Florida Senate - 2012                        COMMITTEE AMENDMENT
       Bill No. CS for SB 1860
                                Barcode 616172                          
                              LEGISLATIVE ACTION                        
                    Senate             .             House              
                 Comm: UNFAV           .                                
                  02/29/2012           .                                

       The Committee on Budget (Negron and Richter) recommended the
    1         Senate Amendment (with title amendment)
    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.
  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.
  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.
  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.
  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:
  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.
  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.
  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.
  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.
  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.
  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.