosure and acknowledgment form is not
628 required for services billed by a provider for emergency
629 services as defined in s. 395.002, for emergency services and
630 care as defined in s. 395.002 rendered in a hospital emergency
631 department, or for transport and treatment rendered by an
632 ambulance provider licensed pursuant to part III of chapter 401.
633 7. The Financial Services Commission shall adopt, by rule,
634 a standard disclosure and acknowledgment form to that shall be
635 used to fulfill the requirements of this paragraph, effective 90
636 days after such form is adopted and becomes final. The
637 commission shall adopt a proposed rule by October 1, 2003. Until
638 the rule is final, the provider may use a form of its own which
639 otherwise complies with the requirements of this paragraph.
640 8. As used in this paragraph, the term “countersign” or
641 “countersignature” “countersigned” means a second or verifying
642 signature, as on a previously signed document, and is not
643 satisfied by the statement “signature on file” or any similar
644 statement.
645 9. The requirements of this paragraph apply only with
646 respect to the initial treatment or service of the insured by a
647 provider. For subsequent treatments or service, the provider
648 must maintain a patient log signed by the patient, in
649 chronological order by date of service, which that is consistent
650 with the services being rendered to the patient as claimed. The
651 requirement to maintain requirements of this subparagraph for
652 maintaining a patient log signed by the patient may be met by a
653 hospital that maintains medical records as required by s.
654 395.3025 and applicable rules and makes such records available
655 to the insurer upon request.
656 (f) Upon written notification by any person, an insurer
657 shall investigate any claim of improper billing by a physician
658 or other medical provider. The insurer shall determine if the
659 insured was properly billed for only those services and
660 treatments that the insured actually received. If the insurer
661 determines that the insured has been improperly billed, the
662 insurer shall notify the insured, the person making the written
663 notification, and the provider of its findings and shall reduce
664 the amount of payment to the provider by the amount determined
665 to be improperly billed. If a reduction is made due to a such
666 written notification by any person, the insurer shall pay to the
667 person 20 percent of the amount of the reduction, up to $500. If
668 the provider is arrested due to the improper billing, then the
669 insurer shall pay to the person 40 percent of the amount of the
670 reduction, up to $500.
671 (g) An insurer may not systematically downcode with the
672 intent to deny reimbursement otherwise due. Such action
673 constitutes a material misrepresentation under s.
674 626.9541(1)(i)2.
675 (h) As provided in s. 400.9905, an entity excluded from the
676 definition of a clinic shall be deemed a clinic and must be
677 licensed under part X of chapter 400 in order to receive
678 reimbursement under ss. 627.730-627.7405. However, this
679 licensing requirement does not apply to:
680 1. An entity wholly owned by a physician licensed under
681 chapter 458 or chapter 459, or by the physician and the spouse,
682 parent, child, or sibling of the physician;
683 2. An entity wholly owned by a dentist licensed under
684 chapter 466, or by the dentist and the spouse, parent, child, or
685 sibling of the dentist;
686 3. An entity wholly owned by a chiropractic physician
687 licensed under chapter 460, or by the chiropractic physician and
688 the spouse, parent, child, or sibling of the chiropractic
689 physician;
690 4. A hospital or ambulatory surgical center licensed under
691 chapter 395; or
692 5. An entity that wholly owns or is wholly owned, directly
693 or indirectly, by a hospital or hospitals licensed under chapter
694 395.
695 (6) DISCOVERY OF FACTS ABOUT AN INJURED PERSON; DISPUTES.—
696 (a) Every employer shall, If a request is made by an
697 insurer providing personal injury protection benefits under ss.
698 627.730-627.7405 against whom a claim has been made, an employer
699 must furnish forthwith, in a form approved by the office, a
700 sworn statement of the earnings, since the time of the bodily
701 injury and for a reasonable period before the injury, of the
702 person upon whose injury the claim is based.
703 (b) Every physician, hospital, clinic, or other medical
704 institution providing, before or after bodily injury upon which
705 a claim for personal injury protection insurance benefits is
706 based, any products, services, or accommodations in relation to
707 that or any other injury, or in relation to a condition claimed
708 to be connected with that or any other injury, shall, if
709 requested to do so by the insurer against whom the claim has
710 been made, furnish forthwith a written report of the history,
711 condition, treatment, dates, and costs of such treatment of the
712 injured person and why the items identified by the insurer were
713 reasonable in amount and medically necessary, together with a
714 sworn statement that the treatment or services rendered were
715 reasonable and necessary with respect to the bodily injury
716 sustained and identifying which portion of the expenses for such
717 treatment or services was incurred as a result of such bodily
718 injury, and produce forthwith, and allow permit the inspection
719 and copying of, his or her or its records regarding such
720 history, condition, treatment, dates, and costs of treatment if;
721 provided that this does shall not limit the introduction of
722 evidence at trial. Such sworn statement must shall read as
723 follows: “Under penalty of perjury, I declare that I have read
724 the foregoing, and the facts alleged are true, to the best of my
725 knowledge and belief.” A No cause of action for violation of the
726 physician-patient privilege or invasion of the right of privacy
727 may not be brought shall be permitted against any physician,
728 hospital, clinic, or other medical institution complying with
729 the provisions of this section. The person requesting such
730 records and such sworn statement shall pay all reasonable costs
731 connected therewith. If an insurer makes a written request for
732 documentation or information under this paragraph within 30 days
733 after having received notice of the amount of a covered loss
734 under paragraph (4)(a), the amount or the partial amount that
735 which is the subject of the insurer’s inquiry is shall become
736 overdue if the insurer does not pay in accordance with paragraph
737 (4)(b) or within 10 days after the insurer’s receipt of the
738 requested documentation or information, whichever occurs later.
739 As used in For purposes of this paragraph, the term “receipt”
740 includes, but is not limited to, inspection and copying pursuant
741 to this paragraph. An Any insurer that requests documentation or
742 information pertaining to reasonableness of charges or medical
743 necessity under this paragraph without a reasonable basis for
744 such requests as a general business practice is engaging in an
745 unfair trade practice under the insurance code.
746 (c) In the event of a any dispute regarding an insurer’s
747 right to discovery of facts under this section, the insurer may
748 petition a court of competent jurisdiction to enter an order
749 permitting such discovery. The order may be made only on motion
750 for good cause shown and upon notice to all persons having an
751 interest, and must it shall specify the time, place, manner,
752 conditions, and scope of the discovery. Such court may, In order
753 to protect against annoyance, embarrassment, or oppression, as
754 justice requires, the court may enter an order refusing
755 discovery or specifying conditions of discovery and may order
756 payments of costs and expenses of the proceeding, including
757 reasonable fees for the appearance of attorneys at the
758 proceedings, as justice requires.
759 (d) The injured person shall be furnished, upon request, a
760 copy of all information obtained by the insurer under the
761 provisions of this section, and shall pay a reasonable charge,
762 if required by the insurer.
763 (e) Notice to an insurer of the existence of a claim may
764 shall not be unreasonably withheld by an insured.
765 (f) In a dispute between the insured and the insurer, or
766 between an assignee of the insured’s rights and the insurer, the
767 insurer must notify the insured or the assignee that the policy
768 limits under this section have been reached within 15 days after
769 the limits have been reached.
770 (8) APPLICABILITY OF PROVISION REGULATING ATTORNEY
771 ATTORNEY’S FEES.—With respect to any dispute under the
772 provisions of ss. 627.730-627.7405 between the insured and the
773 insurer, or between an assignee of an insured’s rights and the
774 insurer, the provisions of ss. s. 627.428 and 768.79 shall
775 apply, except as provided in subsections (10) and (15).
776 (9) PREFERRED PROVIDERS.—An insurer may negotiate and
777 contract enter into contracts with preferred licensed health
778 care providers for the benefits described in this section,
779 referred to in this section as “preferred providers,” which
780 shall include health care providers licensed under chapter
781 chapters 458, chapter 459, chapter 460, chapter 461, or chapter
782 and 463. The insurer may provide an option to an insured to use
783 a preferred provider at the time of purchasing purchase of the
784 policy for personal injury protection benefits, if the
785 requirements of this subsection are met. If the insured elects
786 to use a provider who is not a preferred provider, whether the
787 insured purchased a preferred provider policy or a nonpreferred
788 provider policy, the medical benefits provided by the insurer
789 shall be as required by this section. If the insured elects to
790 use a provider who is a preferred provider, the insurer may pay
791 medical benefits in excess of the benefits required by this
792 section and may waive or lower the amount of any deductible that
793 applies to such medical benefits. If the insurer offers a
794 preferred provider policy to a policyholder or applicant, it
795 must also offer a nonpreferred provider policy. The insurer
796 shall provide each insured policyholder with a current roster of
797 preferred providers in the county in which the insured resides
798 at the time of purchase of such policy, and shall make such list
799 available for public inspection during regular business hours at
800 the insurer’s principal office of the insurer within the state.
801 (10) DEMAND LETTER.—
802 (a) As a condition precedent to filing any action for
803 benefits under this section, the insurer must be provided with
804 written notice of an intent to initiate litigation must be
805 provided to the insurer. Such notice may not be sent until the
806 claim is overdue, including any additional time the insurer has
807 to pay the claim pursuant to paragraph (4)(b).
808 (b) The notice must required shall state that it is a
809 “demand letter under s. 627.736(10)” and shall state with
810 specificity:
811 1. The name of the insured upon which such benefits are
812 being sought, including a copy of the assignment giving rights
813 to the claimant if the claimant is not the insured.
814 2. The claim number or policy number upon which such claim
815 was originally submitted to the insurer.
816 3. To the extent applicable, the name of any medical
817 provider who rendered to an insured the treatment, services,
818 accommodations, or supplies that form the basis of such claim;
819 and an itemized statement specifying each exact amount, the date
820 of treatment, service, or accommodation, and the type of benefit
821 claimed to be due. A completed form satisfying the requirements
822 of paragraph (5)(d) or the lost-wage statement previously
823 submitted may be used as the itemized statement. To the extent
824 that the demand involves an insurer’s withdrawal of payment
825 under paragraph (7)(a) for future treatment not yet rendered,
826 the claimant shall attach a copy of the insurer’s notice
827 withdrawing such payment and an itemized statement of the type,
828 frequency, and duration of future treatment claimed to be
829 reasonable and medically necessary.
830 (c) Each notice required by this subsection must be
831 delivered to the insurer by United States certified or
832 registered mail, return receipt requested. Such postal costs
833 shall be reimbursed by the insurer if so requested by the
834 claimant in the notice, when the insurer pays the claim. Such
835 notice must be sent to the person and address specified by the
836 insurer for the purposes of receiving notices under this
837 subsection. Each licensed insurer, whether domestic, foreign, or
838 alien, shall file with the office designation of the name and
839 address of the person to whom notices must pursuant to this
840 subsection shall be sent which the office shall make available
841 on its Internet website. The name and address on file with the
842 office pursuant to s. 624.422 are shall be deemed the authorized
843 representative to accept notice pursuant to this subsection if
844 in the event no other designation has been made.
845 (d) If, within 30 days after receipt of notice by the
846 insurer, the overdue claim specified in the notice is paid by
847 the insurer together with applicable interest and a penalty of
848 10 percent of the overdue amount paid by the insurer, subject to
849 a maximum penalty of $250, no action may be brought against the
850 insurer. If the demand involves an insurer’s withdrawal of
851 payment under paragraph (7)(a) for future treatment not yet
852 rendered, no action may be brought against the insurer if,
853 within 30 days after its receipt of the notice, the insurer
854 mails to the person filing the notice a written statement of the
855 insurer’s agreement to pay for such treatment in accordance with
856 the notice and to pay a penalty of 10 percent, subject to a
857 maximum penalty of $250, when it pays for such future treatment
858 in accordance with the requirements of this section. To the
859 extent the insurer determines not to pay any amount demanded,
860 the penalty is shall not be payable in any subsequent action.
861 For purposes of this subsection, payment or the insurer’s
862 agreement shall be treated as being made on the date a draft or
863 other valid instrument that is equivalent to payment, or the
864 insurer’s written statement of agreement, is placed in the
865 United States mail in a properly addressed, postpaid envelope,
866 or if not so posted, on the date of delivery. The insurer is not
867 obligated to pay any attorney attorney’s fees if the insurer
868 pays the claim or mails its agreement to pay for future
869 treatment within the time prescribed by this subsection.
870 (e) The applicable statute of limitation for an action
871 under this section shall be tolled for a period of 30 business
872 days by the mailing of the notice required by this subsection.
873 (f) Any insurer making a general business practice of not
874 paying valid claims until receipt of the notice required by this
875 subsection is engaging in an unfair trade practice under the
876 insurance code.
877 (11) FAILURE TO PAY VALID CLAIMS; UNFAIR OR DECEPTIVE
878 PRACTICE.—
879 (a) If An insurer fails to pay valid claims for personal
880 injury protection with such frequency so as to indicate a
881 general business practice, the insurer is engaging in a
882 prohibited unfair or deceptive practice that is subject to the
883 penalties provided in s. 626.9521 and the office has the powers
884 and duties specified in ss. 626.9561-626.9601 if the insurer,
885 with such frequency so as to indicate a general business
886 practice: with respect thereto
887 1. Fails to pay valid claims for personal injury
888 protection; or
889 2. Fails to pay valid claims until receipt of the notice
890 required by subsection (10).
891 (b) Notwithstanding s. 501.212, the Department of Legal
892 Affairs may investigate and initiate actions for a violation of
893 this subsection, including, but not limited to, the powers and
894 duties specified in part II of chapter 501.
895 Section 8. Effective December 1, 2012, subsection (16) of
896 section 627.736, Florida Statutes, is amended to read:
897 627.736 Required personal injury protection benefits;
898 exclusions; priority; claims.—
899 (16) SECURE ELECTRONIC DATA TRANSFER.—If all parties
900 mutually and expressly agree, A notice, documentation,
901 transmission, or communication of any kind required or
902 authorized under ss. 627.730-627.7405 may be transmitted
903 electronically if it is transmitted by secure electronic data
904 transfer that is consistent with state and federal privacy and
905 security laws.
906 Section 9. Subsection (9) is added to section 627.7407,
907 Florida Statutes, to read:
908 627.7407 Application of the Florida Motor Vehicle No-Fault
909 Law.—
910 (9) All forms and rates for policies that are issued or
911 renewed on or after July 1, 2012, for purposes of maintaining
912 security as required by s. 627.733 must reflect the reforms to
913 the Florida Motor Vehicle No-Fault Law made by this act and must
914 be approved by the office before their use.
915
916 ================= T I T L E A M E N D M E N T ================
917 And the title is amended as follows:
918 Delete lines 46 - 80
919 and insert:
920 627.736, F.S.; revising the cap on benefits to provide
921 that death benefits are in addition to medical and
922 disability benefits; revising medical benefits;
923 excluding massage and acupuncture from medical
924 benefits that may be reimbursed under the motor
925 vehicle no-fault law; requiring that an insurer repay
926 any benefits covered by the Medicaid program;
927 requiring that an insurer provide a claimant an
928 opportunity to revise claims that contain errors;
929 authorizing an insurer to provide notice to the
930 claimant and conduct an investigation if fraud is
931 suspected; requiring that an insurer create and
932 maintain a log of personal injury protection benefits
933 paid and that the insurer provide to the insured or an
934 assignee of the insured, upon request, a copy of the
935 log; revising the Medicare fee schedules that an
936 insurer may use as a basis for limiting reimbursement
937 of personal injury protection benefits; providing that
938 the Medicare fee schedule in effect on a specific date
939 applies for purposes of limiting such reimbursement;
940 authorizing insurers to apply certain Medicare coding
941 policies and payment methodologies; requiring that an
942 insurer that limits payments based on the statutory
943 fee schedule include a notice in insurance policies at
944 the time of issuance or renewal; deleting obsolete
945 provisions; providing that certain entities exempt
946 from licensure as a clinic must nonetheless be
947 licensed to receive reimbursement for the provision of
948 personal injury protection benefits; providing
949 exceptions; requiring that an insurer notify parties
950 in disputes over personal injury protection claims
951 when policy limits are reached; consolidating
952 provisions relating to unfair or deceptive practices
953 under certain conditions; eliminating a requirement
954 that all parties mutually and expressly agree for the
955 use of electronic transmission of data; amending s.
956 627.7407, F.S.; requiring all forms and rates for
957 policies applicable to the no-fault law to reflect
958 changes made by the act; amending s.