Health Care Claims Disputes: Statutes and Legal Practice Guide for Florida

Fla. Stat. § 641.3154 prohibits balance billing by an anesthesiology group for services rendered at a participating hospital. See Joseph L. Riley Anesthesia Assocs. v. Stein, 27 So. 3d 140 (Fla. Dist. Ct. App. 5th Dist. 2010)

Title 59. Agency for Health Care Administration - Implements Florida's Medicaid Program.

Reimbursement to participating inpatient hospitals for services provided shall be in accordance with the Florida Title XIX Inpatient Hospital Reimbursement Plan.

Fla. Admin. Code Ann. r. 59G-6.020

Fla. Stat. § 627.613 provides that health insurers must reimburse claims from an insured or an insured's assignees within 45 days of receiving the claim. Notice of any disputed portions must be provided to the insured/assignee in writing within 45 days of receiving the claim and identify the contested portion of the claim and the reasons for contesting the claim. When this information is received, the insurer must pay or deny the claim within 60 days. Any claim must be paid or denied no later than 120 days after receiving the claim. 31A Fla Jur Insurance § 3394

The civil remedy against an insurer authorized by the Insurance Code does not preempt any other remedy or cause of action provided for pursuant to any other statute or pursuant to the common law of the State. Any person may obtain a judgment under either the common law remedy of bad faith or the statutory remedy, but will not be entitled to a judgment under both remedies. The provision of the Insurance Code authorizing the civil action is not to be construed to create a common law cause of action.

The insurer's duty of good faith is a contractual duty, and an action for its breach is governed by contract law. There must first be a determination regarding coverage and contractual issues between insured and insurer before an action for bad faith can proceed.n9 Without a contractual relationship between an insured and an insurer, an action for statutory bad faith cannot lie under Florida law. 3414 Fla Jur Insurance § 3803

In some jurisdictions, statutes have been enacted making insurance companies liable for damages and attorney's fees in case of a failure or delay in bad faith in paying a claim, or for a failure to pay claims against them within a specified period after they have accrued.

123 A.L.R.5th 259 (Originally published in 2004)

What is "medically necessary" for purposes of coverage under medical insurance?

75 A.L.R.4th 763 (Originally published in 1989)

“Disputed Claim” means a claim that has been submitted by a provider to the health plan or by a health plan to a provider for payment and has been denied in full or in part, or is presumed to have been underpaid or overpaid.

Fla. Admin. Code Ann. r. 59A-12.030

SHANDS TEACHING HOSPITAL AND CLINICS, INCORPORATED, Appellant,

v.

BEECH STREET CORPORATION and Unisys Corporation, Appellees.

Shands Teaching Hosp. & Clinics, Inc. v. Beech St. Corp., 899 So. 2d 1222 (Fla. Dist. Ct. App. 2005)

A good example of ERISA preemption can be seen in this case where the "employer provides contributions ... to help [participants] pay for some of [their] elections, the plan . . . is subject to ERISA." De Aza v. Humana, Inc., 07 20454 CIV HUCK, 2007 WL 1128893 (S.D. Fla. Apr. 16, 2007)

Because Plaintiff's breach of contract claim is preempted by federal Medicare law, and because Plaintiff has not yet presented his claim to the Secretary or exhausted his claim through the administrative appeals process, the Court is deprived of subject matter jurisdiction over the breach of contract claim. Kaye v. Humana Ins. Co., 08-80819-CIV, 2009 WL 455438 (S.D. Fla. Feb. 23, 2009)

A state common law claim for breach of contract is removable if it relates to an ERISA plan. Four elements are required for complete preemption: 1) there must be a relevant ERISA plan; 2) plaintiff must have standing to sue under that plan; 3) the defendant must be an ERISA entity; and 4) the complaint must seek compensatory relief akin to that available under 29 U.S.C. § 1132(a)

Riverside Med. Associates v. Humana, Inc., 06-61490-CIV-COHN, 2006 WL 3827541 (S.D. Fla. Dec. 28, 2006)

A medical service provider may bring a cause of action as a third-party beneficiary to the contract between the health maintenance organization and its subscriber based on allegations that the health maintenance organization failed to comply with section 641.3155, Florida Statutes (2001), the “prompt pay provisions” of the Health Maintenance Organization Act.

Found. Health v. Westside EKG Associates, 944 So. 2d 188, 191 (Fla. 2006)

See also;
We conclude that service providers, claiming as third party beneficiaries under a subscriber's contract, may bring an action founded on the HMOs' failure to comply with the prompt pay provisions of the Act.

Westside EKG Assocs. v. Found. Health, 932 So. 2d 214, 220 (Fla. Dist. Ct. App. 4th Dist. 2005)

Hospital brought action . . . seeking an interpretation of statute governing reimbursement non-contracted HMO. Usual and customary reimbursement is the amount to be reimbursed. Baker Cnty. Med. Servs., Inc. v. Aetna Health Mgmt., LLC, 31 So. 3d 842 (Fla. Dist. Ct. App. 2010)

The Act requires that health maintenance organizations pay or deny a claim no later than 120 days after receipt. § 641.3155(2),(4), Fla. Stat. Failure to do so results in an uncontestable obligation that the health maintenance organization pay the claim to the health care provider. Id. See § 641.3155(4). Westside EKG Associates v. Found. Health, 932 So. 2d 214, 216 (Fla. Dist. Ct. App. 2005) approved, 944 So. 2d 188 (Fla. 2006)

641.3154(4) provides:


A provider ..., regardless of whether the provider is under contract with the health maintenance organization, may not collect or attempt to collect money from, maintain any action at law against or report to any credit agency a subscriber of an organization for payment of services for which the organizations is liable, if the provider in good faith knows or should know that the organization is liable.

Westside EKG Associates v. Found. Health, 932 So. 2d 214, 217 (Fla. Dist. Ct. App. 2005) approved, 944 So. 2d 188 (Fla. 2006)