Legislation seeks mandatory participation of health insurers in claims processing

by | Nov 28, 2023



  • A pair of Florida lawmakers filed companion bills this week that would require health insurance providers to participate in filed claims. 
  • Non-compliance with the provisions, should they be adopted, would result in a default against the health plan. 
  • The House bill, brought forth by Rep. Shane Abbott, also imposes penalties on health plans that fail to comply with agency orders to pay providers following claim disputes.

A pair of Florida lawmakers filed companion bill proposals this week that would tighten regulations on health insurance providers, focusing on their involvement in claims disputes and payment obligations.

House Bill 659, introduced by Rep. Shane Abbott, outlines amendments to preexisting state statutes that, if adopted, would prohibit health insurance providers from declining participation in filed claims, with non-compliance resulting in a default against the health plan.

The Senate version of the legislation, brought forth by Sen. Gayle Harrell, while largely identical, details that providers would be required to submit supporting documentation for their position in a dispute within 15 days upon request, with failure to do so also resulting in a default.

“A health plan may not decline to participate in the claim-dispute-resolution process,” reads Abbott’s filing.

In addition to mandating participation in claims, the bills would establish penalties for health plans that fail to comply with agency orders to pay providers following claim disputes. If a health plan, under the House bill, does not pay the ordered amount within 35 days of the agency’s order, it faces a potential penalty of up to $500 per day until the payment is made.

“A health plan that does not prevail in the agency’s order shall pay the provider the amount provided in the order within 35 days after the order is entered,” Abbott’s bill continues. “A health plan that does not pay the required amount within this timeframe is subject to a penalty of not more than $500 per day until the amount is paid.”

Another key component of the bill concerns health insurance and health maintenance organization (HMO) identification cards. The legislation mandates these cards to carry detailed information, including the claim processor’s name and payor identification number. Cards issued or reissued after January 1, 2025, must also include a “FL” designation and a QR code linking to the consumer services website of the Division of Consumer Services for state-regulated plans.

The filings ahead of the coming Legislative Session help to shape Senate President Kathleen Passidomo’s desire to hone in on improvements to the state’s healthcare ecosystem, citing a growing population and subsequent ballooning demand.

In a memorandum sent to lawmakers this month, the Senate President directed attention to what she referred to as the inadequacy of insurance coverage alone in guaranteeing access to healthcare and identified technology as a potential tool to refine healthcare workforce productivity and delivery.

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