CODING: Words stricken are deletions; words underlined are additions.House Bill 1799
Florida House of Representatives - 1997 HB 1799
By Representative Cosgrove
1 A bill to be entitled
2 An act relating to workers' compensation;
3 amending s. 440.13, F.S.; providing for
4 alternative medical care under certain
5 circumstances; requiring the Agency for Health
6 Care Administration to adopt guidelines for
7 certain medical procedures; amending s.
8 440.134, F.S.; revising definitions; providing
9 for informal and formal grievances; providing
10 procedures; providing an additional criterion
11 for agency suspension of certain insurer
12 authority; authorizing certain insurers to opt
13 out of mandatory managed care arrangements
14 under certain circumstances; amending s.
15 440.191, F.S.; requiring employees to provide
16 notice to certain persons or entities of
17 alleged entitlement of benefits; providing an
18 effective date.
19
20 Be It Enacted by the Legislature of the State of Florida:
21
22 Section 1. Paragraph (f) is added to subsection (2) of
23 section 440.13, Florida Statutes, 1996 Supplement, and
24 paragraph (a) of subsection (15) of said section is amended,
25 to read:
26 440.13 Medical services and supplies; penalty for
27 violations; limitations.--
28 (2) MEDICAL TREATMENT; DUTY OF EMPLOYER TO FURNISH.--
29 (f) If the employee is not enrolled in a managed care
30 arrangement and requests alternative medical care, and the
31 request is denied by the carrier, the employee must establish
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1 by clear and convincing evidence that the alternative medical
2 care in the same or another specialty is medically necessary.
3 Alternative medical care for employees enrolled in a managed
4 care arrangement shall be pursuant to such managed care
5 arrangement.
6 (15) PRACTICE PARAMETERS.--
7 (a) The Agency for Health Care Administration, in
8 conjunction with the division and appropriate health
9 professional associations and health-related organizations
10 shall develop and may adopt by rule guidelines prepared by
11 nationally recognized health care institutions and
12 professional organizations for scientifically sound practice
13 parameters for medical procedures relevant to workers'
14 compensation claimants. Practice parameters developed under
15 this section must focus on identifying effective remedial
16 treatments and promoting the appropriate utilization of health
17 care resources. Priority must be given to those procedures
18 that involve the greatest utilization of resources either
19 because they are the most costly or because they are the most
20 frequently performed. Practice parameters for treatment of the
21 10 top procedures associated with workers' compensation
22 injuries including the remedial treatment of lower-back
23 injuries must be developed by December 31, 1998 1994.
24 Section 2. Subsections (1), (2), (15), and (18) of
25 section 440.134, Florida Statutes, are amended to read:
26 440.134 Workers' compensation managed care
27 arrangement.--
28 (1) As used in this section, the term:
29 (a) "Agency" means the Agency for Health Care
30 Administration.
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1 (b)(h) "Capitated contract" means a contract in which
2 an insurer pays directly or indirectly a fixed amount to a
3 health care provider in exchange for the future rendering of
4 medical services for covered expenses.
5 (c)(b) "Complaint" means any dissatisfaction expressed
6 by an injured worker concerning an insurer's workers'
7 compensation managed care arrangement.
8 (d)(c) "Emergency care" means medical services as
9 defined in chapter 395.
10 (e) "Formal grievance" means a written expression of
11 dissatisfaction with care, services, or benefits received
12 which is submitted by a provider or injured employee, or on
13 the employee's behalf by an agent or a provider.
14 (f)(d) "Grievance" means dissatisfaction with the
15 medical care provided by an insurer's workers' compensation
16 managed care arrangement health care providers, expressed in
17 writing by an injured worker.
18 (g) "Informal grievance" means a verbal complaint of
19 dissatisfaction, expressed by the injured employee or
20 provider, with care, services, or benefits and addressed
21 immediately through telephonic or personal interaction at the
22 time the complaint is made known.
23 (h)(e) "Insurer" means an insurance carrier,
24 self-insurance fund, assessable mutual insurer, or
25 individually self-insured employer.
26 (i) "Medical care coordinator" means a primary care
27 provider within a provider network who is responsible for
28 managing the medical care of an injured worker including
29 determining other health care providers and health care
30 facilities to which the injured employee will be referred for
31 evaluation or treatment. A medical care coordinator shall be a
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1 physician licensed under chapter 458 or an osteopath licensed
2 under chapter 459. The responsibilities for managing the
3 medical care of an injured worker may be performed by a
4 medical care manager.
5 (j) "Medical care manager" means a qualified
6 rehabilitative provider as defined in s. 440.491 or a
7 registered nurse licensed under chapter 464, either of whom
8 act under the supervision of a medical care coordinator.
9 (k) "Primary care provider" means, except in the case
10 of emergency treatment, the initial treating physician and,
11 when appropriate, continuing treating physician, who may be a
12 family practitioner, general practitioner, orthopedic
13 practitioner, or internist physician licensed under chapter
14 458; a family practitioner, general practitioner, or internist
15 osteopath licensed under chapter 459; a chiropractor licensed
16 under chapter 460; a podiatrist licensed under chapter 461; an
17 optometrist licensed under chapter 463; or a dentist licensed
18 under chapter 466.
19 (l)(j) "Provider network" means a comprehensive panel
20 of health care providers and health care facilities who have
21 contracted directly or indirectly with an insurer to provide
22 appropriate remedial treatment, care, and attendance to
23 injured workers in accordance with this chapter.
24 (m)(f) "Service area" means the agency-approved
25 geographic area within which an insurer is authorized to offer
26 a workers' compensation managed care arrangement.
27 (n)(g) "Workers' compensation managed care
28 arrangement" means an arrangement under which a provider of
29 health care, a health care facility, a group of providers of
30 health care, a group of providers of health care and health
31 care facilities, an insurer that has an exclusive provider
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1 organization approved under s. 627.6472 or a health
2 maintenance organization licensed under part I of chapter 641
3 has entered into a written agreement directly or indirectly
4 with an insurer to provide and to manage appropriate remedial
5 treatment, care, and attendance to injured workers in
6 accordance with this chapter.
7 (2)(a) The agency shall, beginning April 1, 1994,
8 authorize an insurer to offer or utilize a workers'
9 compensation managed care arrangement after the insurer files
10 a completed application along with the payment of a $1,000
11 application fee, and upon the agency's being satisfied that
12 the applicant has the ability to provide quality of care
13 consistent with the prevailing professional standards of care
14 and the insurer and its workers' compensation managed care
15 arrangement otherwise meets the requirements of this section.
16 Due to the Legislature's clearly expressed intention that the
17 workers' compensation law is to be interpreted to facilitate
18 an injured worker's return to work at a reasonable cost to the
19 employer, no rule shall be adopted by the agency which gives a
20 preference or advantage to any type of organization, such as,
21 but not limited to, a preferred provider organization, a
22 health maintenance organization, or a similar entity, in order
23 to encourage experimentation and development of the most
24 effective and cost-efficient means possible for returning an
25 injured employee to work. Effective April 1, 1994, no insurer
26 may offer or utilize a managed care arrangement without such
27 authorization. The authorization, unless sooner suspended or
28 revoked, shall automatically expire 2 years after the date of
29 issuance unless renewed by the insurer. The authorization
30 shall be renewed upon application for renewal and payment of a
31 renewal fee of $1,000, provided that the insurer is in
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1 compliance with the requirements of this section and any rules
2 adopted hereunder. An application for renewal of the
3 authorization shall be made 90 days prior to expiration of the
4 authorization, on forms provided by the agency. The renewal
5 application shall not require the resubmission of any
6 documents previously filed with the agency if such documents
7 have remained valid and unchanged since their original filing.
8 (b) Effective January 1, 1997, the employer shall,
9 subject to the limitations specified elsewhere in this
10 chapter, furnish to the employee solely through managed care
11 arrangements such medically necessary remedial treatment,
12 care, and attendance for such period as the nature of the
13 injury or the process of recovery requires. Notwithstanding
14 this paragraph, employers who self-insure pursuant to s.
15 440.38 may opt out of the mandatory managed care arrangements
16 and this section by providing such medically necessary
17 remedial treatment, care, and attendance for such periods as
18 the nature of the injury or process of recovery requires, as
19 specified by s. 440.13. Nothing in this section shall be
20 construed as to prevent an employer who has self-insured
21 pursuant to s. 440.38 from using managed care arrangements to
22 provide treatment to its employees if the employer so chooses.
23 (15)(a) A workers' compensation managed care
24 arrangement must have and use procedures for hearing
25 complaints and resolving written grievances from injured
26 workers and health care providers. The procedures must be
27 aimed at mutual agreement for settlement and may include
28 arbitration procedures. Procedures provided herein are in
29 addition to other procedures contained in this chapter.
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1 (b) The grievance procedure must be described in
2 writing and provided to the affected workers and health care
3 providers.
4 (c) Informal grievances shall be initiated and
5 concluded within 7 calendar days unless the parties and the
6 managed care arrangement mutually agree to an extension. The
7 7-day period shall commence upon telephone or personal contact
8 by the employee, the provider, the agency, or the division. If
9 the informal grievance remains unresolved, the managed care
10 arrangement shall notify the parties of the results in writing
11 and advise the parties of their right to initiate a formal
12 grievance. The written notification shall include the name,
13 address, and telephone number of the contact person
14 responsible for initiating a formal grievance. In addition,
15 the managed care arrangement shall advise the employee to
16 contact the Employee Assistance Office for additional
17 information on rights and responsibilities and the dispute
18 resolution process under the Florida Workers' Compensation
19 Law.
20 (d) In order to ensure that there are no undue delays
21 in the dispute resolution process, the managed care grievance
22 coordinator shall, within 3 business days after initiation of
23 a formal grievance, forward a copy of the formal grievance to
24 the division's employee assistance office. For the purposes of
25 this paragraph, the address of the division's employee
26 assistance office shall be Post Office Box 8010, Tallahassee,
27 Florida, 32314-8010. Formal grievances shall be initiated and
28 concluded within 30 days after receipt of the notice by the
29 managed care arrangement unless the employee or provider and
30 the managed care arrangement mutually agree to an extension.
31 If the grievance involves the collection of information
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1 outside the service area, the managed care arrangement shall
2 have 15 calendar days in addition to the 30 days set forth in
3 this section to process the formal grievance. The managed care
4 arrangement shall notify the employee in writing that
5 additional information is required to complete review of the
6 grievance and that a maximum of 45 days will be allowed for
7 such review. Within 5 business days after providing such
8 notice, the managed care arrangement shall notify the party of
9 such requirements in writing.
10 (e) The managed care arrangement shall provide written
11 notice to its employees and providers of the right to proceed
12 under s. 440.191 with the Division of Workers' Compensation of
13 the Department of Labor and Employment Security upon
14 completion of the formal grievance procedure if the issues are
15 not resolved by both parties. The managed care arrangement
16 shall furnish a copy of the final decision letter from the
17 managed care arrangement regarding the grievance to employer,
18 carrier, and the Division of Workers' Compensation upon
19 request.
20 (f)(c) At the time the workers' compensation managed
21 care arrangement is implemented, the insurer must provide
22 detailed information to workers and health care providers
23 describing how a grievance may be registered with the insurer.
24 (g)(d) Grievances must be considered in a timely
25 manner and must be transmitted to appropriate decisionmakers
26 who have the authority to fully investigate the issue and take
27 corrective action.
28 (h)(e) If a grievance is found to be valid, corrective
29 action must be taken promptly.
30 (i)(f) All concerned parties must be notified of the
31 results of a grievance.
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1 (j)(g) The insurer must report annually, no later than
2 March 31, to the agency regarding its grievance procedure
3 activities for the prior calendar year. The report must be in
4 a format prescribed by the agency and must contain the number
5 of grievances filed in the past year and a summary of the
6 subject, nature, and resolution of such grievances.
7 (18) The agency may suspend the authority of an
8 insurer to offer a workers' compensation managed care
9 arrangement or order compliance within 60 days, if it finds
10 that:
11 (a) The insurer is in substantial violation of its
12 contracts;
13 (b) The insurer is unable to fulfill its obligations
14 under outstanding contracts entered into with its employers;
15 (c) The insurer knowingly utilizes a provider who is
16 furnishing or has furnished health care services and who does
17 not have an existing license or other authority to practice or
18 furnish health care services in this state;
19 (d) The insurer no longer meets the requirements for
20 the authorization as originally issued; or
21 (e) The insurer has violated any lawful rule or order
22 of the agency or any provision of this section.
23
24 Injuries which require medical treatment for which charges
25 will be incurred, whether or not they are reported to the
26 carrier, but which do not disable the employee for more than 7
27 days as a result of the injury shall not be used by the Agency
28 for Health Care Administration in determining insurer
29 compliance with this subsection.
30 Section 3. Paragraph (b) of subsection (2) of section
31 440.191, Florida Statutes, is amended, to read:
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1 440.191 Employee Assistance and Ombudsman Office.--
2 (2)
3 (b) If at any time the employer or its carrier fails
4 to provide benefits to which the employee believes he is
5 entitled, the employee shall contact the office to request
6 assistance in resolving the dispute. The employee shall
7 simultaneously notify the employer, the employer's carrier,
8 and the carrier's attorney if the carrier's attorney is known,
9 in writing, of the benefits to which the employee believes he
10 or she is entitled and for which he or she is requesting the
11 assistance of the office. The office shall investigate the
12 dispute and shall attempt to facilitate an agreement between
13 the employee and the employer or carrier. The employee, the
14 employer, and the carrier shall cooperate with the office and
15 shall timely provide the office with any documents or other
16 information that it may require in connection with its efforts
17 under this section.
18 Section 4. This act shall take effect October 1, 1997.
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21 HOUSE SUMMARY
22
Provides for alternative medical care under managed care
23 arrangements. Requires the Agency for Health Care
Administration to adopt guidelines prepared by nationally
24 recognized health care institutions and professional
organizations for medical procedures relevant to workers'
25 compensation claimants. Provides for informal and formal
grievance procedures. Authorizes insurers to opt out of
26 mandatory managed care arrangements. Requires employees
to provide notice of alleged entitlement of benefits. See
27 bill for details.
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