Florida Administrative Code
69 - DEPARTMENT OF FINANCIAL SERVICES
69O - OIR - Insurance Regulation
Chapter 69O-153 - DECEPTIVE INSURANCE PRACTICES
Section 69O-153.003 - Example of a False Claim

The submission or presentation for payment to an insurer, health maintenance organization or third party of a claim form, bill, or other statement for services rendered, prepared or signed by a health care provider or health care facility which does not disclose a pre-provision of services agreement between the health care provider or health care facility and the patient to accept less for the health care services rendered than is reflected on the claim form, bill or statement is an example of a false claim. The submission of a claim form, bill or other statement shall not be considered a false claim merely because the application of a federal or state statutory sliding-scale fee or other federal or state mandated statutory discount for health care services rendered has not been disclosed. The submission of a claim form, bill or other statement shall, also, not be considered a false claim because of failure to disclose the forgiveness or writing-off of all or any portion of the unpaid deductible portion of the patient's bill after reasonable collection efforts have been made. The disclosure of the existence of a pre-provision of services agreement in accordance with Rule 69O-153.004, F.A.C., neither precludes nor requires an insurer, health maintenance organization, or other third party from considering that agreement in determining the actual or usual and customary charge under the terms of the insurance policy, or health maintenance organization coverage document.

Specific Authority 626.9611, 641.36 FS. Law Implemented 624.307(1), 626.9541(1)(u), 641.3903(11) FS.

New 2-28-90, Formerly 4-86.003, 4-153.003.