No. SB 1130
Filed under Insurance.
Insurance Claims Payments to Health Care Providers; Prohibiting payment adjudicators from downcoding health care services under certain circumstances; specifying that payment adjudicators are solely responsible for certain violations of law; requiring certain utilization review entities to only use a certain prior authorization form; revising the definition of the term “claim”, etc.
Plain English Summary
AI-GENERATEDHealth insurers and their payment adjudicators generally cannot downcode a claim ordered by an in-network provider. Even where a contract allows it, they must review the medical record first and give the provider 15 days to contest it.
Utilization review entities must offer electronic prior-authorization systems and let physicians in the same specialty, with no financial stake in the outcome, decide denials. Missing a deadline automatically approves the request; a granted authorization becomes binding on payment.
Payment deadlines shorten, the overpayment clawback window drops from 30 months to 18, and interest on overdue claims rises to 15 percent. These prompt-payment rules also now cover self-insured plans a health insurer merely administers.
A sentence stating these payment protections cannot be waived by contract is deleted from both statutes. Providers also gain a direct right to sue insurers, HMOs, or utilization review entities over violations of any of these rules.
AIA payment adjudicator generally cannot alter a provider's billed service code or modifier to one paying less, unless the health insurer's participation agreement with that provider expressly allows downcoding.
AIEven when a contract allows downcoding, the payment adjudicator must review the patient's medical record first to confirm the coding change is accurate before reducing payment.
AIThe prompt-payment statute no longer applies only to standard insurance policies. It now reaches any health coverage, policy, or fund a health insurer offers or administers, whether fully insured or self-insured.
AIEvery utilization review entity, not just health insurers, must build a secure online system for submitting and processing prior-authorization requests electronically, a duty that used to be conditional.
AIA utilization review entity's coverage denials must be made by a Florida-licensed physician in the same specialty as the treating provider, with at least five years treating the condition and no financial stake in the outcome.
AIIf a utilization review entity misses the deadlines this section sets for a prior-authorization decision, the requested care is automatically treated as approved without further insurer action.
AIOnce prior authorization is granted, it stands as conclusive proof the care was medically necessary and creates an irrevocable obligation to pay, with only four narrow exceptions such as fraud or the patient losing coverage.
AICurrent law states these payment-timeline, interest, and overpayment protections cannot be waived, voided, or nullified by contract. This bill deletes that sentence from both the insurer and HMO prompt-payment statutes and adds no replacement.