CopyCited 23 times | Published | Supreme Court of Florida
...racts. Nonetheless, as a number of other provisions reveal, the "prompt pay provision" serves an integral role in providing substance or structure to the rights of subscribers and the responsibilities of HMOs established in the HMO Act. For example, section 641.3154 states that an HMO "is liable for services rendered to an eligible subscriber by a provider if the provider follows the [HMO]'s authorization procedures and receives authorization," § 641.3154(2); and that if an HMO is liable for services rendered, "regardless of whether a contract exists between the [HMO] and the provider . . . the subscriber is not liable for payment of fees to the provider." § 641.3154(1)....
CopyCited 9 times | Published | Florida 4th District Court of Appeal | 2005 WL 1026183
...ons for all failures to comply with the Act, and particularly as to its prompt pay provisions. To so hold would require that we disregard other provisions of the Act that recognize or anticipate the existence of parallel legal remedies. Furthermore, section 641.3154(4) provides: A provider ....
...Application of Villazon in this manner would restrict unpaid service providers to relief by administrative proceedings to resolve violations of the Act, under sections 408.7056 and
408.7057, while leaving HMOs free to sue to determine by litigation if the HMO is liable for payment. See §
641.3154(4)(b), Fla....
...[2] HMOs acknowledge that the Act contemplates non-contract, as well as contract, providers rendering services to subscribers, and that the legislature intended that non-contract providers stand on an equal footing with contract providers in enforcing their right to payment. See § 641.3154(4), Fla....
CopyCited 8 times | Published | Florida 3rd District Court of Appeal | 2008 Fla. App. LEXIS 5506, 2008 WL 1733673
...embers by PPS's in-hospital laboratories. [4] Again, however, those stipulated payments did not include a component for reimbursement of PPS's disputed services. As a "non-participating provider" of these services, PPS was nonetheless prohibited (by section 641.3154(4), Florida Statutes (2007)) from directly billing HOI's members if PPS knew or should have known that HOI was liable for payment....
...me a part of the contract. Id. at 195. [6] HOI argues that the statutes and regulations relied upon by the trial court, even if incorporated within the HOI-member contracts, do not obligate HOI to pay for the disputed services. HOI maintains that subsection 641.3154(2) requires a reversal of the directed verdict....
...Additionally, the trial court heard undisputed evidence that HOI never made an issue regarding the authorization of the pathology tests when HOI received claims from PPS. The dispute relates to the amount of money payable for the tests, not authorization or medical necessity. Subsection 641.3154(1) provides that an HMO is liable for services rendered by a provider to an HMO member whether there is a contract between the HMO and the provider....
...[5] Employee Retirement Income Security Act of 1974. See 29 U.S.C. § 18. [6] In this case, HOI's member contracts are expressly subject to "all applicable state and federal laws and regulations." The contracts do not exclude either the "prompt pay" provision (section
641.3155) or subsection
641.3154(1), Florida Statutes (2005)....
CopyCited 2 times | Published | District Court, S.D. Florida | 2006 U.S. Dist. LEXIS 76811, 2006 WL 3059883
...The Court reserves jurisdiction over the issue of costs. The Clerk of the Court is instructed to CLOSE the case and any pending motions are DENIED AS MOOT. NOTES [1] Sheridan alleges that NHP's failure to pay Sheridan for services rendered to NHP members, in violation of Fla. Stat. § 641.3154, and NHP's failure to pay Sheridan's "clean claims" that were filed electronically within a 120-day period, violate Fla....
CopyPublished | Florida 5th District Court of Appeal | 2010 Fla. App. LEXIS 556, 2010 WL 322156
...s of a health maintenance organization plan may balance bill the subscribers for the unpaid portion of its statements for medical services that have not been paid by the health maintenance organization. We agree with the trial court that in light of section 641.3154, Florida Statutes (2007), the provider *142 may not balance bill the subscriber, and affirm....
...JLR received and retained each payment, but denied that the payments fully satisfied its statements, and then sent bills to the subscribers for the balance not paid by Florida Health Care. JLR refers to this as "balance billing." The patients brought suit seeking a declaratory judgment that JLR's balance billing violated section 641.3154, Florida Statutes (2007), and that balance billing violated Florida's Unfair Trade and Deceptive Practices Act under Chapter 501, Florida Statutes....
...ct exists between the HMO and the provider. The statute is quite specific in providing that a health maintenance organization is liable for payment of fees to the provider, and that a subscriber is not liable for payment of fees to the provider. See § 641.3154, Fla. Stat. More specifically, section 641.3154(4) reads as follows: A provider or any representative of 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...
...ber; JLR submitted its bill for each patient/subscriber to Florida Health Care using *144 the appropriate authorization number; Florida Health Care paid some part of the bill directly to JLR; and JLR retained the payments. Thus, JLR was forbidden by section 641.3154(4) to balance bill the patient/subscribers. JLR argues, however, that the second sentence of section 641.3154(4) modifies the first, so that the prohibition against balance billing only applies "during the pendency of any claim made by the provider to the organization for payment of the services and any legal proceedings or dispute resolution process" resulting from the claim....
...entence by saying, "This prohibition only applies during the pendency of any claim...." Accordingly the plain reading of the statute convinces us of this interpretation. Second, we have previously held with respect to section
641.315, a precursor to section
641.3154, that the statute provides that only the HMO is liable for services rendered, not the subscriber or insured....
...tory and other relief in an effort to recover additional payments for the disputed services. The court noted during the course of its opinion that: As a "non-participating provider" of these services, [pathology group] was nonetheless prohibited (by section 641.3154(4), Florida Statutes (2007)) from directly billing [health maintenance organization] members if [pathology group] knew or should have known that [the organization] was liable for payment....
...Palmetto Pathology Servs., P.A.,
983 So.2d 608, 612 (Fla. 3d DCA), review denied,
994 So.2d 1104 (Fla.2008). JLR contends, however, that because it did not specifically seek or obtain Florida Health Care's authorization prior to performing its medical services, its rights are governed not by section
641.3154(4), but by section
641.3156(1)....
