CS for CS for SB 1860 First Engrossed
20121860e1
1 A bill to be entitled
2 An act relating to motor vehicle personal injury
3 protection insurance; amending s. 316.066, F.S.;
4 revising the conditions for completing the long-form
5 traffic crash report; revising the information
6 contained in the short-form report; revising the
7 requirements relating to the driver’s responsibility
8 for submitting a report for crashes not requiring a
9 law enforcement report; amending s. 400.9905, F.S.;
10 providing that certain entities exempt from licensure
11 as a health care clinic must nonetheless be licensed
12 in order to receive reimbursement for the provision of
13 personal injury protection benefits; amending s.
14 400.991, F.S.; requiring that an application for
15 licensure, or exemption from licensure, as a health
16 care clinic include a statement regarding insurance
17 fraud; amending s. 626.989, F.S.; providing that
18 knowingly submitting false, misleading, or fraudulent
19 documents relating to licensure as a health care
20 clinic, or submitting a claim for personal injury
21 protection relating to clinic licensure documents, is
22 a fraudulent insurance act under certain conditions;
23 amending s. 626.9581, F.S.; requiring the Department
24 of Financial Services or the Office of Insurance
25 Regulation to revoke the certificate of authority of
26 an insurer that engages in unfair trade practices
27 while providing motor vehicle personal injury
28 protection insurance; amending s. 626.9894, F.S.;
29 conforming provisions to changes made by act; creating
30 s. 626.9895, F.S.; providing definitions; authorizing
31 the Division of Insurance Fraud of the Department of
32 Financial Services to establish a direct-support
33 organization for the purpose of prosecuting,
34 investigating, and preventing motor vehicle insurance
35 fraud; providing requirements for, and duties of, the
36 organization; requiring that the organization operate
37 pursuant to a contract with the division; providing
38 for the requirements of the contract; providing for a
39 board of directors; authorizing the organization to
40 use the division’s property and facilities subject to
41 certain requirements; requiring that the department
42 adopt rules relating to procedures for the
43 organization’s governance and relating to conditions
44 for the use of the division’s property or facilities;
45 authorizing contributions from insurers; authorizing
46 any moneys received by the organization to be held in
47 a separate depository account in the name of the
48 organization; requiring that the division deposit
49 certain proceeds into the Insurance Regulatory Trust
50 Fund; amending s. 627.736, F.S.; revising the cap on
51 benefits to provide that death benefits are in
52 addition to medical and disability benefits; revising
53 medical benefits; distinguishing between initial and
54 followup services; excluding massage and acupuncture
55 from medical benefits that may be reimbursed under the
56 Florida Motor Vehicle No-Fault Law; adding physical
57 therapists to the list of providers that may provide
58 services; requiring that an insurer repay any benefits
59 covered by the Medicaid program; requiring that an
60 insurer provide a claimant an opportunity to revise
61 claims that contain errors; authorizing an insurer to
62 provide notice to the claimant and conduct an
63 investigation if fraud is suspected; requiring that an
64 insurer create and maintain a log of personal injury
65 protection benefits paid and that the insurer provide
66 to the insured or an assignee of the insured, upon
67 request, a copy of the log if litigation is commenced;
68 revising the Medicare fee schedules that an insurer
69 may use as a basis for limiting reimbursement of
70 personal injury protection benefits; providing that
71 the Medicare fee schedule in effect on a specific date
72 applies for purposes of limiting reimbursement;
73 requiring that an insurer that limits payments based
74 on the statutory fee schedule include a notice in
75 insurance policies at the time of issuance or renewal;
76 deleting obsolete provisions; providing that certain
77 entities exempt from licensure as a clinic must
78 nonetheless be licensed to receive reimbursement for
79 the provision of personal injury protection benefits;
80 providing exceptions; requiring that an insurer notify
81 parties in disputes over personal injury protection
82 claims when policy limits are reached; providing
83 criteria for the award of attorney fees; providing a
84 presumption regarding the use of a contingency risk
85 multiplier; consolidating provisions relating to
86 unfair or deceptive practices under certain
87 conditions; providing for demand notices to be
88 submitted electronically; requiring that a person,
89 entity, or licensee that makes a referral for medical
90 benefits disclose referral fees in writing to the
91 insured and insurer; eliminating a requirement that
92 all parties mutually and expressly agree to the use of
93 electronic transmission of data; amending s. 627.7405,
94 F.S.; providing an exception from an insurer’s right
95 of reimbursement for certain owners or registrants;
96 amending s. 817.234, F.S.; providing that it is
97 insurance fraud to present a claim for personal injury
98 protection benefits payable to a person or entity that
99 knowingly submitted false, misleading, or fraudulent
100 documents relating to licensure as a health care
101 clinic; providing that a licensed health care
102 practitioner guilty of certain insurance fraud loses
103 his or her license and may not receive reimbursement
104 for personal injury protection benefits for a
105 specified period; defining the term “insurer”;
106 amending s. 316.065, F.S.; conforming a cross
107 reference; requiring personal injury protection motor
108 vehicle insurers to file rates with the Office of
109 Insurance Regulation for review under certain
110 circumstances; specifying a presumption with regard to
111 rates for personal injury protection motor vehicle
112 insurance; requiring that the Office of Insurance
113 Regulation perform a data call relating to personal
114 injury protection; prescribing required elements of
115 the data call; providing for severability; providing
116 effective dates.
117
118 Be It Enacted by the Legislature of the State of Florida:
119
120 Section 1. Subsection (1) of section 316.066, Florida
121 Statutes, is amended to read:
122 316.066 Written reports of crashes.—
123 (1)(a) A Florida Traffic Crash Report, Long Form must is
124 required to be completed and submitted to the department within
125 10 days after completing an investigation is completed by the
126 every law enforcement officer who in the regular course of duty
127 investigates a motor vehicle crash that:
128 1. Resulted in death or personal injury;.
129 2. Involved a violation of s. 316.061(1) or s. 316.193;.
130 3. Rendered a vehicle inoperable to a degree that required
131 a wrecker to remove it from the scene of the crash; or
132 4. Involved a commercial motor vehicle.
133 (b) In any every crash for which a Florida Traffic Crash
134 Report, Long Form is not required by this section and which
135 occurs on the public roadways of this state, the law enforcement
136 officer shall may complete a short-form crash report or provide
137 a driver exchange-of-information form, to be completed by all
138 drivers and passengers each party involved in the crash, which
139 requires the identification of each vehicle that the drivers and
140 passengers were in. The short-form report must include:
141 1. The date, time, and location of the crash.
142 2. A description of the vehicles involved.
143 3. The names and addresses of the parties involved,
144 including all drivers and passengers, and the identification of
145 the vehicle in which each was a passenger.
146 4. The names and addresses of witnesses.
147 5. The name, badge number, and law enforcement agency of
148 the officer investigating the crash.
149 6. The names of the insurance companies for the respective
150 parties involved in the crash.
151 (c) Each party to the crash must provide the law
152 enforcement officer with proof of insurance, which must be
153 documented in the crash report. If a law enforcement officer
154 submits a report on the crash, proof of insurance must be
155 provided to the officer by each party involved in the crash. Any
156 party who fails to provide the required information commits a
157 noncriminal traffic infraction, punishable as a nonmoving
158 violation as provided in chapter 318, unless the officer
159 determines that due to injuries or other special circumstances
160 such insurance information cannot be provided immediately. If
161 the person provides the law enforcement agency, within 24 hours
162 after the crash, proof of insurance that was valid at the time
163 of the crash, the law enforcement agency may void the citation.
164 (d) The driver of a vehicle that was in any manner involved
165 in a crash resulting in damage to a any vehicle or other
166 property which does not require a law enforcement report in an
167 amount of $500 or more which was not investigated by a law
168 enforcement agency, shall, within 10 days after the crash,
169 submit a written report of the crash to the department. The
170 report shall be submitted on a form approved by the department.
171 The entity receiving the report may require witnesses of the
172 crash to render reports and may require any driver of a vehicle
173 involved in a crash of which a written report must be made to
174 file supplemental written reports if the original report is
175 deemed insufficient by the receiving entity.
176 (e) Long-form and short-form crash reports prepared by law
177 enforcement must be submitted to the department and may shall be
178 maintained by the law enforcement officer’s agency.
179 Section 2. Subsection (4) of section 400.9905, Florida
180 Statutes, is amended to read:
181 400.9905 Definitions.—
182 (4) “Clinic” means an entity where at which health care
183 services are provided to individuals and which tenders charges
184 for reimbursement for such services, including a mobile clinic
185 and a portable equipment provider. As used in For purposes of
186 this part, the term does not include and the licensure
187 requirements of this part do not apply to:
188 (a) Entities licensed or registered by the state under
189 chapter 395; or entities licensed or registered by the state and
190 providing only health care services within the scope of services
191 authorized under their respective licenses granted under ss.
192 383.30-383.335, chapter 390, chapter 394, chapter 397, this
193 chapter except part X, chapter 429, chapter 463, chapter 465,
194 chapter 466, chapter 478, part I of chapter 483, chapter 484, or
195 chapter 651; end-stage renal disease providers authorized under
196 42 C.F.R. part 405, subpart U; or providers certified under 42
197 C.F.R. part 485, subpart B or subpart H; or any entity that
198 provides neonatal or pediatric hospital-based health care
199 services or other health care services by licensed practitioners
200 solely within a hospital licensed under chapter 395.
201 (b) Entities that own, directly or indirectly, entities
202 licensed or registered by the state pursuant to chapter 395; or
203 entities that own, directly or indirectly, entities licensed or
204 registered by the state and providing only health care services
205 within the scope of services authorized pursuant to their
206 respective licenses granted under ss. 383.30-383.335, chapter
207 390, chapter 394, chapter 397, this chapter except part X,
208 chapter 429, chapter 463, chapter 465, chapter 466, chapter 478,
209 part I of chapter 483, chapter 484, chapter 651; end-stage renal
210 disease providers authorized under 42 C.F.R. part 405, subpart
211 U; or providers certified under 42 C.F.R. part 485, subpart B or
212 subpart H; or any entity that provides neonatal or pediatric
213 hospital-based health care services by licensed practitioners
214 solely within a hospital licensed under chapter 395.
215 (c) Entities that are owned, directly or indirectly, by an
216 entity licensed or registered by the state pursuant to chapter
217 395; or entities that are owned, directly or indirectly, by an
218 entity licensed or registered by the state and providing only
219 health care services within the scope of services authorized
220 pursuant to their respective licenses granted under ss. 383.30
221 383.335, chapter 390, chapter 394, chapter 397, this chapter
222 except part X, chapter 429, chapter 463, chapter 465, chapter
223 466, chapter 478, part I of chapter 483, chapter 484, or chapter
224 651; end-stage renal disease providers authorized under 42
225 C.F.R. part 405, subpart U; or providers certified under 42
226 C.F.R. part 485, subpart B or subpart H; or any entity that
227 provides neonatal or pediatric hospital-based health care
228 services by licensed practitioners solely within a hospital
229 under chapter 395.
230 (d) Entities that are under common ownership, directly or
231 indirectly, with an entity licensed or registered by the state
232 pursuant to chapter 395; or entities that are under common
233 ownership, directly or indirectly, with an entity licensed or
234 registered by the state and providing only health care services
235 within the scope of services authorized pursuant to their
236 respective licenses granted under ss. 383.30-383.335, chapter
237 390, chapter 394, chapter 397, this chapter except part X,
238 chapter 429, chapter 463, chapter 465, chapter 466, chapter 478,
239 part I of chapter 483, chapter 484, or chapter 651; end-stage
240 renal disease providers authorized under 42 C.F.R. part 405,
241 subpart U; or providers certified under 42 C.F.R. part 485,
242 subpart B or subpart H; or any entity that provides neonatal or
243 pediatric hospital-based health care services by licensed
244 practitioners solely within a hospital licensed under chapter
245 395.
246 (e) An entity that is exempt from federal taxation under 26
247 U.S.C. s. 501(c)(3) or (4), an employee stock ownership plan
248 under 26 U.S.C. s. 409 that has a board of trustees at least not
249 less than two-thirds of which are Florida-licensed health care
250 practitioners and provides only physical therapy services under
251 physician orders, any community college or university clinic,
252 and any entity owned or operated by the federal or state
253 government, including agencies, subdivisions, or municipalities
254 thereof.
255 (f) A sole proprietorship, group practice, partnership, or
256 corporation that provides health care services by physicians
257 covered by s. 627.419, that is directly supervised by one or
258 more of such physicians, and that is wholly owned by one or more
259 of those physicians or by a physician and the spouse, parent,
260 child, or sibling of that physician.
261 (g) A sole proprietorship, group practice, partnership, or
262 corporation that provides health care services by licensed
263 health care practitioners under chapter 457, chapter 458,
264 chapter 459, chapter 460, chapter 461, chapter 462, chapter 463,
265 chapter 466, chapter 467, chapter 480, chapter 484, chapter 486,
266 chapter 490, chapter 491, or part I, part III, part X, part
267 XIII, or part XIV of chapter 468, or s. 464.012, and that is
268 which are wholly owned by one or more licensed health care
269 practitioners, or the licensed health care practitioners set
270 forth in this paragraph and the spouse, parent, child, or
271 sibling of a licensed health care practitioner if, so long as
272 one of the owners who is a licensed health care practitioner is
273 supervising the business activities and is legally responsible
274 for the entity’s compliance with all federal and state laws.
275 However, a health care practitioner may not supervise services
276 beyond the scope of the practitioner’s license, except that, for
277 the purposes of this part, a clinic owned by a licensee in s.
278 456.053(3)(b) which that provides only services authorized
279 pursuant to s. 456.053(3)(b) may be supervised by a licensee
280 specified in s. 456.053(3)(b).
281 (h) Clinical facilities affiliated with an accredited
282 medical school at which training is provided for medical
283 students, residents, or fellows.
284 (i) Entities that provide only oncology or radiation
285 therapy services by physicians licensed under chapter 458 or
286 chapter 459 or entities that provide oncology or radiation
287 therapy services by physicians licensed under chapter 458 or
288 chapter 459 which are owned by a corporation whose shares are
289 publicly traded on a recognized stock exchange.
290 (j) Clinical facilities affiliated with a college of
291 chiropractic accredited by the Council on Chiropractic Education
292 at which training is provided for chiropractic students.
293 (k) Entities that provide licensed practitioners to staff
294 emergency departments or to deliver anesthesia services in
295 facilities licensed under chapter 395 and that derive at least
296 90 percent of their gross annual revenues from the provision of
297 such services. Entities claiming an exemption from licensure
298 under this paragraph must provide documentation demonstrating
299 compliance.
300 (l) Orthotic or prosthetic clinical facilities that are a
301 publicly traded corporation or that are wholly owned, directly
302 or indirectly, by a publicly traded corporation. As used in this
303 paragraph, a publicly traded corporation is a corporation that
304 issues securities traded on an exchange registered with the
305 United States Securities and Exchange Commission as a national
306 securities exchange.
307
308 Notwithstanding this subsection, an entity shall be deemed a
309 clinic and must be licensed under this part in order to receive
310 reimbursement under the Florida Motor Vehicle No-Fault Law, ss.
311 627.730-627.7405, unless exempted under s. 627.736(5)(h). An
312 entity required to be licensed in order to receive reimbursement
313 under the Florida Motor Vehicle No-Fault Law is exempt from all
314 license fees under this part.
315 Section 3. Subsection (6) is added to section 400.991,
316 Florida Statutes, to read:
317 400.991 License requirements; background screenings;
318 prohibitions.—
319 (6) All agency forms for licensure application or exemption
320 from licensure under this part must contain the following
321 statement:
322
323 INSURANCE FRAUD NOTICE.—A person who knowingly submits
324 a false, misleading, or fraudulent application or
325 other document when applying for licensure as a health
326 care clinic, seeking an exemption from licensure as a
327 health care clinic, or demonstrating compliance with
328 part X of chapter 400, Florida Statutes, with the
329 intent to use the license, exemption from licensure,
330 or demonstration of compliance to provide services or
331 seek reimbursement under the Florida Motor Vehicle No
332 Fault Law, commits a fraudulent insurance act, as
333 defined in s. 626.989, Florida Statutes. A person who
334 presents a claim for personal injury protection
335 benefits knowing that the payee knowingly submitted
336 such health care clinic application or document,
337 commits insurance fraud, as defined in s. 817.234,
338 Florida Statutes.
339 Section 4. Subsection (1) of section 626.989, Florida
340 Statutes, is amended to read:
341 626.989 Investigation by department or Division of
342 Insurance Fraud; compliance; immunity; confidential information;
343 reports to division; division investigator’s power of arrest.—
344 (1) For the purposes of this section:,
345 (a) A person commits a “fraudulent insurance act” if the
346 person:
347 1. Knowingly and with intent to defraud presents, causes to
348 be presented, or prepares with knowledge or belief that it will
349 be presented, to or by an insurer, self-insurer, self-insurance
350 fund, servicing corporation, purported insurer, broker, or any
351 agent thereof, any written statement as part of, or in support
352 of, an application for the issuance of, or the rating of, any
353 insurance policy, or a claim for payment or other benefit
354 pursuant to any insurance policy, which the person knows to
355 contain materially false information concerning any fact
356 material thereto or if the person conceals, for the purpose of
357 misleading another, information concerning any fact material
358 thereto.
359 2. Knowingly submits:
360 a. A false, misleading, or fraudulent application or other
361 document when applying for licensure as a health care clinic,
362 seeking an exemption from licensure as a health care clinic, or
363 demonstrating compliance with part X of chapter 400 with an
364 intent to use the license, exemption from licensure, or
365 demonstration of compliance to provide services or seek
366 reimbursement under the Florida Motor Vehicle No-Fault Law.
367 b. A claim for payment or other benefit pursuant to a
368 personal injury protection insurance policy under the Florida
369 Motor Vehicle No-Fault Law if the person knows that the payee
370 knowingly submitted a false, misleading, or fraudulent
371 application or other document when applying for licensure as a
372 health care clinic, seeking an exemption from licensure as a
373 health care clinic, or demonstrating compliance with part X of
374 chapter 400. For the purposes of this section,
375 (b) The term “insurer” also includes a any health
376 maintenance organization, and the term “insurance policy” also
377 includes a health maintenance organization subscriber contract.
378 Section 5. Section 626.9581, Florida Statutes, is amended
379 to read:
380 626.9581 Cease and desist and penalty orders.—After the
381 hearing provided in s. 626.9571, the department or office shall
382 enter a final order in accordance with s. 120.569. If it is
383 determined that the person charged has engaged in an unfair or
384 deceptive act or practice or the unlawful transaction of
385 insurance, the department or office shall also issue an order
386 requiring the violator to cease and desist from engaging in such
387 method of competition, act, or practice or the unlawful
388 transaction of insurance. Further, if the act or practice is a
389 violation of s. 626.9541, or s. 626.9551, or s. 627.736(11), the
390 department or office may, at its discretion, order any one or
391 more of the following:
392 (1) Suspension or revocation of the person’s certificate of
393 authority, license, or eligibility for any certificate of
394 authority or license, if he or she knew, or reasonably should
395 have known, he or she was in violation of this act. However, the
396 office must revoke the certificate of authority of an insurer
397 that violates s. 627.736(11) for at least 5 years, and all board
398 members of such insurer are prohibited from serving on the board
399 of another insurer for 5 years.
400 (2) Such other relief as may be provided under in the
401 insurance code.
402 Section 6. Subsection (5) of section 626.9894, Florida
403 Statutes, is amended to read:
404 626.9894 Gifts and grants.—
405 (5) Notwithstanding the provisions of s. 216.301 and
406 pursuant to s. 216.351, any balance of moneys deposited into the
407 Insurance Regulatory Trust Fund pursuant to this section or s.
408 626.9895 remaining at the end of any fiscal year is shall be
409 available for carrying out the duties and responsibilities of
410 the division. The department may request annual appropriations
411 from the grants and donations received pursuant to this section
412 or s. 626.9895 and cash balances in the Insurance Regulatory
413 Trust Fund for the purpose of carrying out its duties and
414 responsibilities related to the division’s anti-fraud efforts,
415 including the funding of dedicated prosecutors and related
416 personnel.
417 Section 7. Section 626.9895, Florida Statutes, is created
418 to read:
419 626.9895 Motor vehicle insurance fraud direct-support
420 organization.—
421 (1) DEFINITIONS.—As used in this section, the term:
422 (a) “Division” means the Division of Insurance Fraud of the
423 Department of Financial Services.
424 (b) “Motor vehicle insurance fraud” means any act defined
425 as a “fraudulent insurance act” under s. 626.989, which relates
426 to the coverage of motor vehicle insurance as described in part
427 XI of chapter 627.
428 (c) “Organization” means the direct-support organization
429 established under this section.
430 (2) ORGANIZATION ESTABLISHED.—The division may establish a
431 direct-support organization, to be known as the “Automobile
432 Insurance Fraud Strike Force,” whose sole purpose is to support
433 the prosecution, investigation, and prevention of motor vehicle
434 insurance fraud. The organization shall:
435 (a) Be a not-for-profit corporation incorporated under
436 chapter 617 and approved by the Department of State.
437 (b) Be organized and operated to conduct programs and
438 activities; raise funds; request and receive grants, gifts, and
439 bequests of money; acquire, receive, hold, invest, and
440 administer, in its own name, securities, funds, objects of
441 value, or other property, real or personal; and make grants and
442 expenditures to or for the direct or indirect benefit of the
443 division, state attorneys’ offices, the statewide prosecutor,
444 the Agency for Health Care Administration, and the Department of
445 Health to the extent that such grants and expenditures are used
446 exclusively to advance the prosecution, investigation, or
447 prevention of motor vehicle insurance fraud. Grants and
448 expenditures may include the cost of salaries or benefits of
449 motor vehicle insurance fraud investigators, prosecutors, or
450 support personnel if such grants and expenditures do not
451 interfere with prosecutorial independence or otherwise create
452 conflicts of interest which threaten the success of
453 prosecutions.
454 (c) Be determined by the division to operate in a manner
455 that promotes the goals of laws relating to motor vehicle
456 insurance fraud, that is in the best interest of the state, and
457 that is in accordance with the adopted goals and mission of the
458 division.
459 (d) Use all of its grants and expenditures solely for the
460 purpose of preventing and decreasing motor vehicle insurance
461 fraud, and not for the purpose of lobbying as defined in s.
462 11.045.
463 (e) Be subject to an annual financial audit in accordance
464 with s. 215.981.
465 (3) CONTRACT.—The organization shall operate under written
466 contract with the division. The contract must provide for:
467 (a) Approval of the articles of incorporation and bylaws of
468 the organization by the division.
469 (b) Submission of an annual budget for approval of the
470 division. The budget must require the organization to minimize
471 costs to the division and its members at all times by using
472 existing personnel and property and allowing for telephonic
473 meetings if appropriate.
474 (c) Certification by the division that the organization is
475 complying with the terms of the contract and in a manner
476 consistent with the goals and purposes of the department and in
477 the best interest of the state. Such certification must be made
478 annually and reported in the official minutes of a meeting of
479 the organization.
480 (d) Allocation of funds to address motor vehicle insurance
481 fraud.
482 (e) Reversion of moneys and property held in trust by the
483 organization for motor vehicle insurance fraud prosecution,
484 investigation, and prevention to the division if the
485 organization is no longer approved to operate for the department
486 or if the organization ceases to exist, or to the state if the
487 division ceases to exist.
488 (f) Specific criteria to be used by the organization’s
489 board of directors to evaluate the effectiveness of funding used
490 to combat motor vehicle insurance fraud.
491 (g) The fiscal year of the organization, which begins July
492 1 of each year and ends June 30 of the following year.
493 (h) Disclosure of the material provisions of the contract,
494 and distinguishing between the department and the organization
495 to donors of gifts, contributions, or bequests, including
496 providing such disclosure on all promotional and fundraising
497 publications.
498 (4) BOARD OF DIRECTORS.—
499 (a) The board of directors of the organization shall
500 consist of the following eleven members:
501 1. The Chief Financial Officer, or designee, who shall
502 serve as chair.
503 2. Two state attorneys, one of whom shall be appointed by
504 the Chief Financial Officer and one of whom shall be appointed
505 by the Attorney General.
506 3. Two representatives of motor vehicle insurers appointed
507 by the Chief Financial Officer.
508 4. Two representatives of local law enforcement agencies,
509 one of whom shall be appointed by the Chief Financial Officer
510 and one of whom shall be appointed by the Attorney General.
511 5. Two representatives of the types of health care
512 providers who regularly make claims for benefits under ss.
513 627.730-627.7405, one of whom shall be appointed by the
514 President of the Senate and one of whom shall be appointed by
515 the Speaker of the House of Representatives. The appointees may
516 not represent the same type of health care provider.
517 6. A private attorney that has experience in representing
518 claimants in actions for benefits under ss. 627.730-627.7405,
519 who shall be appointed by the President of the Senate.
520 7. A private attorney who has experience in representing
521 insurers in actions for benefits under ss. 627.730-627.7405, who
522 shall be appointed by the Speaker of the House of
523 Representatives.
524 (b) The officer who appointed a member of the board may
525 remove that member for cause. The term of office of an appointed
526 member expires at the same time as the term of the officer who
527 appointed him or her or at such earlier time as the person
528 ceases to be qualified.
529 (5) USE OF PROPERTY.—The department may authorize, without
530 charge, appropriate use of fixed property and facilities of the
531 division by the organization, subject to this subsection.
532 (a) The department may prescribe any condition with which
533 the organization must comply in order to use the division’s
534 property or facilities.
535 (b) The department may not authorize the use of the
536 division’s property or facilities if the organization does not
537 provide equal membership and employment opportunities to all
538 persons regardless of race, religion, sex, age, or national
539 origin.
540 (c) The department shall adopt rules prescribing the
541 procedures by which the organization is governed and any
542 conditions with which the organization must comply to use the
543 division’s property or facilities.
544 (6) CONTRIBUTIONS FROM INSURERS.—Contributions from an
545 insurer to the organization shall be allowed as an appropriate
546 business expense of the insurer for all regulatory purposes.
547 (7) DEPOSITORY ACCOUNT.—Any moneys received by the
548 organization may be held in a separate depository account in the
549 name of the organization and subject to the contract with the
550 division.
551 (8) DIVISION’S RECEIPT OF PROCEEDS.—Proceeds received by
552 the division from the organization shall be deposited into the
553 Insurance Regulatory Trust Fund.
554 Section 8. Subsections (1), (4), (5), (6), (8), (9), (10),
555 and (11) of section 627.736, Florida Statutes, are amended, and
556 subsection (17) is added to that section, to read:
557 627.736 Required personal injury protection benefits;
558 exclusions; priority; claims.—
559 (1) REQUIRED BENEFITS.—An Every insurance policy complying
560 with the security requirements of s. 627.733 must shall provide
561 personal injury protection to the named insured, relatives
562 residing in the same household, persons operating the insured
563 motor vehicle, passengers in the such motor vehicle, and other
564 persons struck by the such motor vehicle and suffering bodily
565 injury while not an occupant of a self-propelled vehicle,
566 subject to the provisions of subsection (2) and paragraph
567 (4)(e), to a limit of $10,000 in medical and disability benefits
568 and $5,000 in death benefits resulting from for loss sustained
569 by any such person as a result of bodily injury, sickness,
570 disease, or death arising out of the ownership, maintenance, or
571 use of a motor vehicle as follows:
572 (a) Medical benefits.—Eighty percent of all reasonable
573 expenses for medically necessary medical, surgical, X-ray,
574 dental, and rehabilitative services, including prosthetic
575 devices, and medically necessary ambulance, hospital, and
576 nursing services if the individual receives initial services and
577 care pursuant to subparagraph 1. within 14 days after the motor
578 vehicle accident. However, The medical benefits shall provide
579 reimbursement only for: such
580 1. Initial services and care that are lawfully provided,
581 supervised, ordered, or prescribed by a physician licensed under
582 chapter 458 or chapter 459, a dentist licensed under chapter
583 466, or a chiropractic physician licensed under chapter 460 or
584 that are provided in a hospital or in a facility that owns, or
585 is wholly owned by, a hospital. Initial services and care may
586 also be provided by a person or entity licensed under part III
587 of chapter 401 which provides emergency transportation and
588 treatment.
589 2. Followup services and care consistent with the
590 underlying medical diagnosis rendered pursuant to subparagraph
591 1. which may be provided, supervised, ordered, or prescribed
592 only by a physician licensed under chapter 458 or chapter 459, a
593 chiropractic physician licensed under chapter 460, a dentist
594 licensed under chapter 466, or, to the extent permitted by
595 applicable law and under the supervision of such physician,
596 osteopathic physician, chiropractic physician, or dentist, by a
597 physician assistant licensed under chapter 458 or chapter 459 or
598 an advanced registered nurse practitioner licensed under chapter
599 464. Followup services and care may also be provided by any of
600 the following persons or entities:
601 a.1. A hospital or ambulatory surgical center licensed
602 under chapter 395.
603 2. A person or entity licensed under ss. 401.2101-401.45
604 that provides emergency transportation and treatment.
605 b.3. An entity wholly owned by one or more physicians
606 licensed under chapter 458 or chapter 459, chiropractic
607 physicians licensed under chapter 460, or dentists licensed
608 under chapter 466 or by such practitioner or practitioners and
609 the spouse, parent, child, or sibling of such that practitioner
610 or those practitioners.
611 c.4. An entity that owns or is wholly owned, directly or
612 indirectly, by a hospital or hospitals.
613 d. A physical therapist licensed under chapter 486.
614 e.5. A health care clinic licensed under part X of chapter
615 400 which ss. 400.990-400.995 that is:
616 a. accredited by the Joint Commission on Accreditation of
617 Healthcare Organizations, the American Osteopathic Association,
618 the Commission on Accreditation of Rehabilitation Facilities, or
619 the Accreditation Association for Ambulatory Health Care, Inc.;
620 or
621 b. A health care clinic that:
622 (I) Has a medical director licensed under chapter 458,
623 chapter 459, or chapter 460;
624 (II) Has been continuously licensed for more than 3 years
625 or is a publicly traded corporation that issues securities
626 traded on an exchange registered with the United States
627 Securities and Exchange Commission as a national securities
628 exchange; and
629 (III) Provides at least four of the following medical
630 specialties:
631 (A) General medicine.
632 (B) Radiography.
633 (C) Orthopedic medicine.
634 (D) Physical medicine.
635 (E) Physical therapy.
636 (F) Physical rehabilitation.
637 (G) Prescribing or dispensing outpatient prescription
638 medication.
639 (H) Laboratory services.
640 3. Reimbursement for services and care provided by each
641 type of licensed medical provider authorized to render such
642 services and care is limited to the lesser of 24 visits or to
643 services or care rendered within 12 weeks after the date of the
644 initial treatment, whichever comes first, unless the insurer
645 authorizes additional services or care.
646 4. Medical benefits do not include massage as defined in s.
647 480.033 or acupuncture as defined in s. 457.102, regardless of
648 the person, entity, or licensee providing massage or
649 acupuncture, and a licensed massage therapist or licensed
650 acupuncturist may not be reimbursed for medical benefits under
651 this section.
652 5. The Financial Services Commission shall adopt by rule
653 the form that must be used by an insurer and a health care
654 provider specified in sub-subparagraph 2.b., sub-subparagraph
655 2.c., or sub-subparagraph 2.e. subparagraph 3., subparagraph 4.,
656 or subparagraph 5. to document that the health care provider
657 meets the criteria of this paragraph, which rule must include a
658 requirement for a sworn statement or affidavit.
659 (b) Disability benefits.—Sixty percent of any loss of gross
660 income and loss of earning capacity per individual from
661 inability to work proximately caused by the injury sustained by
662 the injured person, plus all expenses reasonably incurred in
663 obtaining from others ordinary and necessary services in lieu of
664 those that, but for the injury, the injured person would have
665 performed without income for the benefit of his or her
666 household. All disability benefits payable under this provision
667 must shall be paid at least not less than every 2 weeks.
668 (c) Death benefits.—Death benefits equal to the lesser of
669 $5,000 or the remainder of unused personal injury protection
670 benefits per individual. Death benefits are in addition to the
671 medical and disability benefits provided under the insurance
672 policy. The insurer may pay death such benefits to the executor
673 or administrator of the deceased, to any of the deceased’s
674 relatives by blood, or legal adoption, or connection by
675 marriage, or to any person appearing to the insurer to be
676 equitably entitled to such benefits thereto.
677
678 Only insurers writing motor vehicle liability insurance in this
679 state may provide the required benefits of this section, and no
680 such insurer may not shall require the purchase of any other
681 motor vehicle coverage other than the purchase of property
682 damage liability coverage as required by s. 627.7275 as a
683 condition for providing such required benefits. Insurers may not
684 require that property damage liability insurance in an amount
685 greater than $10,000 be purchased in conjunction with personal
686 injury protection. Such insurers shall make benefits and
687 required property damage liability insurance coverage available
688 through normal marketing channels. An Any insurer writing motor
689 vehicle liability insurance in this state who fails to comply
690 with such availability requirement as a general business
691 practice violates shall be deemed to have violated part IX of
692 chapter 626, and such violation constitutes shall constitute an
693 unfair method of competition or an unfair or deceptive act or
694 practice involving the business of insurance. An; and any such
695 insurer committing such violation is shall be subject to the
696 penalties provided under that afforded in such part, as well as
697 those provided which may be afforded elsewhere in the insurance
698 code.
699 (4) PAYMENT OF BENEFITS; WHEN DUE.—Benefits due from an
700 insurer under ss. 627.730-627.7405 are shall be primary, except
701 that benefits received under any workers’ compensation law must
702 shall be credited against the benefits provided by subsection
703 (1) and are shall be due and payable as loss accrues, upon
704 receipt of reasonable proof of such loss and the amount of
705 expenses and loss incurred which are covered by the policy
706 issued under ss. 627.730-627.7405. If When the Agency for Health
707 Care Administration provides, pays, or becomes liable for
708 medical assistance under the Medicaid program related to injury,
709 sickness, disease, or death arising out of the ownership,
710 maintenance, or use of a motor vehicle, the benefits under ss.
711 627.730-627.7405 are shall be subject to the provisions of the
712 Medicaid program. However, within 30 days after receiving notice
713 that the Medicaid program paid such benefits, the insurer shall
714 repay the full amount of the benefits to the Medicaid program.
715 (a) An insurer may require written notice to be given as
716 soon as practicable after an accident involving a motor vehicle
717 with respect to which the policy affords the security required
718 by ss. 627.730-627.7405.
719 (b) Personal injury protection insurance benefits paid
720 pursuant to this section are shall be overdue if not paid within
721 30 days after the insurer is furnished written notice of the
722 fact of a covered loss and of the amount of same. However:
723 1. If such written notice of the entire claim is not
724 furnished to the insurer as to the entire claim, any partial
725 amount supported by written notice is overdue if not paid within
726 30 days after such written notice is furnished to the insurer.
727 Any part or all of the remainder of the claim that is
728 subsequently supported by written notice is overdue if not paid
729 within 30 days after such written notice is furnished to the
730 insurer.
731 2. If When an insurer pays only a portion of a claim or
732 rejects a claim, the insurer shall provide at the time of the
733 partial payment or rejection an itemized specification of each
734 item that the insurer had reduced, omitted, or declined to pay
735 and any information that the insurer desires the claimant to
736 consider related to the medical necessity of the denied
737 treatment or to explain the reasonableness of the reduced charge
738 if, provided that this does shall not limit the introduction of
739 evidence at trial.; and The insurer must also shall include the
740 name and address of the person to whom the claimant should
741 respond and a claim number to be referenced in future
742 correspondence.
743 3. If an insurer pays only a portion of a claim or rejects
744 a claim due to an alleged error in the claim, the insurer, at
745 the time of the partial payment or rejection, shall provide an
746 itemized specification or explanation of benefits due to the
747 specified error. Upon receiving the specification or
748 explanation, the person making the claim, at the person’s option
749 and without waiving any other legal remedy for payment, has 15
750 days to submit a revised claim, which shall be considered a
751 timely submission of written notice of a claim.
752 4. However, Notwithstanding the fact that written notice
753 has been furnished to the insurer, any payment is shall not be
754 deemed overdue if when the insurer has reasonable proof to
755 establish that the insurer is not responsible for the payment.
756 5. For the purpose of calculating the extent to which any
757 benefits are overdue, payment shall be treated as being made on
758 the date a draft or other valid instrument that which is
759 equivalent to payment was placed in the United States mail in a
760 properly addressed, postpaid envelope or, if not so posted, on
761 the date of delivery.
762 6. This paragraph does not preclude or limit the ability of
763 the insurer to assert that the claim was unrelated, was not
764 medically necessary, or was unreasonable or that the amount of
765 the charge was in excess of that permitted under, or in
766 violation of, subsection (5). Such assertion by the insurer may
767 be made at any time, including after payment of the claim or
768 after the 30-day time period for payment set forth in this
769 paragraph.
770 (c) Upon receiving notice of an accident that is
771 potentially covered by personal injury protection benefits, the
772 insurer must reserve $5,000 of personal injury protection
773 benefits for payment to physicians licensed under chapter 458 or
774 chapter 459 or dentists licensed under chapter 466 who provide
775 emergency services and care, as defined in s. 395.002(9), or who
776 provide hospital inpatient care. The amount required to be held
777 in reserve may be used only to pay claims from such physicians
778 or dentists until 30 days after the date the insurer receives
779 notice of the accident. After the 30-day period, any amount of
780 the reserve for which the insurer has not received notice of
781 such claims a claim from a physician or dentist who provided
782 emergency services and care or who provided hospital inpatient
783 care may then be used by the insurer to pay other claims. The
784 time periods specified in paragraph (b) for required payment of
785 personal injury protection benefits are shall be tolled for the
786 period of time that an insurer is required by this paragraph to
787 hold payment of a claim that is not from such a physician or
788 dentist who provided emergency services and care or who provided
789 hospital inpatient care to the extent that the personal injury
790 protection benefits not held in reserve are insufficient to pay
791 the claim. This paragraph does not require an insurer to
792 establish a claim reserve for insurance accounting purposes.
793 (d) All overdue payments shall bear simple interest at the
794 rate established under s. 55.03 or the rate established in the
795 insurance contract, whichever is greater, for the year in which
796 the payment became overdue, calculated from the date the insurer
797 was furnished with written notice of the amount of covered loss.
798 Interest is shall be due at the time payment of the overdue
799 claim is made.
800 (e) The insurer of the owner of a motor vehicle shall pay
801 personal injury protection benefits for:
802 1. Accidental bodily injury sustained in this state by the
803 owner while occupying a motor vehicle, or while not an occupant
804 of a self-propelled vehicle if the injury is caused by physical
805 contact with a motor vehicle.
806 2. Accidental bodily injury sustained outside this state,
807 but within the United States of America or its territories or
808 possessions or Canada, by the owner while occupying the owner’s
809 motor vehicle.
810 3. Accidental bodily injury sustained by a relative of the
811 owner residing in the same household, under the circumstances
812 described in subparagraph 1. or subparagraph 2., if provided the
813 relative at the time of the accident is domiciled in the owner’s
814 household and is not himself or herself the owner of a motor
815 vehicle with respect to which security is required under ss.
816 627.730-627.7405.
817 4. Accidental bodily injury sustained in this state by any
818 other person while occupying the owner’s motor vehicle or, if a
819 resident of this state, while not an occupant of a self
820 propelled vehicle, if the injury is caused by physical contact
821 with such motor vehicle, if provided the injured person is not
822 himself or herself:
823 a. The owner of a motor vehicle with respect to which
824 security is required under ss. 627.730-627.7405; or
825 b. Entitled to personal injury benefits from the insurer of
826 the owner or owners of such a motor vehicle.
827 (f) If two or more insurers are liable for paying to pay
828 personal injury protection benefits for the same injury to any
829 one person, the maximum payable is shall be as specified in
830 subsection (1), and the any insurer paying the benefits is shall
831 be entitled to recover from each of the other insurers an
832 equitable pro rata share of the benefits paid and expenses
833 incurred in processing the claim.
834 (g) It is a violation of the insurance code for an insurer
835 to fail to timely provide benefits as required by this section
836 with such frequency as to constitute a general business
837 practice.
838 (h) Benefits are shall not be due or payable to or on the
839 behalf of an insured person if that person has committed, by a
840 material act or omission, any insurance fraud relating to
841 personal injury protection coverage under his or her policy, if
842 the fraud is admitted to in a sworn statement by the insured or
843 if it is established in a court of competent jurisdiction. Any
844 insurance fraud voids shall void all coverage arising from the
845 claim related to such fraud under the personal injury protection
846 coverage of the insured person who committed the fraud,
847 irrespective of whether a portion of the insured person’s claim
848 may be legitimate, and any benefits paid before prior to the
849 discovery of the insured person’s insurance fraud is shall be
850 recoverable by the insurer in its entirety from the person who
851 committed insurance fraud in their entirety. The prevailing
852 party is entitled to its costs and attorney attorney’s fees in
853 any action in which it prevails in an insurer’s action to
854 enforce its right of recovery under this paragraph.
855 (i) If an insurer has a reasonable belief that a fraudulent
856 insurance act, as defined in s. 626.989 or s. 817.234, has been
857 committed, the insurer shall notify the claimant in writing
858 within 30 days after submission of the claim that the claim is
859 being investigated for suspected fraud and execute and provide
860 to the insured and the office an affidavit under oath stating
861 that there is a factual basis that there is a probability of
862 fraud. The insurer has an additional 60 days, beginning at the
863 end of the initial 30-day period, to conduct its fraud
864 investigation. Notwithstanding subsection (10), no later than
865 the 90th day after the submission of the claim, the insurer must
866 deny the claim or pay the claim along with simple interest as
867 provided in paragraph (d). All claims denied for suspected
868 fraudulent insurance acts shall be reported to the Division of
869 Insurance Fraud.
870 (j) An insurer shall create and maintain for each insured a
871 log of personal injury protection benefits paid by the insurer
872 on behalf of the insured. If litigation is commenced, the
873 insurer shall provide to the insured, or an assignee of the
874 insured, a copy of the log within 30 days after receiving a
875 request for the log from the insured or the assignee.
876 (5) CHARGES FOR TREATMENT OF INJURED PERSONS.—
877 (a)1. A Any physician, hospital, clinic, or other person or
878 institution lawfully rendering treatment to an injured person
879 for a bodily injury covered by personal injury protection
880 insurance may charge the insurer and injured party only a
881 reasonable amount pursuant to this section for the services and
882 supplies rendered, and the insurer providing such coverage may
883 pay for such charges directly to such person or institution
884 lawfully rendering such treatment, if the insured receiving such
885 treatment or his or her guardian has countersigned the properly
886 completed invoice, bill, or claim form approved by the office
887 upon which such charges are to be paid for as having actually
888 been rendered, to the best knowledge of the insured or his or
889 her guardian. In no event, However, may such a charge may not
890 exceed be in excess of the amount the person or institution
891 customarily charges for like services or supplies. In
892 determining With respect to a determination of whether a charge
893 for a particular service, treatment, or otherwise is reasonable,
894 consideration may be given to evidence of usual and customary
895 charges and payments accepted by the provider involved in the
896 dispute, and reimbursement levels in the community and various
897 federal and state medical fee schedules applicable to motor
898 vehicle automobile and other insurance coverages, and other
899 information relevant to the reasonableness of the reimbursement
900 for the service, treatment, or supply.
901 1.2. The insurer may limit reimbursement to 80 percent of
902 the following schedule of maximum charges:
903 a. For emergency transport and treatment by providers
904 licensed under chapter 401, 200 percent of Medicare.
905 b. For emergency services and care provided by a hospital
906 licensed under chapter 395, 75 percent of the hospital’s usual
907 and customary charges.
908 c. For emergency services and care as defined by s.
909 395.002(9) provided in a facility licensed under chapter 395
910 rendered by a physician or dentist, and related hospital
911 inpatient services rendered by a physician or dentist, the usual
912 and customary charges in the community.
913 d. For hospital inpatient services, other than emergency
914 services and care, 200 percent of the Medicare Part A
915 prospective payment applicable to the specific hospital
916 providing the inpatient services.
917 e. For hospital outpatient services, other than emergency
918 services and care, 200 percent of the Medicare Part A Ambulatory
919 Payment Classification for the specific hospital providing the
920 outpatient services.
921 f. For all other medical services, supplies, and care, 200
922 percent of the allowable amount under:
923 (I) The participating physicians fee schedule of Medicare
924 Part B, except as provided in sub-sub-subparagraphs (II) and
925 (III).
926 (II) Medicare Part B, in the case of services, supplies,
927 and care provided by ambulatory surgical centers and clinical
928 laboratories.
929 (III) The Durable Medical Equipment Prosthetics/Orthotics
930 and Supplies fee schedule of Medicare Part B, in the case of
931 durable medical equipment.
932
933 However, if such services, supplies, or care is not reimbursable
934 under Medicare Part B, as provided in this sub-subparagraph, the
935 insurer may limit reimbursement to 80 percent of the maximum
936 reimbursable allowance under workers’ compensation, as
937 determined under s. 440.13 and rules adopted thereunder which
938 are in effect at the time such services, supplies, or care is
939 provided. Services, supplies, or care that is not reimbursable
940 under Medicare or workers’ compensation is not required to be
941 reimbursed by the insurer.
942 2.3. For purposes of subparagraph 1. 2., the applicable fee
943 schedule or payment limitation under Medicare is the fee
944 schedule or payment limitation in effect on January 1 of the
945 year in which at the time the services, supplies, or care is was
946 rendered and for the area in which such services, supplies, or
947 care is were rendered, and the applicable fee schedule or
948 payment limitation applies throughout the remainder of that
949 year, notwithstanding any subsequent change made to the fee
950 schedule or payment limitation, except that it may not be less
951 than the allowable amount under the applicable participating
952 physicians schedule of Medicare Part B for 2007 for medical
953 services, supplies, and care subject to Medicare Part B.
954 3.4. Subparagraph 1. 2. does not allow the insurer to apply
955 any limitation on the number of treatments or other utilization
956 limits that apply under Medicare or workers’ compensation. An
957 insurer that applies the allowable payment limitations of
958 subparagraph 1. 2. must reimburse a provider who lawfully
959 provided care or treatment under the scope of his or her
960 license, regardless of whether such provider is would be
961 entitled to reimbursement under Medicare due to restrictions or
962 limitations on the types or discipline of health care providers
963 who may be reimbursed for particular procedures or procedure
964 codes.
965 4.5. If an insurer limits payment as authorized by
966 subparagraph 1. 2., the person providing such services,
967 supplies, or care may not bill or attempt to collect from the
968 insured any amount in excess of such limits, except for amounts
969 that are not covered by the insured’s personal injury protection
970 coverage due to the coinsurance amount or maximum policy limits.
971 5. Effective July 1, 2012, an insurer may limit payment as
972 authorized by this paragraph only if the insurance policy
973 includes a notice at the time of issuance or renewal that the
974 insurer may limit payment pursuant to the schedule of charges
975 specified in this paragraph. A policy form approved by the
976 office satisfies this requirement. If a provider submits a
977 charge for an amount less than the amount allowed under
978 subparagraph 1., the insurer may pay the amount of the charge
979 submitted.
980 (b)1. An insurer or insured is not required to pay a claim
981 or charges:
982 a. Made by a broker or by a person making a claim on behalf
983 of a broker;
984 b. For any service or treatment that was not lawful at the
985 time rendered;
986 c. To any person who knowingly submits a false or
987 misleading statement relating to the claim or charges;
988 d. With respect to a bill or statement that does not
989 substantially meet the applicable requirements of paragraph (d);
990 e. For any treatment or service that is upcoded, or that is
991 unbundled when such treatment or services should be bundled, in
992 accordance with paragraph (d). To facilitate prompt payment of
993 lawful services, an insurer may change codes that it determines
994 to have been improperly or incorrectly upcoded or unbundled, and
995 may make payment based on the changed codes, without affecting
996 the right of the provider to dispute the change by the insurer,
997 if, provided that before doing so, the insurer contacts must
998 contact the health care provider and discusses discuss the
999 reasons for the insurer’s change and the health care provider’s
1000 reason for the coding, or makes make a reasonable good faith
1001 effort to do so, as documented in the insurer’s file; and
1002 f. For medical services or treatment billed by a physician
1003 and not provided in a hospital unless such services are rendered
1004 by the physician or are incident to his or her professional
1005 services and are included on the physician’s bill, including
1006 documentation verifying that the physician is responsible for
1007 the medical services that were rendered and billed.
1008 2. The Department of Health, in consultation with the
1009 appropriate professional licensing boards, shall adopt, by rule,
1010 a list of diagnostic tests deemed not to be medically necessary
1011 for use in the treatment of persons sustaining bodily injury
1012 covered by personal injury protection benefits under this
1013 section. The initial list shall be adopted by January 1, 2004,
1014 and shall be revised from time to time as determined by the
1015 Department of Health, in consultation with the respective
1016 professional licensing boards. Inclusion of a test on the list
1017 of invalid diagnostic tests shall be based on lack of
1018 demonstrated medical value and a level of general acceptance by
1019 the relevant provider community and may shall not be dependent
1020 for results entirely upon subjective patient response.
1021 Notwithstanding its inclusion on a fee schedule in this
1022 subsection, an insurer or insured is not required to pay any
1023 charges or reimburse claims for an any invalid diagnostic test
1024 as determined by the Department of Health.
1025 (c)1. With respect to any treatment or service, other than
1026 medical services billed by a hospital or other provider for
1027 emergency services and care as defined in s. 395.002 or
1028 inpatient services rendered at a hospital-owned facility, the
1029 statement of charges must be furnished to the insurer by the
1030 provider and may not include, and the insurer is not required to
1031 pay, charges for treatment or services rendered more than 35
1032 days before the postmark date or electronic transmission date of
1033 the statement, except for past due amounts previously billed on
1034 a timely basis under this paragraph, and except that, if the
1035 provider submits to the insurer a notice of initiation of
1036 treatment within 21 days after its first examination or
1037 treatment of the claimant, the statement may include charges for
1038 treatment or services rendered up to, but not more than, 75 days
1039 before the postmark date of the statement. The injured party is
1040 not liable for, and the provider may shall not bill the injured
1041 party for, charges that are unpaid because of the provider’s
1042 failure to comply with this paragraph. Any agreement requiring
1043 the injured person or insured to pay for such charges is
1044 unenforceable.
1045 1.2. If, however, the insured fails to furnish the provider
1046 with the correct name and address of the insured’s personal
1047 injury protection insurer, the provider has 35 days from the
1048 date the provider obtains the correct information to furnish the
1049 insurer with a statement of the charges. The insurer is not
1050 required to pay for such charges unless the provider includes
1051 with the statement documentary evidence that was provided by the
1052 insured during the 35-day period demonstrating that the provider
1053 reasonably relied on erroneous information from the insured and
1054 either:
1055 a. A denial letter from the incorrect insurer; or
1056 b. Proof of mailing, which may include an affidavit under
1057 penalty of perjury, reflecting timely mailing to the incorrect
1058 address or insurer.
1059 2.3. For emergency services and care as defined in s.
1060 395.002 rendered in a hospital emergency department or for
1061 transport and treatment rendered by an ambulance provider
1062 licensed pursuant to part III of chapter 401, the provider is
1063 not required to furnish the statement of charges within the time
1064 periods established by this paragraph,; and the insurer is shall
1065 not be considered to have been furnished with notice of the
1066 amount of covered loss for purposes of paragraph (4)(b) until it
1067 receives a statement complying with paragraph (d), or copy
1068 thereof, which specifically identifies the place of service to
1069 be a hospital emergency department or an ambulance in accordance
1070 with billing standards recognized by the federal Centers for
1071 Medicare and Medicaid Services Health Care Finance
1072 Administration.
1073 3.4. Each notice of the insured’s rights under s. 627.7401
1074 must include the following statement in at least 12-point type
1075 in type no smaller than 12 points:
1076
1077 BILLING REQUIREMENTS.—Florida law provides
1078 Statutes provide that with respect to any treatment or
1079 services, other than certain hospital and emergency
1080 services, the statement of charges furnished to the
1081 insurer by the provider may not include, and the
1082 insurer and the injured party are not required to pay,
1083 charges for treatment or services rendered more than
1084 35 days before the postmark date of the statement,
1085 except for past due amounts previously billed on a
1086 timely basis, and except that, if the provider submits
1087 to the insurer a notice of initiation of treatment
1088 within 21 days after its first examination or
1089 treatment of the claimant, the statement may include
1090 charges for treatment or services rendered up to, but
1091 not more than, 75 days before the postmark date of the
1092 statement.
1093
1094 (d) All statements and bills for medical services rendered
1095 by a any physician, hospital, clinic, or other person or
1096 institution shall be submitted to the insurer on a properly
1097 completed Centers for Medicare and Medicaid Services (CMS) 1500
1098 form, UB 92 forms, or any other standard form approved by the
1099 office or adopted by the commission for purposes of this
1100 paragraph. All billings for such services rendered by providers
1101 must shall, to the extent applicable, follow the Physicians’
1102 Current Procedural Terminology (CPT) or Healthcare Correct
1103 Procedural Coding System (HCPCS), or ICD-9 in effect for the
1104 year in which services are rendered and comply with the Centers
1105 for Medicare and Medicaid Services (CMS) 1500 form instructions,
1106 and the American Medical Association Current Procedural
1107 Terminology (CPT) Editorial Panel, and the Healthcare Correct
1108 Procedural Coding System (HCPCS). All providers, other than
1109 hospitals, must shall include on the applicable claim form the
1110 professional license number of the provider in the line or space
1111 provided for “Signature of Physician or Supplier, Including
1112 Degrees or Credentials.” In determining compliance with
1113 applicable CPT and HCPCS coding, guidance shall be provided by
1114 the Physicians’ Current Procedural Terminology (CPT) or the
1115 Healthcare Correct Procedural Coding System (HCPCS) in effect
1116 for the year in which services were rendered, the Office of the
1117 Inspector General (OIG), Physicians Compliance Guidelines, and
1118 other authoritative treatises designated by rule by the Agency
1119 for Health Care Administration. A No statement of medical
1120 services may not include charges for medical services of a
1121 person or entity that performed such services without possessing
1122 the valid licenses required to perform such services. For
1123 purposes of paragraph (4)(b), an insurer is shall not be
1124 considered to have been furnished with notice of the amount of
1125 covered loss or medical bills due unless the statements or bills
1126 comply with this paragraph, and unless the statements or bills
1127 are properly completed in their entirety as to all material
1128 provisions, with all relevant information being provided
1129 therein.
1130 (e)1. At the initial treatment or service provided, each
1131 physician, other licensed professional, clinic, or other medical
1132 institution providing medical services upon which a claim for
1133 personal injury protection benefits is based shall require an
1134 insured person, or his or her guardian, to execute a disclosure
1135 and acknowledgment form, which reflects at a minimum that:
1136 a. The insured, or his or her guardian, must countersign
1137 the form attesting to the fact that the services set forth
1138 therein were actually rendered;
1139 b. The insured, or his or her guardian, has both the right
1140 and affirmative duty to confirm that the services were actually
1141 rendered;
1142 c. The insured, or his or her guardian, was not solicited
1143 by any person to seek any services from the medical provider;
1144 d. The physician, other licensed professional, clinic, or
1145 other medical institution rendering services for which payment
1146 is being claimed explained the services to the insured or his or
1147 her guardian; and
1148 e. If the insured notifies the insurer in writing of a
1149 billing error, the insured may be entitled to a certain
1150 percentage of a reduction in the amounts paid by the insured’s
1151 motor vehicle insurer.
1152 2. The physician, other licensed professional, clinic, or
1153 other medical institution rendering services for which payment
1154 is being claimed has the affirmative duty to explain the
1155 services rendered to the insured, or his or her guardian, so
1156 that the insured, or his or her guardian, countersigns the form
1157 with informed consent.
1158 3. Countersignature by the insured, or his or her guardian,
1159 is not required for the reading of diagnostic tests or other
1160 services that are of such a nature that they are not required to
1161 be performed in the presence of the insured.
1162 4. The licensed medical professional rendering treatment
1163 for which payment is being claimed must sign, by his or her own
1164 hand, the form complying with this paragraph.
1165 5. The original completed disclosure and acknowledgment
1166 form shall be furnished to the insurer pursuant to paragraph
1167 (4)(b) and may not be electronically furnished.
1168 6. The This disclosure and acknowledgment form is not
1169 required for services billed by a provider for emergency
1170 services as defined in s. 395.002, for emergency services and
1171 care as defined in s. 395.002 rendered in a hospital emergency
1172 department, or for transport and treatment rendered by an
1173 ambulance provider licensed pursuant to part III of chapter 401.
1174 7. The Financial Services Commission shall adopt, by rule,
1175 a standard disclosure and acknowledgment form to that shall be
1176 used to fulfill the requirements of this paragraph, effective 90
1177 days after such form is adopted and becomes final. The
1178 commission shall adopt a proposed rule by October 1, 2003. Until
1179 the rule is final, the provider may use a form of its own which
1180 otherwise complies with the requirements of this paragraph.
1181 8. As used in this paragraph, the term “countersign” or
1182 “countersignature” “countersigned” means a second or verifying
1183 signature, as on a previously signed document, and is not
1184 satisfied by the statement “signature on file” or any similar
1185 statement.
1186 9. The requirements of this paragraph apply only with
1187 respect to the initial treatment or service of the insured by a
1188 provider. For subsequent treatments or service, the provider
1189 must maintain a patient log signed by the patient, in
1190 chronological order by date of service, which that is consistent
1191 with the services being rendered to the patient as claimed. The
1192 requirement to maintain requirements of this subparagraph for
1193 maintaining a patient log signed by the patient may be met by a
1194 hospital that maintains medical records as required by s.
1195 395.3025 and applicable rules and makes such records available
1196 to the insurer upon request.
1197 (f) Upon written notification by any person, an insurer
1198 shall investigate any claim of improper billing by a physician
1199 or other medical provider. The insurer shall determine if the
1200 insured was properly billed for only those services and
1201 treatments that the insured actually received. If the insurer
1202 determines that the insured has been improperly billed, the
1203 insurer shall notify the insured, the person making the written
1204 notification, and the provider of its findings and shall reduce
1205 the amount of payment to the provider by the amount determined
1206 to be improperly billed. If a reduction is made due to a such
1207 written notification by any person, the insurer shall pay to the
1208 person 20 percent of the amount of the reduction, up to $500. If
1209 the provider is arrested due to the improper billing, then the
1210 insurer shall pay to the person 40 percent of the amount of the
1211 reduction, up to $500.
1212 (g) An insurer may not systematically downcode with the
1213 intent to deny reimbursement otherwise due. Such action
1214 constitutes a material misrepresentation under s.
1215 626.9541(1)(i)2.
1216 (h) As provided in s. 400.9905, an entity excluded from the
1217 definition of a clinic shall be deemed a clinic and must be
1218 licensed under part X of chapter 400 in order to receive
1219 reimbursement under ss. 627.730-627.7405. However, this
1220 licensing requirement does not apply to:
1221 1. An entity wholly owned by a physician licensed under
1222 chapter 458 or chapter 459, or by the physician and the spouse,
1223 parent, child, or sibling of the physician;
1224 2. An entity wholly owned by a dentist licensed under
1225 chapter 466, or by the dentist and the spouse, parent, child, or
1226 sibling of the dentist;
1227 3. An entity wholly owned by a chiropractic physician
1228 licensed under chapter 460, or by the chiropractic physician and
1229 the spouse, parent, child, or sibling of the chiropractic
1230 physician;
1231 4. A hospital or ambulatory surgical center licensed under
1232 chapter 395;
1233 5. An entity that wholly owns or is wholly owned, directly
1234 or indirectly, by a hospital or hospitals licensed under chapter
1235 395; or
1236 6. An entity that is a clinical facility affiliated with an
1237 accredited medical school at which training is provided for
1238 medical students, residents, or fellows.
1239 (6) DISCOVERY OF FACTS ABOUT AN INJURED PERSON; DISPUTES.—
1240 (a) Every employer shall, If a request is made by an
1241 insurer providing personal injury protection benefits under ss.
1242 627.730-627.7405 against whom a claim has been made, an employer
1243 must furnish forthwith, in a form approved by the office, a
1244 sworn statement of the earnings, since the time of the bodily
1245 injury and for a reasonable period before the injury, of the
1246 person upon whose injury the claim is based.
1247 (b) Every physician, hospital, clinic, or other medical
1248 institution providing, before or after bodily injury upon which
1249 a claim for personal injury protection insurance benefits is
1250 based, any products, services, or accommodations in relation to
1251 that or any other injury, or in relation to a condition claimed
1252 to be connected with that or any other injury, shall, if
1253 requested to do so by the insurer against whom the claim has
1254 been made, furnish forthwith a written report of the history,
1255 condition, treatment, dates, and costs of such treatment of the
1256 injured person and why the items identified by the insurer were
1257 reasonable in amount and medically necessary, together with a
1258 sworn statement that the treatment or services rendered were
1259 reasonable and necessary with respect to the bodily injury
1260 sustained and identifying which portion of the expenses for such
1261 treatment or services was incurred as a result of such bodily
1262 injury, and produce forthwith, and allow permit the inspection
1263 and copying of, his or her or its records regarding such
1264 history, condition, treatment, dates, and costs of treatment if;
1265 provided that this does shall not limit the introduction of
1266 evidence at trial. Such sworn statement must shall read as
1267 follows: “Under penalty of perjury, I declare that I have read
1268 the foregoing, and the facts alleged are true, to the best of my
1269 knowledge and belief.” A No cause of action for violation of the
1270 physician-patient privilege or invasion of the right of privacy
1271 may not be brought shall be permitted against any physician,
1272 hospital, clinic, or other medical institution complying with
1273 the provisions of this section. The person requesting such
1274 records and such sworn statement shall pay all reasonable costs
1275 connected therewith. If an insurer makes a written request for
1276 documentation or information under this paragraph within 30 days
1277 after having received notice of the amount of a covered loss
1278 under paragraph (4)(a), the amount or the partial amount that
1279 which is the subject of the insurer’s inquiry is shall become
1280 overdue if the insurer does not pay in accordance with paragraph
1281 (4)(b) or within 10 days after the insurer’s receipt of the
1282 requested documentation or information, whichever occurs later.
1283 As used in For purposes of this paragraph, the term “receipt”
1284 includes, but is not limited to, inspection and copying pursuant
1285 to this paragraph. An Any insurer that requests documentation or
1286 information pertaining to reasonableness of charges or medical
1287 necessity under this paragraph without a reasonable basis for
1288 such requests as a general business practice is engaging in an
1289 unfair trade practice under the insurance code.
1290 (c) In the event of a any dispute regarding an insurer’s
1291 right to discovery of facts under this section, the insurer may
1292 petition a court of competent jurisdiction to enter an order
1293 permitting such discovery. The order may be made only on motion
1294 for good cause shown and upon notice to all persons having an
1295 interest, and must it shall specify the time, place, manner,
1296 conditions, and scope of the discovery. Such court may, In order
1297 to protect against annoyance, embarrassment, or oppression, as
1298 justice requires, the court may enter an order refusing
1299 discovery or specifying conditions of discovery and may order
1300 payments of costs and expenses of the proceeding, including
1301 reasonable fees for the appearance of attorneys at the
1302 proceedings, as justice requires.
1303 (d) The injured person shall be furnished, upon request, a
1304 copy of all information obtained by the insurer under the
1305 provisions of this section, and shall pay a reasonable charge,
1306 if required by the insurer.
1307 (e) Notice to an insurer of the existence of a claim may
1308 shall not be unreasonably withheld by an insured.
1309 (f) In a dispute between the insured and the insurer, or
1310 between an assignee of the insured’s rights and the insurer, the
1311 insurer must notify the insured or the assignee that the policy
1312 limits under this section have been reached within 15 days after
1313 the limits have been reached.
1314 (8) APPLICABILITY OF PROVISION REGULATING ATTORNEY
1315 ATTORNEY’S FEES.—
1316 (a) With respect to any dispute under the provisions of ss.
1317 627.730-627.7405 between the insured and the insurer, or between
1318 an assignee of an insured’s rights and the insurer, the
1319 provisions of ss. s. 627.428 and 768.79 shall apply, except as
1320 provided in subsections (10) and (15), and except that any
1321 attorney fees recovered must:
1322 1. Comply with prevailing professional standards;
1323 2. Ensure that the attorney fees for work performed by an
1324 attorney does not duplicate work performed by a paralegal or
1325 legal assistant; and
1326 3. Not overstate or inflate the number of hours reasonably
1327 necessary for a case of comparable skill or complexity.
1328 (b) Notwithstanding s. 627.428 and this subsection, it
1329 shall be presumed that any attorney fees awarded under ss.
1330 627.730-627.7405 are calculated without regard to a contingency
1331 risk multiplier. This presumption may be overcome only if the
1332 court makes findings of fact based upon competent evidence in
1333 the record which establishes that:
1334 1. The party requesting the multiplier would have faced
1335 substantial difficulties finding competent counsel to pursue the
1336 case in the relevant market but for the consideration of a fee
1337 multiplier;
1338 2. Consideration of a fee multiplier was a necessary
1339 incentive to obtain competent counsel to pursue the case;
1340 3. The claim would not be economically feasible to hire an
1341 attorney on a noncontingent, fixed-fee basis;
1342 4. The attorney was unable to mitigate the risk of
1343 nonpayment of attorney fees in any other way; and
1344 5. The use of a multiplier is justified based on factors
1345 such as the amount of risk undertaken by the attorney at the
1346 outset of the case, the results obtained, and the type of fee
1347 arrangement between the attorney and client.
1348 (c) Paragraph (b) does not apply to a case where class
1349 action status has been sought or granted, and a contingency risk
1350 multiplier may be applied in such cases notwithstanding
1351 paragraph (b).
1352 (d) Upon the request of either party, a judge must make
1353 written findings, substantiated by evidence presented at trial
1354 or any hearings associated with the trial, that an award of
1355 attorney fees complies with this subsection.
1356 (9) PREFERRED PROVIDERS.—An insurer may negotiate and
1357 contract enter into contracts with preferred licensed health
1358 care providers for the benefits described in this section,
1359 referred to in this section as “preferred providers,” which
1360 shall include health care providers licensed under chapter
1361 chapters 458, chapter 459, chapter 460, chapter 461, or chapter
1362 and 463. The insurer may provide an option to an insured to use
1363 a preferred provider at the time of purchasing purchase of the
1364 policy for personal injury protection benefits, if the
1365 requirements of this subsection are met. If the insured elects
1366 to use a provider who is not a preferred provider, whether the
1367 insured purchased a preferred provider policy or a nonpreferred
1368 provider policy, the medical benefits provided by the insurer
1369 shall be as required by this section. If the insured elects to
1370 use a provider who is a preferred provider, the insurer may pay
1371 medical benefits in excess of the benefits required by this
1372 section and may waive or lower the amount of any deductible that
1373 applies to such medical benefits. If the insurer offers a
1374 preferred provider policy to a policyholder or applicant, it
1375 must also offer a nonpreferred provider policy. The insurer
1376 shall provide each insured policyholder with a current roster of
1377 preferred providers in the county in which the insured resides
1378 at the time of purchase of such policy, and shall make such list
1379 available for public inspection during regular business hours at
1380 the insurer’s principal office of the insurer within the state.
1381 (10) DEMAND LETTER.—
1382 (a) As a condition precedent to filing any action for
1383 benefits under this section, the insurer must be provided with
1384 written notice of an intent to initiate litigation must be
1385 provided to the insurer. Such notice may not be sent until the
1386 claim is overdue, including any additional time the insurer has
1387 to pay the claim pursuant to paragraph (4)(b).
1388 (b) The notice must required shall state that it is a
1389 “demand letter under s. 627.736(10)” and shall state with
1390 specificity:
1391 1. The name of the insured upon which such benefits are
1392 being sought, including a copy of the assignment giving rights
1393 to the claimant if the claimant is not the insured.
1394 2. The claim number or policy number upon which such claim
1395 was originally submitted to the insurer.
1396 3. To the extent applicable, the name of any medical
1397 provider who rendered to an insured the treatment, services,
1398 accommodations, or supplies that form the basis of such claim;
1399 and an itemized statement specifying each exact amount, the date
1400 of treatment, service, or accommodation, and the type of benefit
1401 claimed to be due. A completed form satisfying the requirements
1402 of paragraph (5)(d) or the lost-wage statement previously
1403 submitted may be used as the itemized statement. To the extent
1404 that the demand involves an insurer’s withdrawal of payment
1405 under paragraph (7)(a) for future treatment not yet rendered,
1406 the claimant shall attach a copy of the insurer’s notice
1407 withdrawing such payment and an itemized statement of the type,
1408 frequency, and duration of future treatment claimed to be
1409 reasonable and medically necessary.
1410 (c) Each notice required by this subsection must be
1411 delivered to the insurer by United States certified or
1412 registered mail, return receipt requested, or by electronic
1413 mail. Such postal costs shall be reimbursed by the insurer if so
1414 requested by the claimant in the notice, when the insurer pays
1415 the claim. Such notice must be sent to the person and address
1416 specified by the insurer for the purposes of receiving notices
1417 under this subsection. Each licensed insurer, whether domestic,
1418 foreign, or alien, shall file with the office designation of the
1419 name and physical and e-mail address of the designated person to
1420 whom notices must pursuant to this subsection shall be sent
1421 which the office shall make available on its Internet website.
1422 The name and address on file with the office pursuant to s.
1423 624.422 are shall be deemed the authorized representative to
1424 accept notice pursuant to this subsection if in the event no
1425 other designation has been made.
1426 (d) If, within 30 days after receipt of notice by the
1427 insurer, the overdue claim specified in the notice is paid by
1428 the insurer together with applicable interest and a penalty of
1429 10 percent of the overdue amount paid by the insurer, subject to
1430 a maximum penalty of $250, no action may be brought against the
1431 insurer. If the demand involves an insurer’s withdrawal of
1432 payment under paragraph (7)(a) for future treatment not yet
1433 rendered, no action may be brought against the insurer if,
1434 within 30 days after its receipt of the notice, the insurer
1435 mails to the person filing the notice a written statement of the
1436 insurer’s agreement to pay for such treatment in accordance with
1437 the notice and to pay a penalty of 10 percent, subject to a
1438 maximum penalty of $250, when it pays for such future treatment
1439 in accordance with the requirements of this section. To the
1440 extent the insurer determines not to pay any amount demanded,
1441 the penalty is shall not be payable in any subsequent action.
1442 For purposes of this subsection, payment or the insurer’s
1443 agreement shall be treated as being made on the date a draft or
1444 other valid instrument that is equivalent to payment, or the
1445 insurer’s written statement of agreement, is placed in the
1446 United States mail in a properly addressed, postpaid envelope,
1447 or if not so posted, on the date of delivery. The insurer is not
1448 obligated to pay any attorney attorney’s fees if the insurer
1449 pays the claim or mails its agreement to pay for future
1450 treatment within the time prescribed by this subsection.
1451 (e) The applicable statute of limitation for an action
1452 under this section shall be tolled for a period of 30 business
1453 days by the mailing of the notice required by this subsection.
1454 (f) Any insurer making a general business practice of not
1455 paying valid claims until receipt of the notice required by this
1456 subsection is engaging in an unfair trade practice under the
1457 insurance code.
1458 (11) FAILURE TO PAY VALID CLAIMS; UNFAIR OR DECEPTIVE
1459 PRACTICE.—
1460 (a) If An insurer fails to pay valid claims for personal
1461 injury protection with such frequency so as to indicate a
1462 general business practice, the insurer is engaging in a
1463 prohibited unfair or deceptive practice that is subject to the
1464 penalties provided in s. 626.9521 and the office has the powers
1465 and duties specified in ss. 626.9561-626.9601 if the insurer,
1466 with such frequency so as to indicate a general business
1467 practice: with respect thereto
1468 1. Fails to pay valid claims for personal injury
1469 protection; or
1470 2. Fails to pay valid claims until receipt of the notice
1471 required by subsection (10).
1472 (b) Notwithstanding s. 501.212, the Department of Legal
1473 Affairs may investigate and initiate actions for a violation of
1474 this subsection, including, but not limited to, the powers and
1475 duties specified in part II of chapter 501.
1476 (17) REFERRAL FEES.—A person, entity, or licensee may not
1477 accept a fee for the referral of the insured to a person,
1478 entity, or licensee for medical benefits under paragraph (1)(a)
1479 unless the person, entity, or licensee making the referral
1480 discloses in writing to the insured and the insurer that he or
1481 she has received a referral fee, the amount of the referral fee,
1482 and the name and business address of the person or entity that
1483 provided the referral fee. Reimbursement under the Florida Motor
1484 Vehicle No-Fault Law to a person, entity, or licensee who
1485 receives and fails to disclose a referral fee to the insured and
1486 insurer as required by this subsection must be reduced by the
1487 amount of the undisclosed referral fee.
1488 Section 9. Effective December 1, 2012, subsection (16) of
1489 section 627.736, Florida Statutes, is amended to read:
1490 627.736 Required personal injury protection benefits;
1491 exclusions; priority; claims.—
1492 (16) SECURE ELECTRONIC DATA TRANSFER.—If all parties
1493 mutually and expressly agree, A notice, documentation,
1494 transmission, or communication of any kind required or
1495 authorized under ss. 627.730-627.7405 may be transmitted
1496 electronically if it is transmitted by secure electronic data
1497 transfer that is consistent with state and federal privacy and
1498 security laws.
1499 Section 10. Section 627.7405, Florida Statutes, is amended
1500 to read:
1501 627.7405 Insurers’ right of reimbursement.—
1502 (1) Notwithstanding any other provisions of ss. 627.730
1503 627.7405, an any insurer providing personal injury protection
1504 benefits on a private passenger motor vehicle shall have, to the
1505 extent of any personal injury protection benefits paid to any
1506 person as a benefit arising out of such private passenger motor
1507 vehicle insurance, a right of reimbursement against the owner or
1508 the insurer of the owner of a commercial motor vehicle, if the
1509 benefits paid result from such person having been an occupant of
1510 the commercial motor vehicle or having been struck by the
1511 commercial motor vehicle while not an occupant of any self
1512 propelled vehicle.
1513 (2) The insurer’s right of reimbursement under this section
1514 does not apply to an owner or registrant as identified in s.
1515 627.733(1)(b).
1516 Section 11. Subsections (1), (10), and (13) of section
1517 817.234, Florida Statutes, are amended to read:
1518 817.234 False and fraudulent insurance claims.—
1519 (1)(a) A person commits insurance fraud punishable as
1520 provided in subsection (11) if that person, with the intent to
1521 injure, defraud, or deceive any insurer:
1522 1. Presents or causes to be presented any written or oral
1523 statement as part of, or in support of, a claim for payment or
1524 other benefit pursuant to an insurance policy or a health
1525 maintenance organization subscriber or provider contract,
1526 knowing that such statement contains any false, incomplete, or
1527 misleading information concerning any fact or thing material to
1528 such claim;
1529 2. Prepares or makes any written or oral statement that is
1530 intended to be presented to any insurer in connection with, or
1531 in support of, any claim for payment or other benefit pursuant
1532 to an insurance policy or a health maintenance organization
1533 subscriber or provider contract, knowing that such statement
1534 contains any false, incomplete, or misleading information
1535 concerning any fact or thing material to such claim; or
1536 3.a. Knowingly presents, causes to be presented, or
1537 prepares or makes with knowledge or belief that it will be
1538 presented to any insurer, purported insurer, servicing
1539 corporation, insurance broker, or insurance agent, or any
1540 employee or agent thereof, any false, incomplete, or misleading
1541 information or written or oral statement as part of, or in
1542 support of, an application for the issuance of, or the rating
1543 of, any insurance policy, or a health maintenance organization
1544 subscriber or provider contract; or
1545 b. Who Knowingly conceals information concerning any fact
1546 material to such application; or.
1547 4. Knowingly presents, causes to be presented, or prepares
1548 or makes with knowledge or belief that it will be presented to
1549 any insurer a claim for payment or other benefit under a
1550 personal injury protection insurance policy if the person knows
1551 that the payee knowingly submitted a false, misleading, or
1552 fraudulent application or other document when applying for
1553 licensure as a health care clinic, seeking an exemption from
1554 licensure as a health care clinic, or demonstrating compliance
1555 with part X of chapter 400.
1556 (b) All claims and application forms must shall contain a
1557 statement that is approved by the Office of Insurance Regulation
1558 of the Financial Services Commission which clearly states in
1559 substance the following: “Any person who knowingly and with
1560 intent to injure, defraud, or deceive any insurer files a
1561 statement of claim or an application containing any false,
1562 incomplete, or misleading information is guilty of a felony of
1563 the third degree.” This paragraph does shall not apply to
1564 reinsurance contracts, reinsurance agreements, or reinsurance
1565 claims transactions.
1566 (10) A licensed health care practitioner who is found
1567 guilty of insurance fraud under this section for an act relating
1568 to a personal injury protection insurance policy loses his or
1569 her license to practice for 5 years and may not receive
1570 reimbursement for personal injury protection benefits for 10
1571 years. As used in this section, the term “insurer” means any
1572 insurer, health maintenance organization, self-insurer, self
1573 insurance fund, or other similar entity or person regulated
1574 under chapter 440 or chapter 641 or by the Office of Insurance
1575 Regulation under the Florida Insurance Code.
1576 (13) As used in this section, the term:
1577 (a) “Insurer” means any insurer, health maintenance
1578 organization, self-insurer, self-insurance fund, or similar
1579 entity or person regulated under chapter 440 or chapter 641 or
1580 by the Office of Insurance Regulation under the Florida
1581 Insurance Code.
1582 (b)(a) “Property” means property as defined in s. 812.012.
1583 (c)(b) “Value” means value as defined in s. 812.012.
1584 Section 12. Subsection (4) of section 316.065, Florida
1585 Statutes, is amended to read:
1586 316.065 Crashes; reports; penalties.—
1587 (4) Any person who knowingly repairs a motor vehicle
1588 without having made a report as required by subsection (3) is
1589 guilty of a misdemeanor of the first degree, punishable as
1590 provided in s. 775.082 or s. 775.083. The owner and driver of a
1591 vehicle involved in a crash who makes a report thereof in
1592 accordance with subsection (1) or s. 316.066(1) is not liable
1593 under this section.
1594 Section 13. Motor vehicle insurance rate rollback.—
1595 (1) The Office of Insurance Regulation shall order insurers
1596 writing personal injury protection insurance in this state to
1597 make a rate filing before October 1, 2012, and effective January
1598 1, 2013, which reduces rates for such insurance by a factor that
1599 reflects the expected effect of the changes contained in this
1600 act. In the absence of clear and convincing evidence to the
1601 contrary, it shall be presumed that the expected impact of the
1602 act will result in at least a 25 percent reduction in the rates
1603 in effect for such insurance on December 31, 2012. In lieu of
1604 making the rate filing required in this subsection, an insurer
1605 may, upon notification to the office, implement a 25 percent
1606 reduction of its rates, effective January 1, 2013.
1607 (2) An insurer or rating organization that contends in the
1608 January 1, 2013, rate filing or any subsequent rate filing made
1609 on or before December 31, 2018, that the presumed reduced rate
1610 provided for in subsection (1) is excessive, inadequate, or
1611 unfairly discriminatory shall separately state in its filing the
1612 rate it contends is appropriate and shall state with specificity
1613 the factors or data that it contends should be considered in
1614 order to produce such appropriate rate. The insurer or rating
1615 organization shall be permitted to use all of the generally
1616 accepted actuarial techniques, as provided in s. 627.062,
1617 Florida Statutes, in making any filing pursuant to this
1618 subsection. The Office of Insurance Regulation shall review each
1619 exception and approve or disapprove it prior to use. It shall be
1620 the insurer’s burden to actuarially justify by clear and
1621 convincing evidence any deviation that results in a rate that is
1622 higher than the presumed reduced rate as provided in subsection
1623 (1).
1624 (3) If any provision of this act is held invalid by a court
1625 of competent jurisdiction, the Office of Insurance Regulation
1626 shall permit an adjustment of all rates filed under this section
1627 to reflect the impact of such holding on such rates so as to
1628 ensure that the rates are not excessive, inadequate, or unfairly
1629 discriminatory.
1630 Section 14. The Office of Insurance Regulation shall
1631 perform a comprehensive personal injury protection data call and
1632 publish the results by January 1, 2015. It is the intent of the
1633 Legislature that the office design the data call with the
1634 expectation that the Legislature will use the data to help
1635 evaluate market conditions relating to the Florida Motor Vehicle
1636 No-Fault Law and the impact on the market of reforms to the law
1637 made by this act. The elements of the data call must address,
1638 but need not be limited to, the following components of the
1639 Florida Motor Vehicle No-Fault Law:
1640 (1) Quantity of personal injury protection claims.
1641 (2) Type or nature of claimants.
1642 (3) Amount and type of personal injury protection benefits
1643 paid and expenses incurred.
1644 (4) Type and quantity of, and charges for, medical
1645 benefits.
1646 (5) Attorney fees related to bringing and defending actions
1647 for benefits.
1648 (6) Direct earned premiums for personal injury protection
1649 coverage, pure loss ratios, pure premiums, and other information
1650 related to premiums and losses.
1651 (7) Licensed drivers and accidents.
1652 (8) Fraud and enforcement.
1653 Section 15. If any provision of this act or its application
1654 to any person or circumstance is held invalid, the invalidity
1655 does not affect other provisions or applications of the act
1656 which can be given effect without the invalid provision or
1657 application, and to this end the provisions of this act are
1658 severable.
1659 Section 16. Except as otherwise expressly provided in this
1660 act, this act shall take effect July 1, 2012.