Senate Bill 1026
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Florida Senate - 1998 SB 1026
By Senator Williams
4-1036-98
1 A bill to be entitled
2 An act relating to workers' compensation;
3 amending s. 440.13, F.S.; providing that the
4 fee schedules adopted under chapter 440, F.S.,
5 are the maximum fees allowed under a workers'
6 compensation managed care arrangement;
7 specifying circumstances under which an
8 additional fee may be paid to a health care
9 provider as part of a risk-sharing arrangement;
10 revising requirements for the Agency for Health
11 Care Administration in adopting practice
12 parameters; amending s. 440.134, F.S.;
13 providing definitions; prohibiting the agency
14 from adopting rules that give a preference to
15 any type of organization; providing additional
16 procedures for handling informal and formal
17 grievances; providing certain time limitations;
18 requiring that a workers' compensation managed
19 care arrangement notify its employees of the
20 right to file a petition for benefits with the
21 Division of Workers' Compensation of the
22 Department of Labor and Employment Security;
23 providing an effective date.
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25 Be It Enacted by the Legislature of the State of Florida:
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27 Section 1. Subsections (14) and (15) of section
28 440.13, Florida Statutes, are amended to read:
29 440.13 Medical services and supplies; penalty for
30 violations; limitations.--
31 (14) PAYMENT OF MEDICAL FEES.--
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1 (a) Except for emergency care treatment, fees for
2 medical services are payable only to a health care provider
3 certified and authorized to render remedial treatment, care,
4 or attendance under this chapter. A health care provider may
5 not collect or receive a fee from an injured employee within
6 this state, except as otherwise provided by this chapter. Such
7 providers have recourse against the employer or carrier for
8 payment for services rendered in accordance with this chapter.
9 (b) Fees charged for remedial treatment, care, and
10 attendance may not exceed the applicable fee schedules adopted
11 under this chapter, which are the maximum reimbursements
12 allowed under a workers' compensation managed care
13 arrangement. However, the applicable fee schedule does not
14 restrict the right of an insurer, self-insurance fund,
15 individually self-insured employer, or assessable mutual
16 insurer to agree to pay additional compensation to a health
17 care provider as part of a contract that provides a
18 risk-sharing arrangement between the insurer, self-insurance
19 fund, individually self-insured employer, or assessable mutual
20 insurer and the provider, or that provides any other incentive
21 for successfully returning an injured employee to work.
22 (c) Notwithstanding any other provision of this
23 chapter, following overall maximum medical improvement from an
24 injury compensable under this chapter, the employee is
25 obligated to pay a copayment of $10 per visit for medical
26 services. The copayment does shall not apply to emergency care
27 provided to the employee.
28 (15) PRACTICE PARAMETERS.--
29 (a) The Agency for Health Care Administration, in
30 conjunction with the division and appropriate health
31 professional associations and health-related organizations
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1 shall develop and may adopt by rule scientifically sound
2 practice parameters for medical procedures relevant to
3 workers' compensation claimants, which must be prepared by
4 nationally recognized health care institutions and
5 professional organizations. Practice parameters developed
6 under this section must focus on identifying effective
7 remedial treatments and promoting the appropriate utilization
8 of health care resources. Priority must be given to those
9 procedures that involve the greatest utilization of resources
10 either because they are the most costly or because they are
11 the most frequently performed. Practice parameters for
12 treatment of the 10 top procedures associated with workers'
13 compensation injuries, including the remedial treatment of
14 lower-back injuries, must be developed by December 31, 2000
15 1994.
16 (b) The practice parameters guidelines may be
17 initially based on guidelines prepared by nationally
18 recognized health care institutions and professional
19 organizations but should be tailored to meet the workers'
20 compensation goal of returning employees to full employment as
21 quickly as medically possible, taking into consideration
22 outcomes data collected from managed care providers and any
23 other inpatient and outpatient facilities serving workers'
24 compensation claimants.
25 (c) Procedures must be instituted which provide for
26 the periodic review and revision of practice parameters based
27 on the latest outcomes data, research findings, technological
28 advancements, and clinical experiences, at least once every 3
29 years.
30 (d) Practice parameters developed under this section
31 must be used by carriers and the division in evaluating the
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1 appropriateness and overutilization of medical services
2 provided to injured employees.
3 Section 2. Subsections (1), (2), (15), and (18) of
4 section 440.134, Florida Statutes, are amended to read:
5 440.134 Workers' compensation managed care
6 arrangement.--
7 (1) As used in this section, the term:
8 (a) "Agency" means the Agency for Health Care
9 Administration.
10 (b) "Complaint" means any dissatisfaction expressed by
11 an injured worker concerning an insurer's workers'
12 compensation managed care arrangement.
13 (c) "Emergency care" means medical services as defined
14 in chapter 395.
15 (d) "Informal grievance" means a verbal expression of
16 dissatisfaction with care, services, or benefits, which is
17 expressed by an injured employee or a provider, and which is
18 addressed immediately, in person or by telephone, at the time
19 the complaint is made known.
20 (e) "Formal grievance" means a written expression of
21 dissatisfaction with care, services, or benefits, which is
22 submitted by an injured employee or a provider, or which is
23 submitted on behalf of an employee by an agent or a provider.
24 (d) "Grievance" means dissatisfaction with the medical
25 care provided by an insurer's workers' compensation managed
26 care arrangement health care providers, expressed in writing
27 by an injured worker.
28 (f)(e) "Insurer" means an insurance carrier,
29 self-insurance fund, assessable mutual insurer, or
30 individually self-insured employer.
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1 (g)(f) "Service area" means the agency-approved
2 geographic area within which an insurer is authorized to offer
3 a workers' compensation managed care arrangement.
4 (h)(g) "Workers' compensation managed care
5 arrangement" means an arrangement under which a provider of
6 health care, a health care facility, a group of providers of
7 health care, a group of providers of health care and health
8 care facilities, an insurer that has an exclusive provider
9 organization approved under s. 627.6472 or a health
10 maintenance organization licensed under part I of chapter 641
11 has entered into a written agreement directly or indirectly
12 with an insurer to provide and to manage appropriate remedial
13 treatment, care, and attendance to injured workers in
14 accordance with this chapter.
15 (i)(h) "Capitated contract" means a contract in which
16 an insurer pays directly or indirectly a fixed amount to a
17 health care provider in exchange for the future rendering of
18 medical services for covered expenses.
19 (j)(i) "Medical care coordinator" means a primary care
20 provider within a provider network who is responsible for
21 managing the medical care of an injured worker including
22 determining other health care providers and health care
23 facilities to which the injured employee will be referred for
24 evaluation or treatment. A medical care coordinator must shall
25 be a physician licensed under chapter 458 or an osteopathic
26 physician licensed under chapter 459. A medical case manager
27 may also manage the medical care of an injured worker.
28 (k) "Medical case manager" means a qualified
29 rehabilitative provider, as defined in s. 440.491, or a
30 registered nurse licensed under chapter 464. A medical case
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1 manager must act under the supervision of a medical care
2 coordinator.
3 (l)(j) "Provider network" means a comprehensive panel
4 of health care providers and health care facilities who have
5 contracted directly or indirectly with an insurer to provide
6 appropriate remedial treatment, care, and attendance to
7 injured workers in accordance with this chapter.
8 (m)(k) "Primary care provider" means, except in the
9 case of emergency treatment, the initial treating physician
10 and, when appropriate, continuing treating physician, who may
11 be a family practitioner, general practitioner, or internist
12 physician licensed under chapter 458; a family practitioner,
13 general practitioner, or internist osteopathic physician
14 licensed under chapter 459; a chiropractor licensed under
15 chapter 460; a podiatrist licensed under chapter 461; an
16 optometrist licensed under chapter 463; or a dentist licensed
17 under chapter 466.
18 (2)(a) The agency shall, beginning April 1, 1994,
19 authorize an insurer to offer or utilize a workers'
20 compensation managed care arrangement after the insurer files
21 a completed application along with the payment of a $1,000
22 application fee, and upon the agency's being satisfied that
23 the applicant has the ability to provide quality of care
24 consistent with the prevailing professional standards of care
25 and the insurer and its workers' compensation managed care
26 arrangement otherwise meets the requirements of this section.
27 Effective April 1, 1994, an no insurer may not offer or
28 utilize a managed care arrangement without such authorization.
29 The authorization, unless sooner suspended or revoked, shall
30 automatically expires expire 2 years after the date of
31 issuance unless renewed by the insurer. The authorization
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1 shall be renewed upon application for renewal and payment of a
2 renewal fee of $1,000, if provided that the insurer is in
3 compliance with the requirements of this section and any rules
4 adopted under this section hereunder. In view of the fact that
5 the Legislature has clearly expressed its intention that the
6 Workers' Compensation Law be interpreted to facilitate
7 returning an injured employee to work at a reasonable cost to
8 the employer, and in order to encourage experimentation and
9 the development of the most effective and cost-efficient means
10 possible for returning an injured employee to work, the agency
11 may not adopt rules that give a preference or advantage to any
12 type of organization, such as a preferred provider
13 organization, a health maintenance organization, or a similar
14 entity. An application for renewal of the authorization must
15 shall be made 90 days prior to expiration of the
16 authorization, on forms provided by the agency. The renewal
17 application may shall not require the resubmission of any
18 documents previously filed with the agency if such documents
19 have remained valid and unchanged since their original filing.
20 (b) Effective January 1, 1997, the employer shall,
21 subject to the limitations specified elsewhere in this
22 chapter, furnish to the employee solely through managed care
23 arrangements such medically necessary remedial treatment,
24 care, and attendance for such period as the nature of the
25 injury or the process of recovery requires.
26 (15)(a) A workers' compensation managed care
27 arrangement must have and use procedures for hearing
28 complaints and resolving formal written grievances from
29 injured workers and health care providers. The procedures must
30 be aimed at mutual agreement for settlement and may include
31 arbitration procedures. Procedures provided in this section
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1 herein are in addition to other procedures contained in this
2 chapter.
3 (b) The grievance procedure must be described in
4 writing and provided to the affected workers and health care
5 providers.
6 (c) An informal grievance must be concluded within 7
7 calendar days after it is initiated, unless the party who
8 makes the complaint and the managed care arrangement mutually
9 agree to extend the time for concluding the grievance
10 procedure. The 7-day period commences upon contact by
11 telephone or in person by the employee, provider, agency, or
12 division. If the informal grievance remains unresolved after 7
13 days, the managed care arrangement shall notify the party
14 making the complaint, in writing, of the results and of the
15 right to activate a formal grievance procedure. The written
16 notification must include the name, address, and telephone
17 number of the contact person responsible for activating the
18 formal grievance procedure. In addition, if an employee has
19 made the complaint, the managed care arrangement shall advise
20 the employee to contact the division's employee assistance
21 office for additional information on the employee's rights and
22 responsibilities and for information on the dispute resolution
23 process under the Workers' Compensation Law.
24 (d) In order to ensure that the grievance procedure is
25 not unduly delayed, the managed care grievance coordinator
26 shall, within 3 business days after receiving a formal
27 grievance, forward a copy of the formal grievance to the
28 division's employee assistance office. A formal grievance must
29 be concluded within 30 days after receipt by the managed care
30 arrangement, unless the parties mutually agree to an
31 extension. If the grievance involves collecting information
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1 outside the service area, the managed care arrangement may
2 extend the period by 15 calendar days. The managed care
3 arrangement shall notify the employee in writing that
4 additional information is required to complete review of the
5 grievance and that a maximum of 45 days is allowed for this
6 review. Within 5 business days after concluding a formal
7 grievance, the managed care arrangement shall notify all
8 parties of the results in writing.
9 (e) The managed care arrangement shall provide written
10 notice to its employees and providers of the right to file a
11 petition for benefits with the division upon completing the
12 formal grievance procedure. Upon request, the managed care
13 arrangement shall provide a copy of the final decision letter
14 regarding a grievance to the division.
15 (f)(c) At the time the workers' compensation managed
16 care arrangement is implemented, the insurer must provide
17 detailed information to workers and health care providers
18 describing how a grievance may be registered with the insurer.
19 (g)(d) Grievances must be considered in a timely
20 manner and must be transmitted to appropriate decisionmakers
21 who have the authority to fully investigate the issue and take
22 corrective action.
23 (h)(e) If a grievance is found to be valid, corrective
24 action must be taken promptly.
25 (i)(f) All concerned parties must be notified of the
26 results of a grievance.
27 (j)(g) The insurer must report annually, no later than
28 March 31, to the agency regarding its grievance procedure
29 activities for the prior calendar year. The report must be in
30 a format prescribed by the agency and must contain the number
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1 of grievances filed in the past year and a summary of the
2 subject, nature, and resolution of such grievances.
3 (18) The agency may suspend the authority of an
4 insurer to offer a workers' compensation managed care
5 arrangement or order compliance within 60 days, if it finds
6 that:
7 (a) The insurer is in substantial violation of its
8 contracts;
9 (b) The insurer is unable to fulfill its obligations
10 under outstanding contracts entered into with its employers;
11 (c) The insurer knowingly utilizes a provider who is
12 furnishing or has furnished health care services and who does
13 not have an existing license or other authority to practice or
14 furnish health care services in this state;
15 (d) The insurer no longer meets the requirements for
16 the authorization as originally issued; or
17 (e) The insurer has violated any lawful rule or order
18 of the agency or any provision of this section.
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20 The agency may not determine insurer compliance with this
21 subsection by including any injury that requires medical
22 treatment for which charges are incurred, but which does not
23 disable the employee for more than 7 days, regardless of
24 whether the injury is reported to the insurer.
25 Section 3. This act shall take effect July 1, 1998.
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2 SENATE SUMMARY
3 Revises various provisions under which workers'
compensation is paid under a managed care arrangement.
4 Provides for maximum fees for remedial treatment, care,
and attendance. Authorizes an insurer or self-insured
5 employer to pay additional compensation to a health care
provider as part of a risk-sharing arrangement. Requires
6 that the Agency for Health Care Administration develop
practice parameters for the 10 top procedures associated
7 with workers' compensation injuries by December 31, 2000.
Provides procedures and timeframes for filing informal
8 grievances and formal grievances. Prohibits the Agency
for Health Care Administration from considering certain
9 injuries when determining whether to suspend an insurer's
authority to offer a workers' compensation managed care
10 arrangement.
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