House Bill 3751
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Florida House of Representatives - 1998 HB 3751
By Representative Stabins
1 A bill to be entitled
2 An act relating to workers' compensation
3 insurance; amending s. 440.02, F.S.; excluding
4 certain injuries from the definition of
5 "catastrophic injury"; amending s. 440.13,
6 F.S.; authorizing insurers to pay certain
7 amounts exceeding fee schedules under certain
8 circumstances; requiring the Agency for Health
9 Care Administration to adopt certain rules and
10 to use certain national guidelines; amending s.
11 440.134, F.S.; providing additional
12 definitions; providing for informal and formal
13 grievances; providing procedures; providing
14 requirements; prohibiting the agency from using
15 certain information to determine insurer
16 compliance under certain circumstances;
17 providing an effective date.
18
19 Be It Enacted by the Legislature of the State of Florida:
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21 Section 1. Subsection (34) of section 440.02, Florida
22 Statutes, is amended to read:
23 440.02 Definitions.--When used in this chapter, unless
24 the context clearly requires otherwise, the following terms
25 shall have the following meanings:
26 (34) "Catastrophic injury" means a permanent
27 impairment constituted by:
28 (a) Spinal cord injury involving severe paralysis of
29 an arm, a leg, or the trunk;
30 (b) Amputation of an arm, a hand, a foot, or a leg
31 involving the effective loss of use of that appendage;
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1 (c) Severe brain or closed-head injury as evidenced
2 by:
3 1. Severe sensory or motor disturbances;
4 2. Severe communication disturbances;
5 3. Severe complex integrated disturbances of cerebral
6 function;
7 4. Severe episodic neurological disorders; or
8 5. Other severe brain and closed-head injury
9 conditions at least as severe in nature as any condition
10 provided in subparagraphs 1.-4.;
11 (d) Second-degree or third-degree burns of 25 percent
12 or more of the total body surface or third-degree burns of 5
13 percent or more to the face and hands; or
14 (e) Total or industrial blindness; or
15 (f) Any other injury that would otherwise qualify
16 under this chapter of a nature and severity that would qualify
17 an employee to receive disability income benefits under Title
18 II or supplemental security income benefits under Title XVI of
19 the federal Social Security Act as the Social Security Act
20 existed on July 1, 1992, without regard to any time
21 limitations provided under that act.
22 Section 2. Paragraph (b) of subsection (14) and
23 paragraph (a) of subsection (15) of section 440.13, Florida
24 Statutes, are amended to read:
25 440.13 Medical services and supplies; penalty for
26 violations; limitations.--
27 (14) PAYMENT OF MEDICAL FEES.--
28 (b) Fees charged for remedial treatment, care, and
29 attendance may not exceed the applicable fee schedules adopted
30 under this chapter, which shall be the maximum reimbursement
31 allowance under a workers' compensation managed care
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1 arrangement. The applicable fee schedule shall not restrict
2 the right of an insurer, self-insurance fund, individually
3 self-insured employer, or assessable mutual insurer from
4 agreeing to pay any additional compensation to any health care
5 provider as part of a contract in which there is a risk
6 sharing arrangement between the insurer, self-insurance fund,
7 individually self-insured employer, or assessable mutual
8 insurer and the provider or any other incentives for
9 successful outcomes in returning an injured employee to work.
10 (15) PRACTICE PARAMETERS.--
11 (a) The Agency for Health Care Administration, in
12 conjunction with the division and appropriate health
13 professional associations and health-related organizations
14 shall develop and may adopt by rule guidelines, prepared by
15 nationally recognized health care institutions and
16 professional organizations, for scientifically sound practice
17 parameters for medical procedures relevant to workers'
18 compensation claimants. Practice parameters developed under
19 this section must focus on identifying effective remedial
20 treatments and promoting the appropriate utilization of health
21 care resources. Priority must be given to those procedures
22 that involve the greatest utilization of resources either
23 because they are the most costly or because they are the most
24 frequently performed. Practice parameters for treatment of the
25 10 top procedures associated with workers' compensation
26 injuries including the remedial treatment of lower-back
27 injuries must be developed by December 31, 1999 1994.
28 Section 3. Subsections (1), (2), and (15) of section
29 440.134, Florida Statutes, are amended, and subsection (25) is
30 added to said section, to read:
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1 440.134 Workers' compensation managed care
2 arrangement.--
3 (1) As used in this section, the term:
4 (a) "Agency" means the Agency for Health Care
5 Administration.
6 (b)(h) "Capitated contract" means a contract in which
7 an insurer pays directly or indirectly a fixed amount to a
8 health care provider in exchange for the future rendering of
9 medical services for covered expenses.
10 (c)(b) "Complaint" means any dissatisfaction expressed
11 by an injured worker concerning an insurer's workers'
12 compensation managed care arrangement.
13 (d)(c) "Emergency care" means medical services as
14 defined in chapter 395.
15 (e)(d) "Formal grievance" means a written expression
16 of dissatisfaction with the medical care, services, or
17 benefits received which is submitted by a provider or an
18 injured employee, or on an employee's behalf by an agent or
19 provider and addressed through a dispute resolution process
20 provided by an insurer's workers' compensation managed care
21 arrangement health care providers, expressed in writing by an
22 injured worker.
23 (f) "Informal grievance" means a verbal complaint of
24 dissatisfaction, expressed by an injured employee or a
25 provider, with care services, or benefits received and
26 addressed immediately through telephonic or personal
27 interaction at the time the complaint is made known.
28 (g)(e) "Insurer" means an insurance carrier,
29 self-insurance fund, assessable mutual insurer, or
30 individually self-insured employer.
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1 (h)(i) "Medical care coordinator" means a primary care
2 provider within a provider network who is responsible for
3 managing the medical care of an injured worker including
4 determining other health care providers and health care
5 facilities to which the injured employee will be referred for
6 evaluation or treatment. A medical care coordinator shall be a
7 physician licensed under chapter 458 or an osteopathic
8 physician licensed under chapter 459. The responsibilities for
9 managing the medical care of an injured worker may be
10 performed by a medical case manager.
11 (i) "Medical case manager" means a qualified
12 rehabilitation provider as defined in s. 440.491 or a
13 registered nurse licensed under chapter 464, either of whom
14 act under the supervision of a medical care coordinator.
15 (j)(k) "Primary care provider" means, except in the
16 case of emergency treatment, the initial treating physician
17 and, when appropriate, continuing treating physician, who may
18 be a family practitioner, general practitioner, or internist
19 physician licensed under chapter 458; a family practitioner,
20 general practitioner, or internist osteopathic physician
21 licensed under chapter 459; a chiropractor licensed under
22 chapter 460; a podiatrist licensed under chapter 461; an
23 optometrist licensed under chapter 463; or a dentist licensed
24 under chapter 466.
25 (k)(j) "Provider network" means a comprehensive panel
26 of health care providers and health care facilities who have
27 contracted directly or indirectly with an insurer to provide
28 appropriate remedial treatment, care, and attendance to
29 injured workers in accordance with this chapter.
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1 (l)(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 (m)(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 (2)(a) The agency shall, beginning April 1, 1994,
16 authorize an insurer to offer or utilize a workers'
17 compensation managed care arrangement after the insurer files
18 a completed application along with the payment of a $1,000
19 application fee, and upon the agency's being satisfied that
20 the applicant has the ability to provide quality of care
21 consistent with the prevailing professional standards of care
22 and the insurer and its workers' compensation managed care
23 arrangement otherwise meets the requirements of this section.
24 Effective April 1, 1994, no insurer may offer or utilize a
25 managed care arrangement without such authorization. The
26 authorization, unless sooner suspended or revoked, shall
27 automatically expire 2 years after the date of issuance unless
28 renewed by the insurer. The authorization shall be renewed
29 upon application for renewal and payment of a renewal fee of
30 $1,000, provided that the insurer is in compliance with the
31 requirements of this section and any rules adopted hereunder.
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1 An application for renewal of the authorization shall be made
2 90 days prior to expiration of the authorization, on forms
3 provided by the agency. The renewal application shall not
4 require the resubmission of any documents previously filed
5 with the agency if such documents have remained valid and
6 unchanged since their original filing.
7 (b) Effective January 1, 1997, the employer shall,
8 subject to the limitations specified elsewhere in this
9 chapter, furnish to the employee solely through managed care
10 arrangements such medically necessary remedial treatment,
11 care, and attendance for such period as the nature of the
12 injury or the process of recovery requires. Notwithstanding
13 such requirement, any employer who self-insures pursuant to s.
14 440.38 may opt out of a mandatory managed care arrangement and
15 the requirements of this section by providing such medically
16 necessary remedial treatment, care, and attendance for such
17 periods as the nature of the injury or process of recovery
18 requires, as provided by s. 440.13. Nothing in this section
19 shall be construed to prevent an employer who has self-insured
20 pursuant to s. 440.38 from using managed care arrangements to
21 provide treatment to employees of the employer.
22 (c) The agency shall not adopt any rule which gives a
23 preference or advantage to any organization, including, but
24 not limited to, a preferred provider organization, health
25 maintenance organization, or similar entity, in order to
26 encourage experimentation and development of the most
27 effective and cost-efficient means possible for returning an
28 injured employee to work.
29 (15)(a) A workers' compensation managed care
30 arrangement must have and use formal and informal procedures
31 for hearing complaints and resolving written grievances from
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1 injured workers and health care providers. The procedures must
2 be aimed at mutual agreement for settlement and may include
3 arbitration procedures. Procedures provided herein are in
4 addition to other procedures contained in this chapter.
5 (b) The grievance procedure must be described in
6 writing and provided to the affected workers and health care
7 providers.
8 (c) At the time the workers' compensation managed care
9 arrangement is implemented, the insurer must provide detailed
10 information to workers and health care providers describing
11 how a grievance may be registered with the insurer.
12 (d) Grievances must be considered in a timely manner
13 and must be transmitted to appropriate decisionmakers who have
14 the authority to fully investigate the issue and take
15 corrective action.
16 (e) Informal grievances shall be concluded within 7
17 calendar days after initiation unless the parties and the
18 managed care arrangement mutually agree to an extension. The
19 7-day period shall commence upon telephone or personal contact
20 initiated by the employee or provider, the agency, or the
21 division. If the informal grievance remains unresolved, the
22 managed care arrangement shall notify the parties, in writing,
23 of the results and shall advise them of their rights to
24 initiate a formal grievance. The notification shall include
25 the name, address, and telephone number of the contact person
26 responsible for initiating the formal grievance. The managed
27 care arrangement shall also advise the employee to contact the
28 Employee Assistance Office for additional information
29 regarding rights and responsibilities and the dispute
30 resolution process under the Workers' Compensation Law. To
31 ensure no undue delays in the dispute resolution process, the
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1 managed care grievance coordinator shall, within 3 business
2 days after receiving a formal grievance, forward a copy of the
3 grievance to the division's Employee Assistance Office. A
4 formal grievance shall be concluded within 30 days after
5 receipt by the managed care arrangement unless the employee or
6 provider and the managed care arrangement mutually agree to an
7 extension. If the grievance involves the collection of
8 information outside the service area, the managed care
9 arrangement shall have 15 calendar days in addition to the
10 30-day period within which to process the grievance. The
11 managed care arrangement shall notify the employee in writing
12 that additional information is required to complete review of
13 the grievance and that a maximum of 45 days will be allowed
14 for such review. Within 5 business days after conclusion of
15 the review, the managed care arrangement shall notify the
16 parties of the results of the review. The managed care
17 arrangement shall provide written notice to its employees and
18 providers of the right to file a petition for benefits with
19 the Division of Workers' Compensation of the Department of
20 Labor and Employment Security upon completion of the formal
21 grievance procedure. The managed care arrangement shall
22 furnish a copy of the final decision letter from the managed
23 care arrangement regarding the grievance to the division upon
24 request.
25 (f)(e) If a grievance is found to be valid, corrective
26 action must be taken promptly.
27 (g)(f) All concerned parties must be notified of the
28 results of a grievance.
29 (h)(g) The insurer must report annually, no later than
30 March 31, to the agency regarding its grievance procedure
31 activities for the prior calendar year. The report must be in
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1 a format prescribed by the agency and must contain the number
2 of grievances filed in the past year and a summary of the
3 subject, nature, and resolution of such grievances.
4 (25) Injuries which require medical treatment for
5 which charges will be incurred whether or not such injuries
6 are reported to the carrier, but which do not disable the
7 employee for more than 7 days, shall not be used by the agency
8 in determining insurer compliance with this section.
9 Section 4. This act shall take effect October 1 of the
10 year in which enacted.
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13 HOUSE SUMMARY
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Revises various provisions of workers' compensation
15 insurance, including modifying the definition of
catastrophic injury; allowing insurers to exceed fee
16 schedule amounts; providing for informal and formal
grievances; prohibiting the Agency for Health Care
17 Administration from prohibiting insurers from using
alternative managed care arrangements; and allowing
18 self-insureds to opt out of mandatory managed care
arrangements. See bill for details.
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