Florida Statute 641.3154 | Lawyer Caselaw & Research

The 2024 Florida Statutes

Title XXXVII
INSURANCE

Chapter 641
HEALTH CARE SERVICE PROGRAMS

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F.S. 641.3154

641.3154 Organization liability; provider billing prohibited.—

(1) If a health maintenance organization is liable for services rendered to a subscriber by a provider, regardless of whether a contract exists between the organization and the provider, the organization is liable for payment of fees to the provider and the subscriber is not liable for payment of fees to the provider.

(2) For purposes of this section, a health maintenance organization is liable for services rendered to an eligible subscriber by a provider if the provider follows the health maintenance organization’s authorization procedures and receives authorization for a covered service for an eligible subscriber, unless the provider provided information to the health maintenance organization with the willful intention to misinform the health maintenance organization.

(3) The liability of an organization for payment of fees for services is not affected by any contract the organization has with a third party for the functions of authorizing, processing, or paying claims.

(4) 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 at law against, or report to a credit agency a subscriber of an organization for payment of services for which the organization is liable, if the provider in good faith knows or should know that the organization is liable. This prohibition applies during the pendency of any claim for payment made by the provider to the organization for payment of the services and any legal proceedings or dispute resolution process to determine whether the organization is liable for the services if the provider is informed that such proceedings are taking place. It is presumed that a provider does not know and should not know that an organization is liable unless:

(a) The provider is informed by the organization that it accepts liability;

(b) A court of competent jurisdiction determines that the organization is liable; or

(c) The agency issues a final order that the organization is required to pay for such services subsequent to a recommendation made by a resolution organization pursuant to s. 408.7057.

(5) An organization, the office, and the department shall report any suspected violation of this section by a health care practitioner to the Department of Health and by a facility to the agency, which shall take such action as authorized by law.

History.—s. 2, ch. 2000-252; s. 11, ch. 2002-389; s. 1583, ch. 2003-261; s. 14, ch. 2004-297; s. 113, ch. 2018-24.

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Amendments to 641.3154

Arrestable Offenses / Crimes under Fla. Stat. 641.3154

Level: Degree
Misdemeanor/Felony: First/Second/Third

Current data shows no reason an arrest or criminal charge should have occurred directly under Florida Statute 641.3154.

Annotations, Discussions, Cases:

Cases Citing Statute 641.3154

Total Results: 4

Joseph L. Riley Anesthesia Associates v. Stein

Court: Fla. Dist. Ct. App. | Date Filed: 2010-01-29T00:00:00-08:00

Citation: 27 So. 3d 140, 2010 Fla. App. LEXIS 556, 2010 WL 322156

Snippet: to the provider. See § 641.3154, Fla. Stat. More specifically, section 641.3154(4) reads as follows: A… with the trial court that in light of section 641.3154, Florida Statutes (2007), the provider *142 may…that JLR's balance billing violated section 641.3154, Florida Statutes (2007), and that balance billing…the payments. Thus, JLR was forbidden by section 641.3154(4) to balance bill the patient/subscribers. JLR…, however, that the second sentence of section 641.3154(4) modifies the first, so that the prohibition

HEALTH OPTIONS v. Palmetto Pathology Servs.

Court: Fla. Dist. Ct. App. | Date Filed: 2008-04-16T00:53:00-07:00

Citation: 983 So. 2d 608

Snippet: services, PPS was nonetheless prohibited (by section 641.3154(4), Florida Statutes (2007)) from directly billing…disputed services. HOI maintains that subsection 641.3154(2) requires a reversal of the directed verdict…authorization or medical necessity. Subsection 641.3154(1) provides that an HMO is liable for services…quot; provision (section 641.3155) or subsection 641.3154(1), Florida Statutes (2005). [7] These rules

Foundation Health v. WESTSIDE EKG ASSOC.

Court: Fla. | Date Filed: 2006-10-19T00:00:00-07:00

Citation: 944 So. 2d 188

Snippet: established in the HMO Act. For example, section 641.3154 states that an HMO "is liable for services…procedures and receives authorization," § 641.3154(2); and that if an HMO is liable for services …liable for payment of fees to the provider." § 641.3154(1). Section 641.3156(1) requires HMOs to pay &

Westside EKG Associates v. Foundation Health

Court: Fla. Dist. Ct. App. | Date Filed: 2005-05-04T00:00:00-07:00

Citation: 932 So. 2d 214

Snippet: parallel legal remedies. Furthermore, section 641.3154(4) provides: A provider . . ., regardless of whether…litigation if the HMO is liable for payment. See § 641.3154(4)(b), Fla. Stat. We note that if such was the…providers in enforcing their right to payment. See § 641.3154(4), Fla. Stat. Failure to allow providers to enforce