CODING: Words stricken are deletions; words underlined are additions.House Bill 0631
Florida House of Representatives - 1997 HB 631
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, 1996 Supplement, 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 osteopath licensed
8 under chapter 459. The responsibilities for managing the
9 medical care of an injured worker may be performed by a
10 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 osteopath licensed under
21 chapter 459; a chiropractor licensed under chapter 460; a
22 podiatrist licensed under chapter 461; an optometrist licensed
23 under chapter 463; or a dentist licensed under chapter 466.
24 (k)(j) "Provider network" means a comprehensive panel
25 of health care providers and health care facilities who have
26 contracted directly or indirectly with an insurer to provide
27 appropriate remedial treatment, care, and attendance to
28 injured workers in accordance with this chapter.
29 (l)(f) "Service area" means the agency-approved
30 geographic area within which an insurer is authorized to offer
31 a workers' compensation managed care arrangement.
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1 (m)(g) "Workers' compensation managed care
2 arrangement" means an arrangement under which a provider of
3 health care, a health care facility, a group of providers of
4 health care, a group of providers of health care and health
5 care facilities, an insurer that has an exclusive provider
6 organization approved under s. 627.6472 or a health
7 maintenance organization licensed under part I of chapter 641
8 has entered into a written agreement directly or indirectly
9 with an insurer to provide and to manage appropriate remedial
10 treatment, care, and attendance to injured workers in
11 accordance with this chapter.
12 (2)(a) The agency shall, beginning April 1, 1994,
13 authorize an insurer to offer or utilize a workers'
14 compensation managed care arrangement after the insurer files
15 a completed application along with the payment of a $1,000
16 application fee, and upon the agency's being satisfied that
17 the applicant has the ability to provide quality of care
18 consistent with the prevailing professional standards of care
19 and the insurer and its workers' compensation managed care
20 arrangement otherwise meets the requirements of this section.
21 Effective April 1, 1994, no insurer may offer or utilize a
22 managed care arrangement without such authorization. The
23 authorization, unless sooner suspended or revoked, shall
24 automatically expire 2 years after the date of issuance unless
25 renewed by the insurer. The authorization shall be renewed
26 upon application for renewal and payment of a renewal fee of
27 $1,000, provided that the insurer is in compliance with the
28 requirements of this section and any rules adopted hereunder.
29 An application for renewal of the authorization shall be made
30 90 days prior to expiration of the authorization, on forms
31 provided by the agency. The renewal application shall not
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1 require the resubmission of any documents previously filed
2 with the agency if such documents have remained valid and
3 unchanged since their original filing.
4 (b) Effective January 1, 1997, the employer shall,
5 subject to the limitations specified elsewhere in this
6 chapter, furnish to the employee solely through managed care
7 arrangements such medically necessary remedial treatment,
8 care, and attendance for such period as the nature of the
9 injury or the process of recovery requires. Notwithstanding
10 such requirement, any employer who self-insures pursuant to s.
11 440.38 may opt out of a mandatory managed care arrangement and
12 the requirements of this section by providing such medically
13 necessary remedial treatment, care, and attendance for such
14 periods as the nature of the injury or process of recovery
15 requires, as provided by s. 440.13. Nothing in this section
16 shall be construed to prevent an employer who has self-insured
17 pursuant to s. 440.38 from using managed care arrangements to
18 provide treatment to employees of the employer.
19 (c) The agency shall not adopt any rule which gives a
20 preference or advantage to any organization, including, but
21 not limited to, a preferred provider organization, health
22 maintenance organization, or similar entity, in order to
23 encourage experimentation and development of the most
24 effective and cost-efficient means possible for returning an
25 injured employee to work.
26 (15)(a) A workers' compensation managed care
27 arrangement must have and use formal and informal procedures
28 for hearing complaints and resolving written grievances from
29 injured workers and health care providers. The procedures must
30 be aimed at mutual agreement for settlement and may include
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1 arbitration procedures. Procedures provided herein are in
2 addition to other procedures contained in this 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) At the time the workers' compensation managed care
7 arrangement is implemented, the insurer must provide detailed
8 information to workers and health care providers describing
9 how a grievance may be registered with the insurer.
10 (d) Grievances must be considered in a timely manner
11 and must be transmitted to appropriate decisionmakers who have
12 the authority to fully investigate the issue and take
13 corrective action.
14 (e) Informal grievances shall be concluded within 7
15 calendar days after initiation unless the parties and the
16 managed care arrangement mutually agree to an extension. The
17 7-day period shall commence upon telephone or personal contact
18 initiated by the employee or provider, the agency, or the
19 division. If the informal grievance remains unresolved, the
20 managed care arrangement shall notify the parties, in writing,
21 of the results and shall advise them of their rights to
22 initiate a formal grievance. The notification shall include
23 the name, address, and telephone number of the contact person
24 responsible for initiating the formal grievance. The managed
25 care arrangement shall also advise the employee to contact the
26 Employee Assistance Office for additional information
27 regarding rights and responsibilities and the dispute
28 resolution process under the Workers' Compensation Law. To
29 ensure no undue delays in the dispute resolution process, the
30 managed care grievance coordinator shall, within 3 business
31 days after receiving a formal grievance, forward a copy of the
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1 grievance to the division's Employee Assistance Office. A
2 formal grievance shall be concluded within 30 days after
3 receipt by the managed care arrangement unless the employee or
4 provider and the managed care arrangement mutually agree to an
5 extension. If the grievance involves the collection of
6 information outside the service area, the managed care
7 arrangement shall have 15 calendar days in addition to the
8 30-day period within which to process the grievance. The
9 managed care arrangement shall notify the employee in writing
10 that additional information is required to complete review of
11 the grievance and that a maximum of 45 days will be allowed
12 for such review. Within 5 business days after conclusion of
13 the review, the managed care arrangement shall notify the
14 parties of the results of the review. The managed care
15 arrangement shall provide written notice to its employees and
16 providers of the right to file a petition for benefits with
17 the Division of Workers' Compensation of the Department of
18 Labor and Employment Security upon completion of the formal
19 grievance procedure. The managed care arrangement shall
20 furnish a copy of the final decision letter from the managed
21 care arrangement regarding the grievance to the division upon
22 request.
23 (f)(e) If a grievance is found to be valid, corrective
24 action must be taken promptly.
25 (g)(f) All concerned parties must be notified of the
26 results of a grievance.
27 (h)(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 (25) Injuries which require medical treatment for
4 which charges will be incurred whether or not such injuries
5 are reported to the carrier, but which do not disable the
6 employee for more than 7 days, shall not be used by the agency
7 in determining insurer compliance with this section.
8 Section 4. This act shall take effect October 1, 1997.
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11 HOUSE SUMMARY
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Revises various provisions of workers' compensation
13 insurance, including modifying the definition of
catastrophic injury; allowing insurers to exceed fee
14 schedule amounts; providing for informal and formal
grievances; prohibiting the Agency for Health Care
15 Administration from prohibiting insurers from using
alternative managed care arrangements; and allowing
16 self-insureds to opt out of mandatory managed care
arrangements. See bill for details.
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