division of workers’ compensation · •allows carrier’s to deviate from oir approved...

Division of Workers’ Compensation

Wednesday, August 14, 2019

Regulatory and Legislative Update

Andrew Sabolic

Assistant Director

[email protected]

850-413-1628

mailto:[email protected]

2019 Legislative UpdateHB 1399 – WC Reform, sponsored by Rep. Byrd

• Provides additional criteria to meet the definition of “specificity” for purposes of filing a PFB. Must also provide “evidence of good faith to resolve the dispute”.

• Explicitly requires the carrier to authorize or deny a request for medical authorization in 3 or 10 days after receipt, unless a material deficiency exists.

• Revises outpatient facility reimbursements: 160% of Medicare for scheduled surgeries and 200% of Medicare for non-scheduled surgeries. Adds a stop-loss provision to the schedule of per diem rates for inpatient services.

• Increases the combined maximum TTD and TPD durations to 260 weeks. Allows for additional 26 weeks of TTD if the IW has not reached MMI. Conforms to the Westphal Supreme Court decision.

• Requires carriers to report defense attorney costs to the OJCC.• Allows carrier’s to deviate from OIR approved workers’ compensation rates, up to 5%,

without prior approval from OIR.• Requires the Department to develop additional claims performance measures specifically

related to the quality, timeliness, and cost-effectiveness of the delivery of care to injured workers. The Department must also create a rating system for all by November 30, 2019 and publish the carrier performance results on its website beginning in fiscal year 2019/2020.

• Died in the House.

440.61 Insurance company performance measures and rating system

(1) The department shall develop performance measures and a rating system to document and rate the performance of insurance companies licensed to write workers' compensation insurance.

(2) The rating system must: (a) Include the capability of listing results by rating, searching by company or industry

group, and facilitating the comparison of companies. (b) Be designed to assist employers in choosing a workers' compensation insurance

company by making the insurance company's performances related to the quality, timeliness, and cost effectiveness of the delivery of care to injured workers transparent.

(c) Be completed by November 30, 2019.

(3) Beginning with the 2019-2020 fiscal year and for each fiscal year thereafter, the department shall make the results of the insurance companies' performances publicly available on the department's website.

2019 Legislative Update

Insurer Regulatory Report (IRR)• Developed in Spring of 2017

• Engages and informs regulated entities about their overall claims-handling performance

• Provides comparative data and industry trends

• Assists regulated entities in identifying key processes, policies, or practices that are instrumental in maintaining or improving performance levels

• Audit History

• Centralized Performance System Data

• Claims and Medical EDI Data

• Reimbursement Manual MRAs vs. Contracted Rate Medical Bill Payment Data

• Opioid Medication Data

• Injured Worker Feedback Data

• Assessment Data

• In the future: • PFB Data• Denial Data • Claim Cost Data

2019 Legislative UpdateSB 1636 – Workers’ Compensation Reform, sponsored by Sen. Perry

• Provides additional criteria to meet the definition of “specificity” for purposes of filing a PFB. Must also provide “evidence of good faith to resolve the dispute”.

• Increases the combined maximum TTD and TPD durations to 260 weeks. Allows for additional 26 weeks of TTD if the IW has not reached MMI. Conforms to the Westphal Supreme Court decision.

• Codifies the First District Court of Appeals opinion in the Miles case allowing an injured worker to contract with and directly pay an attorney. Requires the reporting of attorney fees and costs paid by the claimant directly to their attorney.

• Extends the timeframe from 30 to 45 days from the date a PFB is filed with the JCC for the attachment of E/C paid attorney fees.

• Allows the JCC, at its discretion, to award E/C paid attorney fees not to exceed $150 per hour should the percentage of benefits secured fee schedule is in adequate.

• Resolves the PEO “gap coverage” issue• Died in Senate.


HB 983 – Ratification of Department Rules relating to expanded workers’ compensation benefits for First Responders, sponsored by Rep. Casello and Sen. Book

• 69L-3.009 Injuries that Qualify as Grievous Bodily Harm of a Nature that Shocks the Conscience. Pursuant to section 112.1815, F.S., for purposes of determining the compensability of employment-related posttraumatic stress disorder for first responders, the following injuries qualify as grievous bodily harm of a nature that shocks the conscience:

(continues on next page)


(1) Decapitation (full or partial),

(2) Degloving,

(3) Enucleation

(4) Evisceration

(5) Exposure of one or moreinternal organs (a) Brain, (b) Heart, (c) Intestines, (d) Kidneys, (e) Liver, or (f) Lungs

(6) Impalement

(7) Severance (full or partial),and

(8) Third degree burn on 9% ormore of the body.

Adopted in December of 2018 with a ratification and effective date of:

June 25, 2019

Medical Cost Distribution

Three-Member Panel Draft Policy Recommendations

Outpatient Reimbursement:

As recommended in previous Biennial Reports, the Legislature should reduce reimbursements for outpatient services to rebalance system costs.

The Legislature should replace the charge-based reimbursement system for outpatient services in hospitals and ambulatory surgical centers with a percentage of Medicare or other alternative framework that adequately reimburses facilities and provides cost containment and reimbursement predictability.

Stop-Loss Per Diem


Inpatient Reimbursement:

The Legislature should establish specific per diem amounts and a stop-loss threshold to appropriately reimburse hospitals for catastrophic and complex injuries.

The new amounts and threshold should createlong-term cost-containment and reimbursement predictability.


Physician Reimbursement:

The Legislature should increase the percentage of Medicare rates paid to physicians.

The increase in physician reimbursements can be off-set by the justifiable decrease in reimbursements to hospitals and ambulatory surgical centers, as discussed in the previous sections.


Repackaged Drug Reimbursements:

Numerous states have sought to curtail the physician-dispensing of drugs to workers’ compensation patients, with some states banning the practice.

To avoid a repeat of the escalation of costs for physician-dispended drugs, which Florida experienced prior to 2013, the Legislature should require physicians to receive prior approval from insurance carriers to specifically dispense prescription drugs directly to workers’ compensation patients.


Legislative Ratification of the Reimbursement Manuals:

To promote the self-execution of the workers’ compensation system, the Legislature should either exempt the reimbursement manuals from legislative ratification or establish a maximum cost impact percentage threshold for each reimbursement manual for which ratification is not required.

Medical AuthorizationAttorney Fees


Medical Authorization:

The Legislature should amend section 440.13(3)(d), F.S., to clarify the term “respond” as that term does not definitively obligate carriers to render a decision on a request for authorization in a consistent manner.

The Legislature should also consider modifying a carrier’s 3-day and 10-day “response” deadline to expedite requested medical treatment based on a physician’s use of evidence-based treatment guidelines.


Treatment Guidelines:

At a minimum, the Legislature should repeal subsection 440.13(14), F.S. and all the references to practice parameters and protocols contained in section 440.13, F.S.

If the Legislature still supports in the merits of evidence-based treatment guidelines, subsection 440.13(15), F.S., Standards of Care should be amended to include the use evidence-based treatment guidelines in providing medical care to injured workers, and all references to practice parameters and protocols should be eliminated.

Opportunities for Industry Improvement

Charlene Miller

Bureau Chief

Monitoring & Audit

Lisel Laslie

Bureau Chief

Employee Assistance & Ombudsman Office

Our Roles & ResponsibilitiesMonitoring & Audit• Ensuring the timely and accurate payment of benefits to injured workers

• Timely and accurate filing and payment of medical bills

• Timely and accurate filing of required claims forms and other electronic data

• Responsible for ensuring that the practices of insurers and claims handling entities meet the requirements of Chapter 440 F.S. and the Florida Administrative Code

• Efficiently and effectively collecting and storing data to provide accurate, meaningful, timely, and readily accessible information to all stakeholders

• Facilitates data distribution to other Division bureaus

• Manages high volumes of data from claims-handling entities and vendors for Claims, Medical and Proof of Coverage data as required by Chapter 440, F.S. and the Florida Administrative Code

Our Roles & ResponsibilitiesEmployee Assistance & Ombudsman• Investigates disputes and facilitates resolution without undue expense,

costly litigation or delay in the provision of benefits.• Assists system participants in fulfilling their statutory responsibilities.• Educates and disseminates information to all system participants.• Initiates contacts with injured workers to discuss their rights and

responsibilities and advise them of services available through EAO.• Reviews claims in which injured workers' benefits have been denied,

stopped, or suspended.• Provides reemployment services to eligible injured employees who are

unable to return to work as a result of their work place injuries or illnesses.

• Provides for collection, distribution and archival of the Division' s imaged records.

• Provides public record information.• Responds to requests for Division data

Opportunities for Industry Improvement

•Medical Authorization

• IRR

• Training

Medical Authorization 440.13 (3) (d); (i) F.S.(d) A carrier must respond, by telephone or in writing, to a request for authorization from an authorized health care provider by the close of the third business day after receipt of the request. A carrier who fails to respond to a written request for authorization for referral for medical treatment by the close of the third business day after receipt of the request consents to the medical necessity for such treatment. All such requests must be made to the carrier. Notice to the carrier does not include notice to the employer.

(i) Notwithstanding paragraph (d), a claim for specialist consultations, surgical operations, physiotherapeutic or occupational therapy procedures, X-ray examinations, or special diagnostic laboratory tests that cost more than $1,000 and other specialty services that the department identifies by rule is not valid and reimbursable unless the services have been expressly authorized by the carrier, unless the carrier has failed to respond within 10 days to a written request for authorization, or unless emergency care is required. The insurer shall authorize such consultation or procedure unless the health care provider or facility is not authorized, unless such treatment is not in accordance with practice parameters and protocols of treatment established in this chapter, or unless a judge of compensation claims has determined that the consultation or procedure is not medically necessary, not in accordance with the practice parameters and protocols of treatment established in this chapter, or otherwise not compensable under this chapter. Authorization of a treatment plan does not constitute express authorization for purposes of this section, except to the extent the carrier provides otherwise in its authorization procedures. This paragraph does not limit the carrier’s obligation to identify and disallow overutilization or billing errors.

• Determining Medical Authorization

• Procedures for receiving, reviewing, documenting, and responding to requests for authorization

• Communicating

• Stories

Medical Authorization (continued)

Insurer Regulatory Report (IRR)

• Used to help further engage and inform regulated entities

• Provides comparative data and industry trends

• Used to identify key processes, policies, or practices

• Instrumental in the entity maintaining or improving its performance level

TrainingStart your claims out right

• 3 point contact

• Brochures and letters mailed

• Communicate with providers

• Open lines of communication with the employer

• Talk with the injured worker or their representative about what is happening

Other training for staff can include:

• A set of best practices to use as a guide

• Setting and maintaining accurate reserves

• Making timely payments for indemnity and medical bills

• Importance of communication

• Filing appropriate forms with the jurisdiction

• Meeting to evaluate the claims itself

Contact Us for Training or Questions

For Claims Training contact:[email protected]

For Claims EDI contact:[email protected]

For Medical Submitter training contact:[email protected]

Employer Coverage and Medical Requests for Assistance Questions:[email protected]

Injured Worker Email Questions:[email protected]

Reemployment Services Questions:[email protected]







EAO Contacts:Bureau Chief, Employee Assistance & Ombudsman Office

[email protected]

(850) 413-1737

Sr. Management Analyst Supervisor – Ombudsman Team & Re-employment

[email protected]

(850) 413-1638

Insurance Administrator- Injured Worker Hotline/First Report Team

[email protected]

(800) 342-1741 ext. 43243

Insurance Administrator- Records Management

Stuart. [email protected]

(850) 413-1704





M&A Contacts:

Bureau Chief, Bureau of Monitoring & Audit

[email protected]

(850) 413-1738

Operations Management Consultant

[email protected]

(850) 413-1671

Operations Management Consultant

[email protected]

(850) 413-1701




Understanding the “New” Medical Reimbursement

Dispute Process

Theresa Pugh

Program Administrator

Medical Services Section

Discussion Topics69L-7 Rule Series: Workers’ Compensation Medical Reimbursement and Utilization Review

69L-8 Rule Series: Selected Materials Incorporated by Reference

69L-7.100: Reimbursement Manual for Ambulatory Surgical Centers

69L-7.020: Healthcare Provider Reimbursement Manual

69L-7.501: Reimbursement Manual for Hospitals

69L-30: Expert Medical Advisors

69L-31: Utilization and Reimbursement Dispute Rule

69L-34: Carrier Report of Health Care Provider Violations

Workers’ Compensation Medical Reimbursement and Utilization Review, 69L-7 Rule Series

• Effective as of February 18, 2016

• No Change

69L-7

7.710

7.720

7.7307.740

7.750


Five separate rules:

69L-7.710: Definitions

69L-7.720: Forms Incorporated by Reference

69L-7.730: Health Care Medical Billing and Reporting Responsibilities

69L-7.740: Insurer Authorization and Medical Bill Review Responsibilities

69L-7.750: Insurer Electronic Medical Report Filing to the Division


69L-7.740: Insurer Responsibilities:

• 45 days to adjudicate and issue EOBR

• Unless returning the bill to the provider under provisions of 7.740(11)(c); or

• EOBR not required for bills for pharmaceutical services provided by pharmacist or pharmacy on which a binding contract exists


An EOBR meets the requirements of 69L-7.740(14), F.A.C.,if it contains the following elements:• The insurer’s name• Insurer’s mailing address • Division issued insurer number• Statement that “the EOBR constitutes notice of disallowance or adjustment of

payment within the meaning of Section 440.13(7), F.S.”• The name of the carrier’s designee to receive service of a copy of a petition on

behalf of the “carrier and all affected parties” pursuant to Section 440.13(7)(a), F.S.• The mailing address of the carrier’s designee to receive service of a copy of a

petition on behalf of the “carrier and all affected parties” pursuant to Section 440.13(7)(a), F.S.

• EOBR codes as specified in 69L-7.740(13), F.A.C.• EOBR descriptors as specified in 69L-7.740(13), F.A.C. (commonly accepted

abbreviations may be used)


Florida specific EOBR codes and descriptors• Use the appropriate FL EOBR Code for each line item• Internal reason codes may be appended in addition to Florida specific

EOBR codes• EOBR Code 10 versus EOBR Code 11• EOBR Code 10 = total denial• EOBR Code 11 = partial denial• Medical Necessity EOBR Codes• 21, 22, 23, 24, and 25• EOBR Code 30 is for lack of authorization• Paid per Manual Codes• 90, 91, and 92• Original intent was not to be used for adjusted or disallowed line items


Non-payment complaints

• When an accurately completed medical bill is submitted to a carrier for authorized medical treatment or service and the carrier fails to adjudicate the bill and issue a compliant EOBR within 45 days

Contact us at: [email protected]


Selected Materials Incorporated by Reference,69L-8 Rule Series

Rule Chapter 69L-8 currently contains the following:

• 69L-8.071: Materials for use with the Florida Workers’ Compensation Health Care Provider Reimbursement Manual

• 69L-8.072: Materials for use with the Florida Workers’ Compensation Reimbursement Manual for Ambulatory Surgical Centers

• 69L-8.073: Materials for use with the Florida Workers’ Compensation Hospital Reimbursement Manual

• 69L-8.074: Materials for use throughout Rule Chapter 69L-7, F.A.C.

Selected Materials Incorporated by Reference, 69L-8 Rule Series

69L-8.071 and 69L-8.074

• No change. Effective January 01, 2018

69L-8.072 and 69L-8.073

• No change. Effective February 18, 2016

Selected Materials Incorporated by Reference,69L-8 Rule Series

• The contents of these rules have been moved to the individual reimbursement manual rule texts

• When manuals are adopted, the 8 rule series will be withdrawn

Reimbursement Manuals

Reimbursement Manual for Ambulatory Surgical Centers,

Rule 69L-7.100, 2018 Edition, F.A.C.

• Workshop held August 24, 2018

• Hearing held November 27, 2018

• The 2015 edition remains in effect

• Rule development process ongoing

Reimbursement Manual for Ambulatory Surgical Centers, 2019 Edition , Rule 69L-7.100, F.A.C.

Healthcare Provider Reimbursement Manual, Rule 69L-7.020, 2018 Edition, F.A.C.

• Workshop held August 24, 2018

• Hearing held November 27, 2018

• 2016 edition remains in effect

Healthcare Provider Reimbursement Manual, 2019 Edition, Rule 69L-7.020, F.A.C.


Hospital Reimbursement Manual Rule 69L-7.501, 2018 Edition, F.A.C.

• Workshop held November 27, 2018

• The 2014 edition remains in effect

Hospital Reimbursement Manual, 2019 Edition, Rule 69L-7.501, F.A.C.


Expert Medical Advisors, Rule 69L-30, F.A.C.

• Effective May 18, 2017

• No change

Expert Medical Advisors• About 148 Expert Medical Advisors

• We need EMAs in the following specialties• Internal Medicine

• Neurology and Psychiatry

• Pain Management

• Anesthesiology

• Florida DWC EMA Website: • Apply for EMA certification:

https://msuwebportal.fldfs.com/

• Search EMA database:https://apps.fldfs.com/provider/

https://msuwebportal.fldfs.com/

https://apps.fldfs.com/provider/

Utilization and Reimbursement Dispute Rule, Rule 69L-31, F.A.C.

69L-31.003 Petition Form69L-31.004 Carrier Response Form69L-31.005 Petition Requirements69L-31.006 Consolidation of Petitions69L-31.007 Service of Petition on Carrier and Affected Parties69L-31.008 Computation of Time69L-31.009 Carrier Response Requirements69L-31.010 Effect of Non-Response by Carrier69L-31.011 Complete Record69L-31.012 Joint Stipulation of the Parties69L-31.013 Petition Withdrawal69L-31.014 Overutilization Issues Raised in Reimbursement

Dispute Resolution69L-31.015 Managed Care Arrangements (Repealed)

Utilization and Reimbursement Dispute Rule, 69L-31, F.A.C.

Workshop 1/12/16

Workshop 6/10/16

Hearing 1/05/17

Notice of Change 5/02/17

Rule Challenge 5/25/17

Workshop 2/23/18

Workshop 5/30/18

Hearing 8/15/18

Hearing 11/27/2018


Post Rule Challenge

• Processing petitions using provisions in current effective 69L-31 (effective 6/26/2008)• Contract, Compensability and Medical Necessity cases

• Determinations issued after 8/2015 until late 11/2017 reworked


Workshop pending

• NODs remain

• Medical Necessity• EMA will be used when both petitioner and carrier have submitted

the required supporting documentation to the Division

• EOBR Codes 10 & 11• Copy of the DWC-12, Notice of Denial must be part of

supporting documentation


42%

11%15%

32%

Petitions Received FY 2018 - 2019(Over 3,300 total)

HCP ASC Hopsital IP Hospital OP


81%

19%

HCP Petitions FY 2018 - 2019

Dispensing Physician Other


183

175

1383235

3434

317

Petitioner NOD ReasonsFY 2018 - 2019

Form missing

HCP name & address USPS Certified Mail Receipt

Submit all pages of EOBR Other


76

2096

85

Carrier NOD ReasonsFY 2018 - 2019

Detailed breakdown of calculation missing Carrier response form missing

Other


455

478

12584 70

Petition Dismissal Reasons FY 2018 - 2019

NOD Not Cured Withdrawn Filed Late No Jurisdiction Other

Carrier Report of Health Care Provider (HCP) Violations Rule 69L-34, F.A.C.

General Violation types:

• Improper Billing of Services

• Improper Reporting of Services

• Improper Form Completion

• Standards of Care Violation, including overutilization

Referral Submission Types:• Manual- Form DFS-F6-DWC-2000, Health Care Provider

Violation Referral

• Health Care Provider Violations Website:https://apps8.fldfs.com/hcprov/default.aspx

https://apps8.fldfs.com/hcprov/default.aspx

Carrier Report of Health Care Provider (HCP) Violations Rule 69L-34, F.A.C.

Must be submitted to the Division no later than 180 days after the issuance of an EOBR or other notice of alleged violation

▪ Include all supportive documentation of the specific violation:• Correspondence and written requests between carrier and

provider • Copies of medical bills and DWC-25 forms• Copies of notices of disallowance or adjustment• Peer review reports• Copies of collection letters• Determinations issued by the Division

HCP Violation Breakdown:Referral by Violation Type FY 2018 - 2019

6

3

7

9

Collecting payment from injured worker Improper billing of services

Improper reporting Standards of care/overutilization

HCP Violation Breakdown: By Referral TypeFY 2018 - 2019

2

21

2

Injured Employee Carrier Attorney

M&A, Medical Services Section Contact:

Medical Services, Program Administrator

[email protected]

(850) 413-1613

Customer Assistance

[email protected]

(850) 413-1613



Performance of theWorkers’ Compensation

and the Obstacles to Self-Execution

Performance Measures, Results, Obstacles, and Solutions

For Employers, Injured Workers, Health Care Providers,

and Carriers

Audience Participation is Required!

Employers’ PerspectiveWhat they want = performance?• Affordable WC rates• Coverage availability• Levels playing field/play by the rules• Reduce unnecessary system costs• Others?

Obstacles to self-execution• Lack of knowledge of coverage and

compliance requirements• Lack of understanding of the insurance

policy and the benefit delivery system• Others?

Results• 65% decrease in rates since 2003• Market stability; 267 carriers writing WC

insurance• Strongest coverage and compliance laws

in the nation• Higher than average facility

reimbursements and payments to doctors who dispense medication

• Higher than average litigation rates; however, 92% of cases are not litigated

• Others

Solutions??

Injured Workers’ PerspectiveWhat they want = performance?• Adequate benefits• Timely and appropriate treatment• Return to gainful employment ASAP• Treated with dignity by the employer

and carrier• Others?

Obstacles to self-execution• Lack of understanding of their benefits

and the claims process• Unrealistic expectations • Fear• Others?

Results• Lower than average statutory benefits• Medical authorization is the #1 issue

listed on a PFB• Poor or non-existent communication

with claims handling personnel is one of the major reasons IWs hire an attorney

• Mid 90% RTW rates within 1 year of injury

• Others

Solutions??

Health Care Providers’ PerspectiveWhat they want = performance?• Increased reimbursement for doctors

and other practitioners• Timely and accurate payment of their

medical bills• Streamlined medical authorization

process• Others?

Obstacles to self-execution• Practitioner communication with IW and

carrier• Lack of understanding of the applicable

network arrangements• Improper use of the DWC-25• Medical reimbursement re-alignment• Others?

Results• Lower than average reimbursement for

practitioners based upon statutory % of Medicare fee schedule

• 98%-99% of all medical bills are paid within 45 days of carrier receipt

• Medical authorization is the #1 issue listed on a PFB

• Inconsistent use of EOBRs• Misapplication of contract provisions

governing reimbursement• Others?

Solutions??

Carriers’ PerspectiveWhat they want = performance?• Rate adequacy• Reduce unnecessary system costs• Predictive and stable regulatory

environment• Timely and accurate payment of

benefits• Others?

Obstacles to self-execution• Perceived or real disconnection between

carriers, IWs, health care providers, and 3rd party intermediaries

• Inadequate resources to effectively manage claims

• Ambiguous statutes or administrative rules

• Others?

Results• Market stability; 267 carriers writing WC

insurance• Higher than average facility

reimbursements and payments to doctors who dispense medication

• Higher than average litigation rates; however 92% of cases are not litigated

• Others

Solutions??

Questions

division of workers’ compensation · •allows carrier’s to deviate from oir approved...

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