| 1 | The Conference Committee on HB 5045 offered the following: |
| 2 |
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| 3 | Conference Committee Amendment (with title amendment) |
| 4 | Remove everything after the enacting clause and insert: |
| 5 | Section 1. All powers, duties, functions, rules, records, |
| 6 | personnel, property, and unexpended balances of appropriations, |
| 7 | allocations, and other funds of the Agency for Health Care |
| 8 | Administration with respect to the agency's responsibilities for |
| 9 | the provision of workers' compensation medical services and |
| 10 | supplies are transferred intact by a type two transfer, as |
| 11 | defined in s. 20.06(2), Florida Statutes, from the Agency for |
| 12 | Health Care Administration to the Department of Financial |
| 13 | Services. |
| 14 | Section 2. Subsections (1), (3), (6) through (9), and (11) |
| 15 | through (13) of section 440.13, Florida Statutes, are amended to |
| 16 | read: |
| 17 | 440.13 Medical services and supplies; penalty for |
| 18 | violations; limitations.-- |
| 19 | (1) DEFINITIONS.--As used in this section, the term: |
| 20 | (a) "Alternate medical care" means a change in treatment |
| 21 | or health care provider. |
| 22 | (b) "Attendant care" means care rendered by trained |
| 23 | professional attendants which is beyond the scope of household |
| 24 | duties. Family members may provide nonprofessional attendant |
| 25 | care, but may not be compensated under this chapter for care |
| 26 | that falls within the scope of household duties and other |
| 27 | services normally and gratuitously provided by family members. |
| 28 | "Family member" means a spouse, father, mother, brother, sister, |
| 29 | child, grandchild, father-in-law, mother-in-law, aunt, or uncle. |
| 30 | (c) "Carrier" means, for purposes of this section, |
| 31 | insurance carrier, self-insurance fund or individually self- |
| 32 | insured employer, or assessable mutual insurer. |
| 33 | (d) "Certified health care provider" means a health care |
| 34 | provider who has been certified by the department agency or who |
| 35 | has entered an agreement with a licensed managed care |
| 36 | organization to provide treatment to injured workers under this |
| 37 | section. Certification of such health care provider must include |
| 38 | documentation that the health care provider has read and is |
| 39 | familiar with the portions of the statute, impairment guides, |
| 40 | practice parameters, protocols of treatment, and rules which |
| 41 | govern the provision of remedial treatment, care, and |
| 42 | attendance. |
| 43 | (e) "Compensable" means a determination by a carrier or |
| 44 | judge of compensation claims that a condition suffered by an |
| 45 | employee results from an injury arising out of and in the course |
| 46 | of employment. |
| 47 | (f) "Emergency services and care" means emergency services |
| 48 | and care as defined in s. 395.002. |
| 49 | (g) "Health care facility" means any hospital licensed |
| 50 | under chapter 395 and any health care institution licensed under |
| 51 | chapter 400 or chapter 429. |
| 52 | (h) "Health care provider" means a physician or any |
| 53 | recognized practitioner who provides skilled services pursuant |
| 54 | to a prescription or under the supervision or direction of a |
| 55 | physician and who has been certified by the department agency as |
| 56 | a health care provider. The term "health care provider" includes |
| 57 | a health care facility. |
| 58 | (i) "Independent medical examiner" means a physician |
| 59 | selected by either an employee or a carrier to render one or |
| 60 | more independent medical examinations in connection with a |
| 61 | dispute arising under this chapter. |
| 62 | (j) "Independent medical examination" means an objective |
| 63 | evaluation of the injured employee's medical condition, |
| 64 | including, but not limited to, impairment or work status, |
| 65 | performed by a physician or an expert medical advisor at the |
| 66 | request of a party, a judge of compensation claims, or the |
| 67 | department agency to assist in the resolution of a dispute |
| 68 | arising under this chapter. |
| 69 | (k) "Instance of overutilization" means a specific |
| 70 | inappropriate service or level of service provided to an injured |
| 71 | employee that includes the provision of treatment in excess of |
| 72 | established practice parameters and protocols of treatment |
| 73 | established in accordance with this chapter. |
| 74 | (l) "Medically necessary" or "medical necessity" means any |
| 75 | medical service or medical supply which is used to identify or |
| 76 | treat an illness or injury, is appropriate to the patient's |
| 77 | diagnosis and status of recovery, and is consistent with the |
| 78 | location of service, the level of care provided, and applicable |
| 79 | practice parameters. The service should be widely accepted among |
| 80 | practicing health care providers, based on scientific criteria, |
| 81 | and determined to be reasonably safe. The service must not be of |
| 82 | an experimental, investigative, or research nature. |
| 83 | (m) "Medicine" means a drug prescribed by an authorized |
| 84 | health care provider and includes only generic drugs or single- |
| 85 | source patented drugs for which there is no generic equivalent, |
| 86 | unless the authorized health care provider writes or states that |
| 87 | the brand-name drug as defined in s. 465.025 is medically |
| 88 | necessary, or is a drug appearing on the schedule of drugs |
| 89 | created pursuant to s. 465.025(6), or is available at a cost |
| 90 | lower than its generic equivalent. |
| 91 | (n) "Palliative care" means noncurative medical services |
| 92 | that mitigate the conditions, effects, or pain of an injury. |
| 93 | (o) "Pattern or practice of overutilization" means |
| 94 | repetition of instances of overutilization within a specific |
| 95 | medical case or multiple cases by a single health care provider. |
| 96 | (p) "Peer review" means an evaluation by two or more |
| 97 | physicians licensed under the same authority and with the same |
| 98 | or similar specialty as the physician under review, of the |
| 99 | appropriateness, quality, and cost of health care and health |
| 100 | services provided to a patient, based on medically accepted |
| 101 | standards. |
| 102 | (q) "Physician" or "doctor" means a physician licensed |
| 103 | under chapter 458, an osteopathic physician licensed under |
| 104 | chapter 459, a chiropractic physician licensed under chapter |
| 105 | 460, a podiatric physician licensed under chapter 461, an |
| 106 | optometrist licensed under chapter 463, or a dentist licensed |
| 107 | under chapter 466, each of whom must be certified by the |
| 108 | department agency as a health care provider. |
| 109 | (r) "Reimbursement dispute" means any disagreement between |
| 110 | a health care provider or health care facility and carrier |
| 111 | concerning payment for medical treatment. |
| 112 | (s) "Utilization control" means a systematic process of |
| 113 | implementing measures that assure overall management and cost |
| 114 | containment of services delivered, including compliance with |
| 115 | practice parameters and protocols of treatment as provided for |
| 116 | in this chapter. |
| 117 | (t) "Utilization review" means the evaluation of the |
| 118 | appropriateness of both the level and the quality of health care |
| 119 | and health services provided to a patient, including, but not |
| 120 | limited to, evaluation of the appropriateness of treatment, |
| 121 | hospitalization, or office visits based on medically accepted |
| 122 | standards. Such evaluation must be accomplished by means of a |
| 123 | system that identifies the utilization of medical services based |
| 124 | on practice parameters and protocols of treatment as provided |
| 125 | for in this chapter. |
| 126 | (3) PROVIDER ELIGIBILITY; AUTHORIZATION.-- |
| 127 | (a) As a condition to eligibility for payment under this |
| 128 | chapter, a health care provider who renders services must be a |
| 129 | certified health care provider and must receive authorization |
| 130 | from the carrier before providing treatment. This paragraph does |
| 131 | not apply to emergency care. The department agency shall adopt |
| 132 | rules to implement the certification of health care providers. |
| 133 | (b) A health care provider who renders emergency care must |
| 134 | notify the carrier by the close of the third business day after |
| 135 | it has rendered such care. If the emergency care results in |
| 136 | admission of the employee to a health care facility, the health |
| 137 | care provider must notify the carrier by telephone within 24 |
| 138 | hours after initial treatment. Emergency care is not compensable |
| 139 | under this chapter unless the injury requiring emergency care |
| 140 | arose as a result of a work-related accident. Pursuant to |
| 141 | chapter 395, all licensed physicians and health care providers |
| 142 | in this state shall be required to make their services available |
| 143 | for emergency treatment of any employee eligible for workers' |
| 144 | compensation benefits. To refuse to make such treatment |
| 145 | available is cause for revocation of a license. |
| 146 | (c) A health care provider may not refer the employee to |
| 147 | another health care provider, diagnostic facility, therapy |
| 148 | center, or other facility without prior authorization from the |
| 149 | carrier, except when emergency care is rendered. Any referral |
| 150 | must be to a health care provider that has been certified by the |
| 151 | department agency, unless the referral is for emergency |
| 152 | treatment, and the referral must be made in accordance with |
| 153 | practice parameters and protocols of treatment as provided for |
| 154 | in this chapter. |
| 155 | (d) A carrier must respond, by telephone or in writing, to |
| 156 | a request for authorization from an authorized health care |
| 157 | provider by the close of the third business day after receipt of |
| 158 | the request. A carrier who fails to respond to a written request |
| 159 | for authorization for referral for medical treatment by the |
| 160 | close of the third business day after receipt of the request |
| 161 | consents to the medical necessity for such treatment. All such |
| 162 | requests must be made to the carrier. Notice to the carrier does |
| 163 | not include notice to the employer. |
| 164 | (e) Carriers shall adopt procedures for receiving, |
| 165 | reviewing, documenting, and responding to requests for |
| 166 | authorization. Such procedures shall be for a health care |
| 167 | provider certified under this section. |
| 168 | (f) By accepting payment under this chapter for treatment |
| 169 | rendered to an injured employee, a health care provider consents |
| 170 | to the jurisdiction of the department agency as set forth in |
| 171 | subsection (11) and to the submission of all records and other |
| 172 | information concerning such treatment to the department agency |
| 173 | in connection with a reimbursement dispute, audit, or review as |
| 174 | provided by this section. The health care provider must further |
| 175 | agree to comply with any decision of the department agency |
| 176 | rendered under this section. |
| 177 | (g) The employee is not liable for payment for medical |
| 178 | treatment or services provided pursuant to this section except |
| 179 | as otherwise provided in this section. |
| 180 | (h) The provisions of s. 456.053 are applicable to |
| 181 | referrals among health care providers, as defined in subsection |
| 182 | (1), treating injured workers. |
| 183 | (i) Notwithstanding paragraph (d), a claim for specialist |
| 184 | consultations, surgical operations, physiotherapeutic or |
| 185 | occupational therapy procedures, X-ray examinations, or special |
| 186 | diagnostic laboratory tests that cost more than $1,000 and other |
| 187 | specialty services that the department agency identifies by rule |
| 188 | is not valid and reimbursable unless the services have been |
| 189 | expressly authorized by the carrier, or unless the carrier has |
| 190 | failed to respond within 10 days to a written request for |
| 191 | authorization, or unless emergency care is required. The insurer |
| 192 | shall authorize such consultation or procedure unless the health |
| 193 | care provider or facility is not authorized or certified, unless |
| 194 | such treatment is not in accordance with practice parameters and |
| 195 | protocols of treatment established in this chapter, or unless a |
| 196 | judge of compensation claims has determined that the |
| 197 | consultation or procedure is not medically necessary, not in |
| 198 | accordance with the practice parameters and protocols of |
| 199 | treatment established in this chapter, or otherwise not |
| 200 | compensable under this chapter. Authorization of a treatment |
| 201 | plan does not constitute express authorization for purposes of |
| 202 | this section, except to the extent the carrier provides |
| 203 | otherwise in its authorization procedures. This paragraph does |
| 204 | not limit the carrier's obligation to identify and disallow |
| 205 | overutilization or billing errors. |
| 206 | (j) Notwithstanding anything in this chapter to the |
| 207 | contrary, a sick or injured employee shall be entitled, at all |
| 208 | times, to free, full, and absolute choice in the selection of |
| 209 | the pharmacy or pharmacist dispensing and filling prescriptions |
| 210 | for medicines required under this chapter. It is expressly |
| 211 | forbidden for the department agency, an employer, or a carrier, |
| 212 | or any agent or representative of the department agency, an |
| 213 | employer, or a carrier, to select the pharmacy or pharmacist |
| 214 | which the sick or injured employee must use; condition coverage |
| 215 | or payment on the basis of the pharmacy or pharmacist utilized; |
| 216 | or to otherwise interfere in the selection by the sick or |
| 217 | injured employee of a pharmacy or pharmacist. |
| 218 | (6) UTILIZATION REVIEW.--Carriers shall review all bills, |
| 219 | invoices, and other claims for payment submitted by health care |
| 220 | providers in order to identify overutilization and billing |
| 221 | errors, including compliance with practice parameters and |
| 222 | protocols of treatment established in accordance with this |
| 223 | chapter, and may hire peer review consultants or conduct |
| 224 | independent medical evaluations. Such consultants, including |
| 225 | peer review organizations, are immune from liability in the |
| 226 | execution of their functions under this subsection to the extent |
| 227 | provided in s. 766.101. If a carrier finds that overutilization |
| 228 | of medical services or a billing error has occurred, or there is |
| 229 | a violation of the practice parameters and protocols of |
| 230 | treatment established in accordance with this chapter, it must |
| 231 | disallow or adjust payment for such services or error without |
| 232 | order of a judge of compensation claims or the department |
| 233 | agency, if the carrier, in making its determination, has |
| 234 | complied with this section and rules adopted by the department |
| 235 | agency. |
| 236 | (7) UTILIZATION AND REIMBURSEMENT DISPUTES.-- |
| 237 | (a) Any health care provider, carrier, or employer who |
| 238 | elects to contest the disallowance or adjustment of payment by a |
| 239 | carrier under subsection (6) must, within 30 days after receipt |
| 240 | of notice of disallowance or adjustment of payment, petition the |
| 241 | department agency to resolve the dispute. The petitioner must |
| 242 | serve a copy of the petition on the carrier and on all affected |
| 243 | parties by certified mail. The petition must be accompanied by |
| 244 | all documents and records that support the allegations contained |
| 245 | in the petition. Failure of a petitioner to submit such |
| 246 | documentation to the department agency results in dismissal of |
| 247 | the petition. |
| 248 | (b) The carrier must submit to the department agency |
| 249 | within 10 days after receipt of the petition all documentation |
| 250 | substantiating the carrier's disallowance or adjustment. Failure |
| 251 | of the carrier to timely submit the requested documentation to |
| 252 | the department agency within 10 days constitutes a waiver of all |
| 253 | objections to the petition. |
| 254 | (c) Within 60 days after receipt of all documentation, the |
| 255 | department agency must provide to the petitioner, the carrier, |
| 256 | and the affected parties a written determination of whether the |
| 257 | carrier properly adjusted or disallowed payment. The department |
| 258 | agency must be guided by standards and policies set forth in |
| 259 | this chapter, including all applicable reimbursement schedules, |
| 260 | practice parameters, and protocols of treatment, in rendering |
| 261 | its determination. |
| 262 | (d) If the department agency finds an improper |
| 263 | disallowance or improper adjustment of payment by an insurer, |
| 264 | the insurer shall reimburse the health care provider, facility, |
| 265 | insurer, or employer within 30 days, subject to the penalties |
| 266 | provided in this subsection. |
| 267 | (e) The department agency shall adopt rules to carry out |
| 268 | this subsection. The rules may include provisions for |
| 269 | consolidating petitions filed by a petitioner and expanding the |
| 270 | timetable for rendering a determination upon a consolidated |
| 271 | petition. |
| 272 | (f) Any carrier that engages in a pattern or practice of |
| 273 | arbitrarily or unreasonably disallowing or reducing payments to |
| 274 | health care providers may be subject to one or more of the |
| 275 | following penalties imposed by the department agency: |
| 276 | 1. Repayment of the appropriate amount to the health care |
| 277 | provider. |
| 278 | 2. An administrative fine assessed by the department |
| 279 | agency in an amount not to exceed $5,000 per instance of |
| 280 | improperly disallowing or reducing payments. |
| 281 | 3. Award of the health care provider's costs, including a |
| 282 | reasonable attorney's fee, for prosecuting the petition. |
| 283 | (8) PATTERN OR PRACTICE OF OVERUTILIZATION.-- |
| 284 | (a) Carriers must report to the department agency all |
| 285 | instances of overutilization including, but not limited to, all |
| 286 | instances in which the carrier disallows or adjusts payment or a |
| 287 | determination has been made that the provided or recommended |
| 288 | treatment is in excess of the practice parameters and protocols |
| 289 | of treatment established in this chapter. The department agency |
| 290 | shall determine whether a pattern or practice of overutilization |
| 291 | exists. |
| 292 | (b) If the department agency determines that a health care |
| 293 | provider has engaged in a pattern or practice of overutilization |
| 294 | or a violation of this chapter or rules adopted by the |
| 295 | department agency, including a pattern or practice of providing |
| 296 | treatment in excess of the practice parameters or protocols of |
| 297 | treatment, it may impose one or more of the following penalties: |
| 298 | 1. An order of the department agency barring the provider |
| 299 | from payment under this chapter; |
| 300 | 2. Deauthorization of care under review; |
| 301 | 3. Denial of payment for care rendered in the future; |
| 302 | 4. Decertification of a health care provider certified as |
| 303 | an expert medical advisor under subsection (9) or of a |
| 304 | rehabilitation provider certified under s. 440.49; |
| 305 | 5. An administrative fine assessed by the department |
| 306 | agency in an amount not to exceed $5,000 per instance of |
| 307 | overutilization or violation; and |
| 308 | 6. Notification of and review by the appropriate licensing |
| 309 | authority pursuant to s. 440.106(3). |
| 310 | (9) EXPERT MEDICAL ADVISORS.-- |
| 311 | (a) The department agency shall certify expert medical |
| 312 | advisors in each specialty to assist the department agency and |
| 313 | the judges of compensation claims within the advisor's area of |
| 314 | expertise as provided in this section. The department agency |
| 315 | shall, in a manner prescribed by rule, in certifying, |
| 316 | recertifying, or decertifying an expert medical advisor, |
| 317 | consider the qualifications, training, impartiality, and |
| 318 | commitment of the health care provider to the provision of |
| 319 | quality medical care at a reasonable cost. As a prerequisite for |
| 320 | certification or recertification, the department agency shall |
| 321 | require, at a minimum, that an expert medical advisor have |
| 322 | specialized workers' compensation training or experience under |
| 323 | the workers' compensation system of this state and board |
| 324 | certification or board eligibility. |
| 325 | (b) The department agency shall contract with one or more |
| 326 | entities that employ, contract with, or otherwise secure expert |
| 327 | medical advisors to provide peer review or expert medical |
| 328 | consultation, opinions, and testimony to the department agency |
| 329 | or to a judge of compensation claims in connection with |
| 330 | resolving disputes relating to reimbursement, differing opinions |
| 331 | of health care providers, and health care and physician services |
| 332 | rendered under this chapter, including utilization issues. The |
| 333 | department agency shall by rule establish the qualifications of |
| 334 | expert medical advisors, including training and experience in |
| 335 | the workers' compensation system in the state and the expert |
| 336 | medical advisor's knowledge of and commitment to the standards |
| 337 | of care, practice parameters, and protocols established pursuant |
| 338 | to this chapter. Expert medical advisors contracting with the |
| 339 | department agency shall, as a term of such contract, agree to |
| 340 | provide consultation or services in accordance with the |
| 341 | timetables set forth in this chapter and to abide by rules |
| 342 | adopted by the department agency, including, but not limited to, |
| 343 | rules pertaining to procedures for review of the services |
| 344 | rendered by health care providers and preparation of reports and |
| 345 | testimony or recommendations for submission to the department |
| 346 | agency or the judge of compensation claims. |
| 347 | (c) If there is disagreement in the opinions of the health |
| 348 | care providers, if two health care providers disagree on medical |
| 349 | evidence supporting the employee's complaints or the need for |
| 350 | additional medical treatment, or if two health care providers |
| 351 | disagree that the employee is able to return to work, the |
| 352 | department agency may, and the judge of compensation claims |
| 353 | shall, upon his or her own motion or within 15 days after |
| 354 | receipt of a written request by either the injured employee, the |
| 355 | employer, or the carrier, order the injured employee to be |
| 356 | evaluated by an expert medical advisor. The opinion of the |
| 357 | expert medical advisor is presumed to be correct unless there is |
| 358 | clear and convincing evidence to the contrary as determined by |
| 359 | the judge of compensation claims. The expert medical advisor |
| 360 | appointed to conduct the evaluation shall have free and complete |
| 361 | access to the medical records of the employee. An employee who |
| 362 | fails to report to and cooperate with such evaluation forfeits |
| 363 | entitlement to compensation during the period of failure to |
| 364 | report or cooperate. |
| 365 | (d) The expert medical advisor must complete his or her |
| 366 | evaluation and issue his or her report to the department agency |
| 367 | or to the judge of compensation claims within 15 days after |
| 368 | receipt of all medical records. The expert medical advisor must |
| 369 | furnish a copy of the report to the carrier and to the employee. |
| 370 | (e) An expert medical advisor is not liable under any |
| 371 | theory of recovery for evaluations performed under this section |
| 372 | without a showing of fraud or malice. The protections of s. |
| 373 | 766.101 apply to any officer, employee, or agent of the |
| 374 | department agency and to any officer, employee, or agent of any |
| 375 | entity with which the department agency has contracted under |
| 376 | this subsection. |
| 377 | (f) If the department agency or a judge of compensation |
| 378 | claims orders the services of a certified expert medical advisor |
| 379 | to resolve a dispute under this section, the party requesting |
| 380 | such examination must compensate the advisor for his or her time |
| 381 | in accordance with a schedule adopted by the department agency. |
| 382 | If the employee prevails in a dispute as determined in an order |
| 383 | by a judge of compensation claims based upon the expert medical |
| 384 | advisor's findings, the employer or carrier shall pay for the |
| 385 | costs of such expert medical advisor. If a judge of compensation |
| 386 | claims, upon his or her motion, finds that an expert medical |
| 387 | advisor is needed to resolve the dispute, the carrier must |
| 388 | compensate the advisor for his or her time in accordance with a |
| 389 | schedule adopted by the department agency. The department agency |
| 390 | may assess a penalty not to exceed $500 against any carrier that |
| 391 | fails to timely compensate an advisor in accordance with this |
| 392 | section. |
| 393 | (11) AUDITS.-- |
| 394 | (a) The department Agency for Health Care Administration |
| 395 | may investigate health care providers to determine whether |
| 396 | providers are complying with this chapter and with rules adopted |
| 397 | by the department agency, whether the providers are engaging in |
| 398 | overutilization, whether providers are engaging in improper |
| 399 | billing practices, and whether providers are adhering to |
| 400 | practice parameters and protocols established in accordance with |
| 401 | this chapter. If the department agency finds that a health care |
| 402 | provider has improperly billed, overutilized, or failed to |
| 403 | comply with department agency rules or the requirements of this |
| 404 | chapter, including, but not limited to, practice parameters and |
| 405 | protocols established in accordance with this chapter, it must |
| 406 | notify the provider of its findings and may determine that the |
| 407 | health care provider may not receive payment from the carrier or |
| 408 | may impose penalties as set forth in subsection (8) or other |
| 409 | sections of this chapter. If the health care provider has |
| 410 | received payment from a carrier for services that were |
| 411 | improperly billed, that constitute overutilization, or that were |
| 412 | outside practice parameters or protocols established in |
| 413 | accordance with this chapter, it must return those payments to |
| 414 | the carrier. The department agency may assess a penalty not to |
| 415 | exceed $500 for each overpayment that is not refunded within 30 |
| 416 | days after notification of overpayment by the department agency |
| 417 | or carrier. |
| 418 | (b) The department shall monitor carriers as provided in |
| 419 | this chapter and the Office of Insurance Regulation shall audit |
| 420 | insurers and group self-insurance funds as provided in s. |
| 421 | 624.3161, to determine if medical bills are paid in accordance |
| 422 | with this section and rules of the department and Financial |
| 423 | Services Commission, respectively. Any employer, if self- |
| 424 | insured, or carrier found by the department or Office of |
| 425 | Insurance Regulation not to be within 90 percent compliance as |
| 426 | to the payment of medical bills after July 1, 1994, must be |
| 427 | assessed a fine not to exceed 1 percent of the prior year's |
| 428 | assessment levied against such entity under s. 440.51 for every |
| 429 | quarter in which the entity fails to attain 90-percent |
| 430 | compliance. The department shall fine or otherwise discipline an |
| 431 | employer or carrier, pursuant to this chapter or rules adopted |
| 432 | by the department, and the Office of Insurance Regulation shall |
| 433 | fine or otherwise discipline an insurer or group self-insurance |
| 434 | fund pursuant to the insurance code or rules adopted by the |
| 435 | Financial Services Commission, for each late payment of |
| 436 | compensation that is below the minimum 95-percent performance |
| 437 | standard. Any carrier that is found to be not in compliance in |
| 438 | subsequent consecutive quarters must implement a medical-bill |
| 439 | review program approved by the department or office, and an |
| 440 | insurer or group self-insurance fund is subject to disciplinary |
| 441 | action by the Office of Insurance Regulation. |
| 442 | (c) The department agency has exclusive jurisdiction to |
| 443 | decide any matters concerning reimbursement, to resolve any |
| 444 | overutilization dispute under subsection (7), and to decide any |
| 445 | question concerning overutilization under subsection (8), which |
| 446 | question or dispute arises after January 1, 1994. |
| 447 | (d) The following department agency actions do not |
| 448 | constitute agency action subject to review under ss. 120.569 and |
| 449 | 120.57 and do not constitute actions subject to s. 120.56: |
| 450 | referral by the entity responsible for utilization review; a |
| 451 | decision by the department agency to refer a matter to a peer |
| 452 | review committee; establishment by a health care provider or |
| 453 | entity of procedures by which a peer review committee reviews |
| 454 | the rendering of health care services; and the review |
| 455 | proceedings, report, and recommendation of the peer review |
| 456 | committee. |
| 457 | (12) CREATION OF THREE-MEMBER PANEL; GUIDES OF MAXIMUM |
| 458 | REIMBURSEMENT ALLOWANCES.-- |
| 459 | (a) A three-member panel is created, consisting of the |
| 460 | Chief Financial Officer, or the Chief Financial Officer's |
| 461 | designee, and two members to be appointed by the Governor, |
| 462 | subject to confirmation by the Senate, one member who, on |
| 463 | account of present or previous vocation, employment, or |
| 464 | affiliation, shall be classified as a representative of |
| 465 | employers, the other member who, on account of previous |
| 466 | vocation, employment, or affiliation, shall be classified as a |
| 467 | representative of employees. The panel shall determine statewide |
| 468 | schedules of maximum reimbursement allowances for medically |
| 469 | necessary treatment, care, and attendance provided by |
| 470 | physicians, hospitals, ambulatory surgical centers, work- |
| 471 | hardening programs, pain programs, and durable medical |
| 472 | equipment. The maximum reimbursement allowances for inpatient |
| 473 | hospital care shall be based on a schedule of per diem rates, to |
| 474 | be approved by the three-member panel no later than March 1, |
| 475 | 1994, to be used in conjunction with a precertification manual |
| 476 | as determined by the department, including maximum hours in |
| 477 | which an outpatient may remain in observation status, which |
| 478 | shall not exceed 23 hours. All compensable charges for hospital |
| 479 | outpatient care shall be reimbursed at 75 percent of usual and |
| 480 | customary charges, except as otherwise provided by this |
| 481 | subsection. Annually, the three-member panel shall adopt |
| 482 | schedules of maximum reimbursement allowances for physicians, |
| 483 | hospital inpatient care, hospital outpatient care, ambulatory |
| 484 | surgical centers, work-hardening programs, and pain programs. An |
| 485 | individual physician, hospital, ambulatory surgical center, pain |
| 486 | program, or work-hardening program shall be reimbursed either |
| 487 | the agreed-upon contract price or the maximum reimbursement |
| 488 | allowance in the appropriate schedule. |
| 489 | (b) It is the intent of the Legislature to increase the |
| 490 | schedule of maximum reimbursement allowances for selected |
| 491 | physicians effective January 1, 2004, and to pay for the |
| 492 | increases through reductions in payments to hospitals. Revisions |
| 493 | developed pursuant to this subsection are limited to the |
| 494 | following: |
| 495 | 1. Payments for outpatient physical, occupational, and |
| 496 | speech therapy provided by hospitals shall be reduced to the |
| 497 | schedule of maximum reimbursement allowances for these services |
| 498 | which applies to nonhospital providers. |
| 499 | 2. Payments for scheduled outpatient nonemergency |
| 500 | radiological and clinical laboratory services that are not |
| 501 | provided in conjunction with a surgical procedure shall be |
| 502 | reduced to the schedule of maximum reimbursement allowances for |
| 503 | these services which applies to nonhospital providers. |
| 504 | 3. Outpatient reimbursement for scheduled surgeries shall |
| 505 | be reduced from 75 percent of charges to 60 percent of charges. |
| 506 | 4. Maximum reimbursement for a physician licensed under |
| 507 | chapter 458 or chapter 459 shall be increased to 110 percent of |
| 508 | the reimbursement allowed by Medicare, using appropriate codes |
| 509 | and modifiers or the medical reimbursement level adopted by the |
| 510 | three-member panel as of January 1, 2003, whichever is greater. |
| 511 | 5. Maximum reimbursement for surgical procedures shall be |
| 512 | increased to 140 percent of the reimbursement allowed by |
| 513 | Medicare or the medical reimbursement level adopted by the |
| 514 | three-member panel as of January 1, 2003, whichever is greater. |
| 515 | (c) As to reimbursement for a prescription medication, the |
| 516 | reimbursement amount for a prescription shall be the average |
| 517 | wholesale price plus $4.18 for the dispensing fee, except where |
| 518 | the carrier has contracted for a lower amount. Fees for |
| 519 | pharmaceuticals and pharmaceutical services shall be |
| 520 | reimbursable at the applicable fee schedule amount. Where the |
| 521 | employer or carrier has contracted for such services and the |
| 522 | employee elects to obtain them through a provider not a party to |
| 523 | the contract, the carrier shall reimburse at the schedule, |
| 524 | negotiated, or contract price, whichever is lower. No such |
| 525 | contract shall rely on a provider that is not reasonably |
| 526 | accessible to the employee. |
| 527 | (d) Reimbursement for all fees and other charges for such |
| 528 | treatment, care, and attendance, including treatment, care, and |
| 529 | attendance provided by any hospital or other health care |
| 530 | provider, ambulatory surgical center, work-hardening program, or |
| 531 | pain program, must not exceed the amounts provided by the |
| 532 | uniform schedule of maximum reimbursement allowances as |
| 533 | determined by the panel or as otherwise provided in this |
| 534 | section. This subsection also applies to independent medical |
| 535 | examinations performed by health care providers under this |
| 536 | chapter. In determining the uniform schedule, the panel shall |
| 537 | first approve the data which it finds representative of |
| 538 | prevailing charges in the state for similar treatment, care, and |
| 539 | attendance of injured persons. Each health care provider, health |
| 540 | care facility, ambulatory surgical center, work-hardening |
| 541 | program, or pain program receiving workers' compensation |
| 542 | payments shall maintain records verifying their usual charges. |
| 543 | In establishing the uniform schedule of maximum reimbursement |
| 544 | allowances, the panel must consider: |
| 545 | 1. The levels of reimbursement for similar treatment, |
| 546 | care, and attendance made by other health care programs or |
| 547 | third-party providers; |
| 548 | 2. The impact upon cost to employers for providing a level |
| 549 | of reimbursement for treatment, care, and attendance which will |
| 550 | ensure the availability of treatment, care, and attendance |
| 551 | required by injured workers; |
| 552 | 3. The financial impact of the reimbursement allowances |
| 553 | upon health care providers and health care facilities, including |
| 554 | trauma centers as defined in s. 395.4001, and its effect upon |
| 555 | their ability to make available to injured workers such |
| 556 | medically necessary remedial treatment, care, and attendance. |
| 557 | The uniform schedule of maximum reimbursement allowances must be |
| 558 | reasonable, must promote health care cost containment and |
| 559 | efficiency with respect to the workers' compensation health care |
| 560 | delivery system, and must be sufficient to ensure availability |
| 561 | of such medically necessary remedial treatment, care, and |
| 562 | attendance to injured workers; and |
| 563 | 4. The most recent average maximum allowable rate of |
| 564 | increase for hospitals determined by the Health Care Board under |
| 565 | chapter 408. |
| 566 | (e) In addition to establishing the uniform schedule of |
| 567 | maximum reimbursement allowances, the panel shall: |
| 568 | 1. Take testimony, receive records, and collect data to |
| 569 | evaluate the adequacy of the workers' compensation fee schedule, |
| 570 | nationally recognized fee schedules and alternative methods of |
| 571 | reimbursement to certified health care providers and health care |
| 572 | facilities for inpatient and outpatient treatment and care. |
| 573 | 2. Survey certified health care providers and health care |
| 574 | facilities to determine the availability and accessibility of |
| 575 | workers' compensation health care delivery systems for injured |
| 576 | workers. |
| 577 | 3. Survey carriers to determine the estimated impact on |
| 578 | carrier costs and workers' compensation premium rates by |
| 579 | implementing changes to the carrier reimbursement schedule or |
| 580 | implementing alternative reimbursement methods. |
| 581 | 4. Submit recommendations on or before January 1, 2003, |
| 582 | and biennially thereafter, to the President of the Senate and |
| 583 | the Speaker of the House of Representatives on methods to |
| 584 | improve the workers' compensation health care delivery system. |
| 585 |
|
| 586 | The agency and the department, as requested, shall provide data |
| 587 | to the panel, including, but not limited to, utilization trends |
| 588 | in the workers' compensation health care delivery system. The |
| 589 | department agency shall provide the panel with an annual report |
| 590 | regarding the resolution of medical reimbursement disputes and |
| 591 | any actions pursuant to s. 440.13(8). The department shall |
| 592 | provide administrative support and service to the panel to the |
| 593 | extent requested by the panel. |
| 594 | (13) REMOVAL OF PHYSICIANS FROM LISTS OF THOSE AUTHORIZED |
| 595 | TO RENDER MEDICAL CARE.--The department agency shall remove from |
| 596 | the list of physicians or facilities authorized to provide |
| 597 | remedial treatment, care, and attendance under this chapter the |
| 598 | name of any physician or facility found after reasonable |
| 599 | investigation to have: |
| 600 | (a) Engaged in professional or other misconduct or |
| 601 | incompetency in connection with medical services rendered under |
| 602 | this chapter; |
| 603 | (b) Exceeded the limits of his or her or its professional |
| 604 | competence in rendering medical care under this chapter, or to |
| 605 | have made materially false statements regarding his or her or |
| 606 | its qualifications in his or her application; |
| 607 | (c) Failed to transmit copies of medical reports to the |
| 608 | employer or carrier, or failed to submit full and truthful |
| 609 | medical reports of all his or her or its findings to the |
| 610 | employer or carrier as required under this chapter; |
| 611 | (d) Solicited, or employed another to solicit for himself |
| 612 | or herself or itself or for another, professional treatment, |
| 613 | examination, or care of an injured employee in connection with |
| 614 | any claim under this chapter; |
| 615 | (e) Refused to appear before, or to answer upon request |
| 616 | of, the department agency or any duly authorized officer of the |
| 617 | state, any legal question, or to produce any relevant book or |
| 618 | paper concerning his or her conduct under any authorization |
| 619 | granted to him or her under this chapter; |
| 620 | (f) Self-referred in violation of this chapter or other |
| 621 | laws of this state; or |
| 622 | (g) Engaged in a pattern of practice of overutilization or |
| 623 | a violation of this chapter or rules adopted by the department |
| 624 | agency, including failure to adhere to practice parameters and |
| 625 | protocols established in accordance with this chapter. |
| 626 | Section 3. This act shall take effect July 1, 2008. |
| 627 |
|
| 628 | ----------------------------------------------------- |
| 629 | T I T L E A M E N D M E N T |
| 630 | Remove the entire title and insert: |
| 631 | A bill to be entitled |
| 632 | An act relating to workers' compensation medical services |
| 633 | and supplies; providing for a type two transfer of |
| 634 | responsibilities with respect to the provision of workers' |
| 635 | compensation medical services and supplies from the Agency |
| 636 | for Health Care Administration to the Department of |
| 637 | Financial Services; amending s. 440.13, F.S.; revising |
| 638 | terminology, to conform; providing an effective date. |