Florida/Georgia Personal Injury & Workers Compensation

...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). Section 641.3156(1) requires HMOs to pay "any hospital-service or referral-service claim for treatment for an eligible subscriber which was authorized" by an appropriate person and in an appropriate manner. In fact, "[a] claim for treatment may not be denied" in this situation, "unless the provider provided information to the [HMO] with the willful intention to misinform the [HMO]." § 641.3156(2)....

...regulate these practices and provide grievance procedures for claims review. See, e.g., Fla. Stat. § 627.4234 (Health care plans "must contain one or more ... procedure or provisions to contain health insurance costs or cost increases"); Fla. Stat. § 641.3156 (prohibiting arbitrary denial of claims), Tex....

...The trial court noted that JLR billed Florida Health Care using the assigned authorization number for each subscriber, and that because Florida Hospital had a contract with Florida Health Care, it was empowered to authorize or direct the provision of JLR's anesthesia services to Florida Health Care members pursuant to section 641.3156(1). When the trial court reviewed section 641.3156(1), it found that under that statute a health maintenance organization was liable for services to a subscriber/patient by a provider, regardless of whether a contract existed between the health maintenance organization and the provider....

...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)....

...contract with Florida Health Care to render services. Thus, according to JLR, because it did not follow the authorization procedures articulated by Florida Health Care, JLR was not in a contract position with the health maintenance organization, and section 641.3156 required Florida Health Care to pay whatever bill JLR sent them without diminishment....