CODING: Words stricken are deletions; words underlined are additions.
SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
CHAMBER ACTION
Senate House
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11 Senator Kirkpatrick moved the following amendment:
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13 Senate Amendment (with title amendment)
14 On page 63, line 30, through page 64, line 8, delete
15 those lines
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17 and insert:
18 Section 41. Present subsection (3) of section 440.02,
19 Florida Statutes, is redesignated as subsection (4), a new
20 subsection (3) is added to that section and subsequent
21 subsections are redesignated, and subsections (11) and (13)
22 are 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 (3) "Agency" means the Agency for Health Care
27 Administration.
28 (11) "Department" means the Department of Insurance
29 Labor and Employment Security.
30 (13) "Division" means the Division of Workers'
31 Compensation of the Department of Insurance Labor and
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 Employment Security.
2 Section 42. Subsections (3), (4), (5), (6), (7), (8),
3 (9), (11), (12), and (13) of section 440.13, Florida Statutes,
4 are amended to read:
5 440.13 Medical services and supplies; penalty for
6 violations; limitations.--
7 (3) PROVIDER ELIGIBILITY; AUTHORIZATION.--
8 (a) As a condition to eligibility for payment under
9 this chapter, a health care provider who renders services must
10 be a certified health care provider and must receive
11 authorization from the carrier before providing treatment.
12 This paragraph does not apply to emergency care. The agency
13 division shall adopt rules to implement the certification of
14 health care providers. As a one-time prerequisite to obtaining
15 certification, the agency division shall require each
16 physician to demonstrate proof of completion of a minimum
17 5-hour course that covers the subject areas of cost
18 containment, utilization control, ergonomics, and the practice
19 parameters adopted by the agency division governing the
20 physician's field of practice. The agency division shall
21 coordinate with the Agency for Health Care Administration, the
22 Florida Medical Association, the Florida Osteopathic Medical
23 Association, the Florida Chiropractic Association, the Florida
24 Podiatric Medical Association, the Florida Optometric
25 Association, the Florida Dental Association, and other health
26 professional organizations and their respective boards as
27 deemed necessary by the agency Agency for Health Care
28 Administration in complying with this subsection. No later
29 than October 1, 1994, the agency division shall adopt rules
30 regarding the criteria and procedures for approval of courses
31 and the filing of proof of completion by the physicians.
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 (b) A health care provider who renders emergency care
2 must notify the carrier by the close of the third business day
3 after it has rendered such care. If the emergency care results
4 in admission of the employee to a health care facility, the
5 health care provider must notify the carrier by telephone
6 within 24 hours after initial treatment. Emergency care is not
7 compensable under this chapter unless the injury requiring
8 emergency care arose as a result of a work-related accident.
9 Pursuant to chapter 395, all licensed physicians and health
10 care providers in this state shall be required to make their
11 services available for emergency treatment of any employee
12 eligible for workers' compensation benefits. To refuse to make
13 such treatment available is cause for revocation of a license.
14 (c) A health care provider may not refer the employee
15 to another health care provider, diagnostic facility, therapy
16 center, or other facility without prior authorization from the
17 carrier, except when emergency care is rendered. Any referral
18 must be to a health care provider that has been certified by
19 the agency division, unless the referral is for emergency
20 treatment.
21 (d) A carrier must respond, by telephone or in
22 writing, to a request for authorization by the close of the
23 third business day after receipt of the request. A carrier who
24 fails to respond to a written request for authorization for
25 referral for medical treatment by the close of the third
26 business day after receipt of the request consents to the
27 medical necessity for such treatment. All such requests must
28 be made to the carrier. Notice to the carrier does not include
29 notice to the employer.
30 (e) Carriers shall adopt procedures for receiving,
31 reviewing, documenting, and responding to requests for
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 authorization. Such procedures shall be for a health care
2 provider certified under this section.
3 (f) By accepting payment under this chapter for
4 treatment rendered to an injured employee, a health care
5 provider consents to the jurisdiction of the agency division
6 as set forth in subsection (11) and to the submission of all
7 records and other information concerning such treatment to the
8 agency division in connection with a reimbursement dispute,
9 audit, or review as provided by this section. The health care
10 provider must further agree to comply with any decision of the
11 agency division rendered under this section.
12 (g) The employee is not liable for payment for medical
13 treatment or services provided pursuant to this section except
14 as otherwise provided in this section.
15 (h) The provisions of s. 455.654 are applicable to
16 referrals among health care providers, as defined in
17 subsection (1), treating injured workers.
18 (i) Notwithstanding paragraph (d), a claim for
19 specialist consultations, surgical operations,
20 physiotherapeutic or occupational therapy procedures, X-ray
21 examinations, or special diagnostic laboratory tests that cost
22 more than $1,000 and other specialty services that the agency
23 division identifies by rule is not valid and reimbursable
24 unless the services have been expressly authorized by the
25 carrier, or unless the carrier has failed to respond within 10
26 days to a written request for authorization, or unless
27 emergency care is required. The insurer shall not refuse to
28 authorize such consultation or procedure unless the health
29 care provider or facility is not authorized or certified or
30 unless an expert medical advisor has determined that the
31 consultation or procedure is not medically necessary or
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 otherwise compensable under this chapter. Authorization of a
2 treatment plan does not constitute express authorization for
3 purposes of this section, except to the extent the carrier
4 provides otherwise in its authorization procedures. This
5 paragraph does not limit the carrier's obligation to identify
6 and disallow overutilization or billing errors.
7 (j) Notwithstanding anything in this chapter to the
8 contrary, a sick or injured employee shall be entitled, at all
9 times, to free, full, and absolute choice in the selection of
10 the pharmacy or pharmacist dispensing and filling
11 prescriptions for medicines required under this chapter. It is
12 expressly forbidden for the agency division, an employer, or a
13 carrier, or any agent or representative of the agency
14 division, an employer, or a carrier to select the pharmacy or
15 pharmacist which the sick or injured employee must use;
16 condition coverage or payment on the basis of the pharmacy or
17 pharmacist utilized; or to otherwise interfere in the
18 selection by the sick or injured employee of a pharmacy or
19 pharmacist.
20 (4) NOTICE OF TREATMENT TO CARRIER; FILING WITH AGENCY
21 DIVISION.--
22 (a) Any health care provider providing necessary
23 remedial treatment, care, or attendance to any injured worker
24 shall submit treatment reports to the carrier in a format
25 prescribed by the agency division. A claim for medical or
26 surgical treatment is not valid or enforceable against such
27 employer or employee, unless, by the close of the third
28 business day following the first treatment, the physician
29 providing the treatment furnishes to the employer or carrier a
30 preliminary notice of the injury and treatment on forms
31 prescribed by the agency division and, within 15 days
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 thereafter, furnishes to the employer or carrier a complete
2 report, and subsequent thereto furnishes progress reports, if
3 requested by the employer or insurance carrier, at intervals
4 of not less than 3 weeks apart or at less frequent intervals
5 if requested on forms prescribed by the agency division.
6 (b) Each medical report or bill obtained or received
7 by the employer, the carrier, or the injured employee, or the
8 attorney for the employer, carrier, or injured employee, with
9 respect to the remedial treatment or care of the injured
10 employee, including any report of an examination, diagnosis,
11 or disability evaluation, must be filed with the Agency for
12 Health Care Administration Division of Workers' Compensation
13 pursuant to rules adopted by the agency division. The health
14 care provider shall also furnish to the injured employee or to
15 his or her attorney, on demand, a copy of his or her office
16 chart, records, and reports, and may charge the injured
17 employee an amount authorized by the agency division for the
18 copies. Each such health care provider shall provide to the
19 agency division any additional information about the remedial
20 treatment, care, and attendance that the agency division
21 reasonably requests.
22 (c) It is the policy for the administration of the
23 workers' compensation system that there be reasonable access
24 to medical information by all parties to facilitate the
25 self-executing features of the law. Notwithstanding the
26 limitations in s. 455.667 and subject to the limitations in s.
27 381.004, upon the request of the employer, the carrier, or the
28 attorney for either of them, the medical records of an injured
29 employee must be furnished to those persons and the medical
30 condition of the injured employee must be discussed with those
31 persons, if the records and the discussions are restricted to
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 conditions relating to the workplace injury. Any such
2 discussions may be held before or after the filing of a claim
3 without the knowledge, consent, or presence of any other party
4 or his or her agent or representative. A health care provider
5 who willfully refuses to provide medical records or to discuss
6 the medical condition of the injured employee, after a
7 reasonable request is made for such information pursuant to
8 this subsection, shall be subject by the agency division to
9 one or more of the penalties set forth in paragraph (8)(b).
10 (5) INDEPENDENT MEDICAL EXAMINATIONS.--
11 (a) In any dispute concerning overutilization, medical
12 benefits, compensability, or disability under this chapter,
13 the carrier or the employee may select an independent medical
14 examiner. The examiner may be a health care provider treating
15 or providing other care to the employee. An independent
16 medical examiner may not render an opinion outside his or her
17 area of expertise, as demonstrated by licensure and applicable
18 practice parameters.
19 (b) Each party is bound by his or her selection of an
20 independent medical examiner and is entitled to an alternate
21 examiner only if:
22 1. The examiner is not qualified to render an opinion
23 upon an aspect of the employee's illness or injury which is
24 material to the claim or petition for benefits;
25 2. The examiner ceases to practice in the specialty
26 relevant to the employee's condition;
27 3. The examiner is unavailable due to injury, death,
28 or relocation outside a reasonably accessible geographic area;
29 or
30 4. The parties agree to an alternate examiner.
31
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 Any party may request, or a judge of compensation claims may
2 require, designation of an agency a division medical advisor
3 as an independent medical examiner. The opinion of the
4 advisors acting as examiners shall not be afforded the
5 presumption set forth in paragraph (9)(c).
6 (c) The carrier may, at its election, contact the
7 claimant directly to schedule a reasonable time for an
8 independent medical examination. The carrier must confirm the
9 scheduling agreement in writing within 5 days and notify
10 claimant's counsel, if any, at least 7 days before the date
11 upon which the independent medical examination is scheduled to
12 occur. An attorney representing a claimant is not authorized
13 to schedule independent medical evaluations under this
14 subsection.
15 (d) If the employee fails to appear for the
16 independent medical examination without good cause and fails
17 to advise the physician at least 24 hours before the scheduled
18 date for the examination that he or she cannot appear, the
19 employee is barred from recovering compensation for any period
20 during which he or she has refused to submit to such
21 examination. Further, the employee shall reimburse the carrier
22 50 percent of the physician's cancellation or no-show fee
23 unless the carrier that schedules the examination fails to
24 timely provide to the employee a written confirmation of the
25 date of the examination pursuant to paragraph (c) which
26 includes an explanation of why he or she failed to appear. The
27 employee may appeal to a judge of compensation claims for
28 reimbursement when the carrier withholds payment in excess of
29 the authority granted by this section.
30 (e) No medical opinion other than the opinion of a
31 medical advisor appointed by the judge of compensation claims
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 or agency division, an independent medical examiner, or an
2 authorized treating provider is admissible in proceedings
3 before the judges of compensation claims.
4 (f) Attorney's fees incurred by an injured employee in
5 connection with delay of or opposition to an independent
6 medical examination, including, but not limited to, motions
7 for protective orders, are not recoverable under this chapter.
8 (6) UTILIZATION REVIEW.--Carriers shall review all
9 bills, invoices, and other claims for payment submitted by
10 health care providers in order to identify overutilization and
11 billing errors, and may hire peer review consultants or
12 conduct independent medical evaluations. Such consultants,
13 including peer review organizations, are immune from liability
14 in the execution of their functions under this subsection to
15 the extent provided in s. 766.101. If a carrier finds that
16 overutilization of medical services or a billing error has
17 occurred, it must disallow or adjust payment for such services
18 or error without order of a judge of compensation claims or
19 the agency division, if the carrier, in making its
20 determination, has complied with this section and rules
21 adopted by the agency division.
22 (7) UTILIZATION AND REIMBURSEMENT DISPUTES.--
23 (a) Any health care provider, carrier, or employer who
24 elects to contest the disallowance or adjustment of payment by
25 a carrier under subsection (6) must, within 30 days after
26 receipt of notice of disallowance or adjustment of payment,
27 petition the agency division to resolve the dispute. The
28 petitioner must serve a copy of the petition on the carrier
29 and on all affected parties by certified mail. The petition
30 must be accompanied by all documents and records that support
31 the allegations contained in the petition. Failure of a
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 petitioner to submit such documentation to the agency division
2 results in dismissal of the petition.
3 (b) The carrier must submit to the agency division
4 within 10 days after receipt of the petition all documentation
5 substantiating the carrier's disallowance or adjustment.
6 Failure of the carrier to submit the requested documentation
7 to the agency division within 10 days constitutes a waiver of
8 all objections to the petition.
9 (c) Within 60 days after receipt of all documentation,
10 the agency division must provide to the petitioner, the
11 carrier, and the affected parties a written determination of
12 whether the carrier properly adjusted or disallowed payment.
13 The agency division must be guided by standards and policies
14 set forth in this chapter, including all applicable
15 reimbursement schedules, in rendering its determination.
16 (d) If the agency division finds an improper
17 disallowance or improper adjustment of payment by an insurer,
18 the insurer shall reimburse the health care provider,
19 facility, insurer, or employer within 30 days, subject to the
20 penalties provided in this subsection.
21 (e) The agency division shall adopt rules to carry out
22 this subsection. The rules may include provisions for
23 consolidating petitions filed by a petitioner and expanding
24 the timetable for rendering a determination upon a
25 consolidated petition.
26 (f) Any carrier that engages in a pattern or practice
27 of arbitrarily or unreasonably disallowing or reducing
28 payments to health care providers may be subject to one or
29 more of the following penalties imposed by the agency
30 division:
31 1. Repayment of the appropriate amount to the health
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 care provider.
2 2. An administrative fine assessed by the agency
3 division in an amount not to exceed $5,000 per instance of
4 improperly disallowing or reducing payments.
5 3. Award of the health care provider's costs,
6 including a reasonable attorney's fee, for prosecuting the
7 petition.
8 (8) PATTERN OR PRACTICE OF OVERUTILIZATION.--
9 (a) Carriers must report to the agency division all
10 instances of overutilization including, but not limited to,
11 all instances in which the carrier disallows or adjusts
12 payment. The agency division shall determine whether a pattern
13 or practice of overutilization exists.
14 (b) If the agency division determines that a health
15 care provider has engaged in a pattern or practice of
16 overutilization or a violation of this chapter or rules
17 adopted by the agency division, it may impose one or more of
18 the following penalties:
19 1. An order of the agency division barring the
20 provider from payment under this chapter;
21 2. Deauthorization of care under review;
22 3. Denial of payment for care rendered in the future;
23 4. Decertification of a health care provider certified
24 as an expert medical advisor under subsection (9) or of a
25 rehabilitation provider certified under s. 440.49;
26 5. An administrative fine assessed by the agency
27 division in an amount not to exceed $5,000 per instance of
28 overutilization or violation; and
29 6. Notification of and review by the appropriate
30 licensing authority pursuant to s. 440.106(3).
31 (9) EXPERT MEDICAL ADVISORS.--
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 (a) The agency division shall certify expert medical
2 advisors in each specialty to assist the agency division and
3 the judges of compensation claims within the advisor's area of
4 expertise as provided in this section. The agency division
5 shall, in a manner prescribed by rule, in certifying,
6 recertifying, or decertifying an expert medical advisor,
7 consider the qualifications, training, impartiality, and
8 commitment of the health care provider to the provision of
9 quality medical care at a reasonable cost. As a prerequisite
10 for certification or recertification, the agency division
11 shall require, at a minimum, that an expert medical advisor
12 have specialized workers' compensation training or experience
13 under the workers' compensation system of this state and board
14 certification or board eligibility.
15 (b) The agency division shall contract with or employ
16 expert medical advisors to provide peer review or medical
17 consultation to the agency division or to a judge of
18 compensation claims in connection with resolving disputes
19 relating to reimbursement, differing opinions of health care
20 providers, and health care and physician services rendered
21 under this chapter. Expert medical advisors contracting with
22 the agency division shall, as a term of such contract, agree
23 to provide consultation or services in accordance with the
24 timetables set forth in this chapter and to abide by rules
25 adopted by the agency division, including, but not limited to,
26 rules pertaining to procedures for review of the services
27 rendered by health care providers and preparation of reports
28 and recommendations for submission to the agency division.
29 (c) If there is disagreement in the opinions of the
30 health care providers, if two health care providers disagree
31 on medical evidence supporting the employee's complaints or
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 the need for additional medical treatment, or if two health
2 care providers disagree that the employee is able to return to
3 work, the agency division may, and the judge of compensation
4 claims shall, upon his or her own motion or within 15 days
5 after receipt of a written request by either the injured
6 employee, the employer, or the carrier, order the injured
7 employee to be evaluated by an expert medical advisor. The
8 opinion of the expert medical advisor is presumed to be
9 correct unless there is clear and convincing evidence to the
10 contrary as determined by the judge of compensation claims.
11 The expert medical advisor appointed to conduct the evaluation
12 shall have free and complete access to the medical records of
13 the employee. An employee who fails to report to and cooperate
14 with such evaluation forfeits entitlement to compensation
15 during the period of failure to report or cooperate.
16 (d) The expert medical advisor must complete his or
17 her evaluation and issue his or her report to the agency
18 division or to the judge of compensation claims within 45 days
19 after receipt of all medical records. The expert medical
20 advisor must furnish a copy of the report to the carrier and
21 to the employee.
22 (e) An expert medical advisor is not liable under any
23 theory of recovery for evaluations performed under this
24 section without a showing of fraud or malice. The protections
25 of s. 766.101 apply to any officer, employee, or agent of the
26 agency division and to any officer, employee, or agent of any
27 entity with which the agency division has contracted under
28 this subsection.
29 (f) If the agency division or a judge of compensation
30 claims determines that the services of a certified expert
31 medical advisor are required to resolve a dispute under this
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 section, the carrier must compensate the advisor for his or
2 her time in accordance with a schedule adopted by the agency
3 division. The agency division may assess a penalty not to
4 exceed $500 against any carrier that fails to timely
5 compensate an advisor in accordance with this section.
6 (11) AUDITS BY AGENCY DIVISION; JURISDICTION.--
7 (a) The Agency for Health Care Administration Division
8 of Workers' Compensation of the Department of Labor and
9 Employment Security may investigate health care providers to
10 determine whether providers are complying with this chapter
11 and with rules adopted by the agency division, whether the
12 providers are engaging in overutilization, and whether
13 providers are engaging in improper billing practices. If the
14 agency division finds that a health care provider has
15 improperly billed, overutilized, or failed to comply with
16 agency division rules or the requirements of this chapter it
17 must notify the provider of its findings and may determine
18 that the health care provider may not receive payment from the
19 carrier or may impose penalties as set forth in subsection (8)
20 or other sections of this chapter. If the health care provider
21 has received payment from a carrier for services that were
22 improperly billed or for overutilization, it must return those
23 payments to the carrier. The agency division may assess a
24 penalty not to exceed $500 for each overpayment that is not
25 refunded within 30 days after notification of overpayment by
26 the agency division or carrier.
27 (b) The agency division shall monitor and audit
28 carriers to determine if medical bills are paid in accordance
29 with this section and agency division rules. Any employer, if
30 self-insured, or carrier found by the agency division not to
31 be within 90 percent compliance as to the payment of medical
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 bills after July 1, 1994, must be assessed a fine not to
2 exceed 1 percent of the prior year's assessment levied against
3 such entity under s. 440.51 for every quarter in which the
4 entity fails to attain 90-percent compliance. The agency
5 division shall fine an employer or carrier, pursuant to rules
6 adopted by the agency division, for each late payment of
7 compensation that is below the minimum 90-percent performance
8 standard. Any carrier that is found to be not in compliance in
9 subsequent consecutive quarters must implement a medical-bill
10 review program approved by the agency division, and the
11 carrier is subject to disciplinary action by the Department of
12 Insurance.
13 (c) The agency division has exclusive jurisdiction to
14 decide any matters concerning reimbursement, to resolve any
15 overutilization dispute under subsection (7), and to decide
16 any question concerning overutilization under subsection (8),
17 which question or dispute arises after January 1, 1994.
18 (d) The following division actions do not constitute
19 agency action subject to review under ss. 120.569 and 120.57
20 and do not constitute actions subject to s. 120.56: referral
21 by the entity responsible for utilization review; a decision
22 by the agency division to refer a matter to a peer review
23 committee; establishment by a health care provider or entity
24 of procedures by which a peer review committee reviews the
25 rendering of health care services; and the review proceedings,
26 report, and recommendation of the peer review committee.
27 (12) CREATION OF THREE-MEMBER PANEL; GUIDES OF MAXIMUM
28 REIMBURSEMENT ALLOWANCES.--
29 (a) A three-member panel is created, consisting of the
30 Insurance Commissioner, or the Insurance Commissioner's
31 designee, and two members to be appointed by the Governor,
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 subject to confirmation by the Senate, one member who, on
2 account of present or previous vocation, employment, or
3 affiliation, shall be classified as a representative of
4 employers, the other member who, on account of previous
5 vocation, employment, or affiliation, shall be classified as a
6 representative of employees. The panel shall determine
7 statewide schedules of maximum reimbursement allowances for
8 medically necessary treatment, care, and attendance provided
9 by physicians, hospitals, ambulatory surgical centers,
10 work-hardening programs, pain programs, and durable medical
11 equipment. The maximum reimbursement allowances for inpatient
12 hospital care shall be based on a schedule of per diem rates,
13 to be approved by the three-member panel no later than March
14 1, 1994, to be used in conjunction with a precertification
15 manual as determined by the agency division. All compensable
16 charges for hospital outpatient care shall be reimbursed at 75
17 percent of usual and customary charges. Until the three-member
18 panel approves a schedule of per diem rates for inpatient
19 hospital care and it becomes effective, all compensable
20 charges for hospital inpatient care must be reimbursed at 75
21 percent of their usual and customary charges. Annually, the
22 three-member panel shall adopt schedules of maximum
23 reimbursement allowances for physicians, hospital inpatient
24 care, hospital outpatient care, ambulatory surgical centers,
25 work-hardening programs, and pain programs. However, the
26 maximum percentage of increase in the individual reimbursement
27 allowance may not exceed the percentage of increase in the
28 Consumer Price Index for the previous year. An individual
29 physician, hospital, ambulatory surgical center, pain program,
30 or work-hardening program shall be reimbursed either the usual
31 and customary charge for treatment, care, and attendance, the
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 agreed-upon contract price, or the maximum reimbursement
2 allowance in the appropriate schedule, whichever is less.
3 (b) As to reimbursement for a prescription medication,
4 the reimbursement amount for a prescription shall be the
5 average wholesale price times 1.2 plus $4.18 for the
6 dispensing fee, except where the carrier has contracted for a
7 lower amount. Fees for pharmaceuticals and pharmaceutical
8 services shall be reimbursable at the applicable fee schedule
9 amount. Where the employer or carrier has contracted for such
10 services and the employee elects to obtain them through a
11 provider not a party to the contract, the carrier shall
12 reimburse at the schedule, negotiated, or contract price,
13 whichever is lower.
14 (c) Reimbursement for all fees and other charges for
15 such treatment, care, and attendance, including treatment,
16 care, and attendance provided by any hospital or other health
17 care provider, ambulatory surgical center, work-hardening
18 program, or pain program, must not exceed the amounts provided
19 by the uniform schedule of maximum reimbursement allowances as
20 determined by the panel or as otherwise provided in this
21 section. This subsection also applies to independent medical
22 examinations performed by health care providers under this
23 chapter. Until the three-member panel approves a uniform
24 schedule of maximum reimbursement allowances and it becomes
25 effective, all compensable charges for treatment, care, and
26 attendance provided by physicians, ambulatory surgical
27 centers, work-hardening programs, or pain programs shall be
28 reimbursed at the lowest maximum reimbursement allowance
29 across all 1992 schedules of maximum reimbursement allowances
30 for the services provided regardless of the place of service.
31 In determining the uniform schedule, the panel shall first
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 approve the data which it finds representative of prevailing
2 charges in the state for similar treatment, care, and
3 attendance of injured persons. Each health care provider,
4 health care facility, ambulatory surgical center,
5 work-hardening program, or pain program receiving workers'
6 compensation payments shall maintain records verifying their
7 usual charges. In establishing the uniform schedule of maximum
8 reimbursement allowances, the panel must consider:
9 1. The levels of reimbursement for similar treatment,
10 care, and attendance made by other health care programs or
11 third-party providers;
12 2. The impact upon cost to employers for providing a
13 level of reimbursement for treatment, care, and attendance
14 which will ensure the availability of treatment, care, and
15 attendance required by injured workers;
16 3. The financial impact of the reimbursement
17 allowances upon health care providers and health care
18 facilities, including trauma centers as defined in s. 395.401,
19 and its effect upon their ability to make available to injured
20 workers such medically necessary remedial treatment, care, and
21 attendance. The uniform schedule of maximum reimbursement
22 allowances must be reasonable, must promote health care cost
23 containment and efficiency with respect to the workers'
24 compensation health care delivery system, and must be
25 sufficient to ensure availability of such medically necessary
26 remedial treatment, care, and attendance to injured workers;
27 and
28 4. The most recent average maximum allowable rate of
29 increase for hospitals determined by the Health Care Board
30 under chapter 408.
31 (13) REMOVAL OF PHYSICIANS FROM LISTS OF THOSE
18
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 AUTHORIZED TO RENDER MEDICAL CARE.--The agency division shall
2 remove from the list of physicians or facilities authorized to
3 provide remedial treatment, care, and attendance under this
4 chapter the name of any physician or facility found after
5 reasonable investigation to have:
6 (a) Engaged in professional or other misconduct or
7 incompetency in connection with medical services rendered
8 under this chapter;
9 (b) Exceeded the limits of his or her or its
10 professional competence in rendering medical care under this
11 chapter, or to have made materially false statements regarding
12 his or her or its qualifications in his or her application;
13 (c) Failed to transmit copies of medical reports to
14 the employer or carrier, or failed to submit full and truthful
15 medical reports of all his or her or its findings to the
16 employer or carrier as required under this chapter;
17 (d) Solicited, or employed another to solicit for
18 himself or herself or itself or for another, professional
19 treatment, examination, or care of an injured employee in
20 connection with any claim under this chapter;
21 (e) Refused to appear before, or to answer upon
22 request of, the agency division or any duly authorized officer
23 of the state, any legal question, or to produce any relevant
24 book or paper concerning his or her conduct under any
25 authorization granted to him or her under this chapter;
26 (f) Self-referred in violation of this chapter or
27 other laws of this state; or
28 (g) Engaged in a pattern of practice of
29 overutilization or a violation of this chapter or rules
30 adopted by the agency division.
31 Section 43. Paragraph (a) of subsection (3) of section
19
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 440.15, Florida Statutes, is amended to read:
2 440.15 Compensation for disability.--Compensation for
3 disability shall be paid to the employee, subject to the
4 limits provided in s. 440.12(2), as follows:
5 (3) PERMANENT IMPAIRMENT AND WAGE-LOSS BENEFITS.--
6 (a) Impairment benefits.--
7 1. Once the employee has reached the date of maximum
8 medical improvement, impairment benefits are due and payable
9 within 20 days after the carrier has knowledge of the
10 impairment.
11 2. The three-member panel, in cooperation with the
12 agency division, shall establish and use a uniform permanent
13 impairment rating schedule. This schedule must be based on
14 medically or scientifically demonstrable findings as well as
15 the systems and criteria set forth in the American Medical
16 Association's Guides to the Evaluation of Permanent
17 Impairment; the Snellen Charts, published by American Medical
18 Association Committee for Eye Injuries; and the Minnesota
19 Department of Labor and Industry Disability Schedules. The
20 schedule should be based upon objective findings. The schedule
21 shall be more comprehensive than the AMA Guides to the
22 Evaluation of Permanent Impairment and shall expand the areas
23 already addressed and address additional areas not currently
24 contained in the guides. On August 1, 1979, and pending the
25 adoption, by rule, of a permanent schedule, Guides to the
26 Evaluation of Permanent Impairment, copyright 1977, 1971,
27 1988, by the American Medical Association, shall be the
28 temporary schedule and shall be used for the purposes hereof.
29 For injuries after July 1, 1990, pending the adoption by
30 division rule of a uniform disability rating schedule, the
31 Minnesota Department of Labor and Industry Disability Schedule
20
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 shall be used unless that schedule does not address an injury.
2 In such case, the Guides to the Evaluation of Permanent
3 Impairment by the American Medical Association shall be used.
4 Determination of permanent impairment under this schedule must
5 be made by a physician licensed under chapter 458, a doctor of
6 osteopathic medicine licensed under chapters 458 and 459, a
7 chiropractic physician licensed under chapter 460, a podiatric
8 physician licensed under chapter 461, an optometrist licensed
9 under chapter 463, or a dentist licensed under chapter 466, as
10 appropriate considering the nature of the injury. No other
11 persons are authorized to render opinions regarding the
12 existence of or the extent of permanent impairment.
13 3. All impairment income benefits shall be based on an
14 impairment rating using the impairment schedule referred to in
15 subparagraph 2. Impairment income benefits are paid weekly at
16 the rate of 50 percent of the employee's average weekly
17 temporary total disability benefit not to exceed the maximum
18 weekly benefit under s. 440.12. An employee's entitlement to
19 impairment income benefits begins the day after the employee
20 reaches maximum medical improvement or the expiration of
21 temporary benefits, whichever occurs earlier, and continues
22 until the earlier of:
23 a. The expiration of a period computed at the rate of
24 3 weeks for each percentage point of impairment; or
25 b. The death of the employee.
26 4. After the employee has been certified by a doctor
27 as having reached maximum medical improvement or 6 weeks
28 before the expiration of temporary benefits, whichever occurs
29 earlier, the certifying doctor shall evaluate the condition of
30 the employee and assign an impairment rating, using the
31 impairment schedule referred to in subparagraph 2.
21
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 Compensation is not payable for the mental, psychological, or
2 emotional injury arising out of depression from being out of
3 work. If the certification and evaluation are performed by a
4 doctor other than the employee's treating doctor, the
5 certification and evaluation must be submitted to the treating
6 doctor, and the treating doctor must indicate agreement or
7 disagreement with the certification and evaluation. The
8 certifying doctor shall issue a written report to the
9 division, the employee, and the carrier certifying that
10 maximum medical improvement has been reached, stating the
11 impairment rating, and providing any other information
12 required by the division. If the employee has not been
13 certified as having reached maximum medical improvement before
14 the expiration of 102 weeks after the date temporary total
15 disability benefits begin to accrue, the carrier shall notify
16 the treating doctor of the requirements of this section.
17 5. The carrier shall pay the employee impairment
18 income benefits for a period based on the impairment rating.
19 6. The division may by rule specify forms and
20 procedures governing the method of payment of wage loss and
21 impairment benefits for dates of accidents before January 1,
22 1994, and for dates of accidents on or after January 1, 1994.
23 Section 44. Subsection (7) of section 440.491, Florida
24 Statutes, is amended to read:
25 440.491 Reemployment of injured workers;
26 rehabilitation.--
27 (7) PROVIDER QUALIFICATIONS.--
28 (a) The Agency for Health Care Administration division
29 shall investigate and maintain a directory of each qualified
30 public and private rehabilitation provider, facility, and
31 agency, and shall establish by rule the minimum
22
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 qualifications, credentials, and requirements that each
2 rehabilitation service provider, facility, and agency must
3 satisfy to be eligible for listing in the directory. These
4 minimum qualifications and credentials must be based on those
5 generally accepted within the service specialty for which the
6 provider, facility, or agency is approved.
7 (b) The agency division shall impose a biennial
8 application fee of $25 for each listing in the directory, and
9 all such fees must be deposited in the Workers' Compensation
10 Administration Trust Fund.
11 (c) The agency division shall monitor and evaluate
12 each rehabilitation service provider, facility, and agency
13 qualified under this subsection to ensure its compliance with
14 the minimum qualifications and credentials established by the
15 division. The failure of a qualified rehabilitation service
16 provider, facility, or agency to provide the agency division
17 with information requested or access necessary for the agency
18 division to satisfy its responsibilities under this subsection
19 is grounds for disqualifying the provider, facility, or agency
20 from further referrals.
21 (d) A qualified rehabilitation service provider,
22 facility, or agency may not be authorized by an employer, a
23 carrier, or the agency division to provide any services,
24 including expert testimony, under this section in this state
25 unless the provider, facility, or agency is listed or has been
26 approved for listing in the directory. This restriction does
27 not apply to services provided outside this state under this
28 section.
29 (e) The agency division, after consultation with
30 representatives of employees, employers, carriers,
31 rehabilitation providers, and qualified training and education
23
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SENATE AMENDMENT
Bill No. CS for CS for SB 1206, 1st Eng.
Amendment No.
1 providers, shall adopt rules governing professional practices
2 and standards.
3
4 (Redesignate subsequent sections.)
5
6
7 ================ T I T L E A M E N D M E N T ===============
8 And the title is amended as follows:
9 On page 8, lines 27-31, delete those lines
10
11 and insert:
12 federal law; amending s. 440.02, F.S.;
13 providing a definition for the term "agency";
14 conforming definitions of "department" and
15 "division" to the transfer of the Division of
16 Workers' Compensation to the Department of
17 Insurance; amending s. 440.13, F.S., relating
18 to medical services and supplies under the
19 workers' compensation law; reassigning certain
20 functions from the Division of Workers'
21 Compensation to the Agency for Health Care
22 Administration; amending s. 440.15, F.S.;
23 providing for the agency to participate in the
24 establishment and use of a uniform permanent
25 impairment rating schedule; amending s.
26 440.491, F.S.; providing for agency oversight
27 of workers' compensation rehabilitation
28 providers; amending s. 440.207, F.S.;
29
30
31
24
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