HB 5045

1	A bill to be entitled
2	An act relating to workers' compensation medical services
3	and supplies; providing for a type two transfer of
4	responsibilities with respect to the provision of workers'
5	compensation medical services and supplies from the Agency
6	for Health Care Administration to the Department of
7	Financial Services; amending ss. 440.13 and 440.125, F.S.;
8	revising terminology and removing language relating to the
9	sharing and maintenance of confidential medical records,
10	reports, and information, to conform; providing an
11	effective date.
12
13	Be It Enacted by the Legislature of the State of Florida:
14
15	Section 1.  All powers, duties, functions, rules, records,
16	personnel, property, and unexpended balances of appropriations,
17	allocations, and other funds of the Agency for Health Care
18	Administration with respect to the agency's responsibilities for
19	the provision of workers' compensation medical services and
20	supplies are transferred intact by a type two transfer, as
21	defined in s. 20.06(2), Florida Statutes, from the Agency for
22	Health Care Administration to the Department of Financial
23	Services.
24	Section 2.  Subsections (1), (3), (6) through (9), and (11)
25	through (13) of section 440.13, Florida Statutes, are amended to
26	read:
27	440.13  Medical services and supplies; penalty for
28	violations; limitations.--
29	(1)  DEFINITIONS.--As used in this section, the term:
30	(a)  "Alternate medical care" means a change in treatment
31	or health care provider.
32	(b)  "Attendant care" means care rendered by trained
33	professional attendants which is beyond the scope of household
34	duties. Family members may provide nonprofessional attendant
35	care, but may not be compensated under this chapter for care
36	that falls within the scope of household duties and other
37	services normally and gratuitously provided by family members.
38	"Family member" means a spouse, father, mother, brother, sister,
39	child, grandchild, father-in-law, mother-in-law, aunt, or uncle.
40	(c)  "Carrier" means, for purposes of this section,
41	insurance carrier, self-insurance fund or individually self-
42	insured employer, or assessable mutual insurer.
43	(d)  "Certified health care provider" means a health care
44	provider who has been certified by the department agency or who
45	has entered an agreement with a licensed managed care
46	organization to provide treatment to injured workers under this
47	section. Certification of such health care provider must include
48	documentation that the health care provider has read and is
49	familiar with the portions of the statute, impairment guides,
50	practice parameters, protocols of treatment, and rules which
51	govern the provision of remedial treatment, care, and
52	attendance.
53	(e)  "Compensable" means a determination by a carrier or
54	judge of compensation claims that a condition suffered by an
55	employee results from an injury arising out of and in the course
56	of employment.
57	(f)  "Emergency services and care" means emergency services
58	and care as defined in s. 395.002.
59	(g)  "Health care facility" means any hospital licensed
60	under chapter 395 and any health care institution licensed under
61	chapter 400 or chapter 429.
62	(h)  "Health care provider" means a physician or any
63	recognized practitioner who provides skilled services pursuant
64	to a prescription or under the supervision or direction of a
65	physician and who has been certified by the department agency as
66	a health care provider. The term "health care provider" includes
67	a health care facility.
68	(i)  "Independent medical examiner" means a physician
69	selected by either an employee or a carrier to render one or
70	more independent medical examinations in connection with a
71	dispute arising under this chapter.
72	(j)  "Independent medical examination" means an objective
73	evaluation of the injured employee's medical condition,
74	including, but not limited to, impairment or work status,
75	performed by a physician or an expert medical advisor at the
76	request of a party, a judge of compensation claims, or the
77	department agency to assist in the resolution of a dispute
78	arising under this chapter.
79	(k)  "Instance of overutilization" means a specific
80	inappropriate service or level of service provided to an injured
81	employee that includes the provision of treatment in excess of
82	established practice parameters and protocols of treatment
83	established in accordance with this chapter.
84	(l)  "Medically necessary" or "medical necessity" means any
85	medical service or medical supply which is used to identify or
86	treat an illness or injury, is appropriate to the patient's
87	diagnosis and status of recovery, and is consistent with the
88	location of service, the level of care provided, and applicable
89	practice parameters. The service should be widely accepted among
90	practicing health care providers, based on scientific criteria,
91	and determined to be reasonably safe. The service must not be of
92	an experimental, investigative, or research nature.
93	(m)  "Medicine" means a drug prescribed by an authorized
94	health care provider and includes only generic drugs or single-
95	source patented drugs for which there is no generic equivalent,
96	unless the authorized health care provider writes or states that
97	the brand-name drug as defined in s. 465.025 is medically
98	necessary, or is a drug appearing on the schedule of drugs
99	created pursuant to s. 465.025(6), or is available at a cost
100	lower than its generic equivalent.
101	(n)  "Palliative care" means noncurative medical services
102	that mitigate the conditions, effects, or pain of an injury.
103	(o)  "Pattern or practice of overutilization" means
104	repetition of instances of overutilization within a specific
105	medical case or multiple cases by a single health care provider.
106	(p)  "Peer review" means an evaluation by two or more
107	physicians licensed under the same authority and with the same
108	or similar specialty as the physician under review, of the
109	appropriateness, quality, and cost of health care and health
110	services provided to a patient, based on medically accepted
111	standards.
112	(q)  "Physician" or "doctor" means a physician licensed
113	under chapter 458, an osteopathic physician licensed under
114	chapter 459, a chiropractic physician licensed under chapter
115	460, a podiatric physician licensed under chapter 461, an
116	optometrist licensed under chapter 463, or a dentist licensed
117	under chapter 466, each of whom must be certified by the
118	department agency as a health care provider.
119	(r)  "Reimbursement dispute" means any disagreement between
120	a health care provider or health care facility and carrier
121	concerning payment for medical treatment.
122	(s)  "Utilization control" means a systematic process of
123	implementing measures that assure overall management and cost
124	containment of services delivered, including compliance with
125	practice parameters and protocols of treatment as provided for
126	in this chapter.
127	(t)  "Utilization review" means the evaluation of the
128	appropriateness of both the level and the quality of health care
129	and health services provided to a patient, including, but not
130	limited to, evaluation of the appropriateness of treatment,
131	hospitalization, or office visits based on medically accepted
132	standards. Such evaluation must be accomplished by means of a
133	system that identifies the utilization of medical services based
134	on practice parameters and protocols of treatment as provided
135	for in this chapter.
136	(3)  PROVIDER ELIGIBILITY; AUTHORIZATION.--
137	(a)  As a condition to eligibility for payment under this
138	chapter, a health care provider who renders services must be a
139	certified health care provider and must receive authorization
140	from the carrier before providing treatment. This paragraph does
141	not apply to emergency care. The department agency shall adopt
142	rules to implement the certification of health care providers.
143	(b)  A health care provider who renders emergency care must
144	notify the carrier by the close of the third business day after
145	it has rendered such care. If the emergency care results in
146	admission of the employee to a health care facility, the health
147	care provider must notify the carrier by telephone within 24
148	hours after initial treatment. Emergency care is not compensable
149	under this chapter unless the injury requiring emergency care
150	arose as a result of a work-related accident. Pursuant to
151	chapter 395, all licensed physicians and health care providers
152	in this state shall be required to make their services available
153	for emergency treatment of any employee eligible for workers'
154	compensation benefits. To refuse to make such treatment
155	available is cause for revocation of a license.
156	(c)  A health care provider may not refer the employee to
157	another health care provider, diagnostic facility, therapy
158	center, or other facility without prior authorization from the
159	carrier, except when emergency care is rendered. Any referral
160	must be to a health care provider that has been certified by the
161	department agency, unless the referral is for emergency
162	treatment, and the referral must be made in accordance with
163	practice parameters and protocols of treatment as provided for
164	in this chapter.
165	(d)  A carrier must respond, by telephone or in writing, to
166	a request for authorization from an authorized health care
167	provider by the close of the third business day after receipt of
168	the request. A carrier who fails to respond to a written request
169	for authorization for referral for medical treatment by the
170	close of the third business day after receipt of the request
171	consents to the medical necessity for such treatment. All such
172	requests must be made to the carrier. Notice to the carrier does
173	not include notice to the employer.
174	(e)  Carriers shall adopt procedures for receiving,
175	reviewing, documenting, and responding to requests for
176	authorization. Such procedures shall be for a health care
177	provider certified under this section.
178	(f)  By accepting payment under this chapter for treatment
179	rendered to an injured employee, a health care provider consents
180	to the jurisdiction of the department agency as set forth in
181	subsection (11) and to the submission of all records and other
182	information concerning such treatment to the department agency
183	in connection with a reimbursement dispute, audit, or review as
184	provided by this section. The health care provider must further
185	agree to comply with any decision of the department agency
186	rendered under this section.
187	(g)  The employee is not liable for payment for medical
188	treatment or services provided pursuant to this section except
189	as otherwise provided in this section.
190	(h)  The provisions of s. 456.053 are applicable to
191	referrals among health care providers, as defined in subsection
192	(1), treating injured workers.
193	(i)  Notwithstanding paragraph (d), a claim for specialist
194	consultations, surgical operations, physiotherapeutic or
195	occupational therapy procedures, X-ray examinations, or special
196	diagnostic laboratory tests that cost more than $1,000 and other
197	specialty services that the department agency identifies by rule
198	is not valid and reimbursable unless the services have been
199	expressly authorized by the carrier, or unless the carrier has
200	failed to respond within 10 days to a written request for
201	authorization, or unless emergency care is required. The insurer
202	shall authorize such consultation or procedure unless the health
203	care provider or facility is not authorized or certified, unless
204	such treatment is not in accordance with practice parameters and
205	protocols of treatment established in this chapter, or unless a
206	judge of compensation claims has determined that the
207	consultation or procedure is not medically necessary, not in
208	accordance with the practice parameters and protocols of
209	treatment established in this chapter, or otherwise not
210	compensable under this chapter. Authorization of a treatment
211	plan does not constitute express authorization for purposes of
212	this section, except to the extent the carrier provides
213	otherwise in its authorization procedures. This paragraph does
214	not limit the carrier's obligation to identify and disallow
215	overutilization or billing errors.
216	(j)  Notwithstanding anything in this chapter to the
217	contrary, a sick or injured employee shall be entitled, at all
218	times, to free, full, and absolute choice in the selection of
219	the pharmacy or pharmacist dispensing and filling prescriptions
220	for medicines required under this chapter. It is expressly
221	forbidden for the department agency, an employer, or a carrier,
222	or any agent or representative of the department agency, an
223	employer, or a carrier, to select the pharmacy or pharmacist
224	which the sick or injured employee must use; condition coverage
225	or payment on the basis of the pharmacy or pharmacist utilized;
226	or to otherwise interfere in the selection by the sick or
227	injured employee of a pharmacy or pharmacist.
228	(6)  UTILIZATION REVIEW.--Carriers shall review all bills,
229	invoices, and other claims for payment submitted by health care
230	providers in order to identify overutilization and billing
231	errors, including compliance with practice parameters and
232	protocols of treatment established in accordance with this
233	chapter, and may hire peer review consultants or conduct
234	independent medical evaluations. Such consultants, including
235	peer review organizations, are immune from liability in the
236	execution of their functions under this subsection to the extent
237	provided in s. 766.101. If a carrier finds that overutilization
238	of medical services or a billing error has occurred, or there is
239	a violation of the practice parameters and protocols of
240	treatment established in accordance with this chapter, it must
241	disallow or adjust payment for such services or error without
242	order of a judge of compensation claims or the department
243	agency, if the carrier, in making its determination, has
244	complied with this section and rules adopted by the department
245	agency.
246	(7)  UTILIZATION AND REIMBURSEMENT DISPUTES.--
247	(a)  Any health care provider, carrier, or employer who
248	elects to contest the disallowance or adjustment of payment by a
249	carrier under subsection (6) must, within 30 days after receipt
250	of notice of disallowance or adjustment of payment, petition the
251	department agency to resolve the dispute. The petitioner must
252	serve a copy of the petition on the carrier and on all affected
253	parties by certified mail. The petition must be accompanied by
254	all documents and records that support the allegations contained
255	in the petition. Failure of a petitioner to submit such
256	documentation to the department agency results in dismissal of
257	the petition.
258	(b)  The carrier must submit to the department agency
259	within 10 days after receipt of the petition all documentation
260	substantiating the carrier's disallowance or adjustment. Failure
261	of the carrier to timely submit the requested documentation to
262	the department agency within 10 days constitutes a waiver of all
263	objections to the petition.
264	(c)  Within 60 days after receipt of all documentation, the
265	department agency must provide to the petitioner, the carrier,
266	and the affected parties a written determination of whether the
267	carrier properly adjusted or disallowed payment. The department
268	agency must be guided by standards and policies set forth in
269	this chapter, including all applicable reimbursement schedules,
270	practice parameters, and protocols of treatment, in rendering
271	its determination.
272	(d)  If the department agency finds an improper
273	disallowance or improper adjustment of payment by an insurer,
274	the insurer shall reimburse the health care provider, facility,
275	insurer, or employer within 30 days, subject to the penalties
276	provided in this subsection.
277	(e)  The department agency shall adopt rules to carry out
278	this subsection. The rules may include provisions for
279	consolidating petitions filed by a petitioner and expanding the
280	timetable for rendering a determination upon a consolidated
281	petition.
282	(f)  Any carrier that engages in a pattern or practice of
283	arbitrarily or unreasonably disallowing or reducing payments to
284	health care providers may be subject to one or more of the
285	following penalties imposed by the department agency:
286	1.  Repayment of the appropriate amount to the health care
287	provider.
288	2.  An administrative fine assessed by the department
289	agency in an amount not to exceed $5,000 per instance of
290	improperly disallowing or reducing payments.
291	3.  Award of the health care provider's costs, including a
292	reasonable attorney's fee, for prosecuting the petition.
293	(8)  PATTERN OR PRACTICE OF OVERUTILIZATION.--
294	(a)  Carriers must report to the department agency all
295	instances of overutilization including, but not limited to, all
296	instances in which the carrier disallows or adjusts payment or a
297	determination has been made that the provided or recommended
298	treatment is in excess of the practice parameters and protocols
299	of treatment established in this chapter. The department agency
300	shall determine whether a pattern or practice of overutilization
301	exists.
302	(b)  If the department agency determines that a health care
303	provider has engaged in a pattern or practice of overutilization
304	or a violation of this chapter or rules adopted by the
305	department agency, including a pattern or practice of providing
306	treatment in excess of the practice parameters or protocols of
307	treatment, it may impose one or more of the following penalties:
308	1.  An order of the department agency barring the provider
309	from payment under this chapter;
310	2.  Deauthorization of care under review;
311	3.  Denial of payment for care rendered in the future;
312	4.  Decertification of a health care provider certified as
313	an expert medical advisor under subsection (9) or of a
314	rehabilitation provider certified under s. 440.49;
315	5.  An administrative fine assessed by the department
316	agency in an amount not to exceed $5,000 per instance of
317	overutilization or violation; and
318	6.  Notification of and review by the appropriate licensing
319	authority pursuant to s. 440.106(3).
320	(9)  EXPERT MEDICAL ADVISORS.--
321	(a)  The department agency shall certify expert medical
322	advisors in each specialty to assist the department agency and
323	the judges of compensation claims within the advisor's area of
324	expertise as provided in this section. The department agency
325	shall, in a manner prescribed by rule, in certifying,
326	recertifying, or decertifying an expert medical advisor,
327	consider the qualifications, training, impartiality, and
328	commitment of the health care provider to the provision of
329	quality medical care at a reasonable cost. As a prerequisite for
330	certification or recertification, the department agency shall
331	require, at a minimum, that an expert medical advisor have
332	specialized workers' compensation training or experience under
333	the workers' compensation system of this state and board
334	certification or board eligibility.
335	(b)  The department agency shall contract with one or more
336	entities that employ, contract with, or otherwise secure expert
337	medical advisors to provide peer review or expert medical
338	consultation, opinions, and testimony to the department agency
339	or to a judge of compensation claims in connection with
340	resolving disputes relating to reimbursement, differing opinions
341	of health care providers, and health care and physician services
342	rendered under this chapter, including utilization issues. The
343	department agency shall by rule establish the qualifications of
344	expert medical advisors, including training and experience in
345	the workers' compensation system in the state and the expert
346	medical advisor's knowledge of and commitment to the standards
347	of care, practice parameters, and protocols established pursuant
348	to this chapter. Expert medical advisors contracting with the
349	department agency shall, as a term of such contract, agree to
350	provide consultation or services in accordance with the
351	timetables set forth in this chapter and to abide by rules
352	adopted by the department agency, including, but not limited to,
353	rules pertaining to procedures for review of the services
354	rendered by health care providers and preparation of reports and
355	testimony or recommendations for submission to the department
356	agency or the judge of compensation claims.
357	(c)  If there is disagreement in the opinions of the health
358	care providers, if two health care providers disagree on medical
359	evidence supporting the employee's complaints or the need for
360	additional medical treatment, or if two health care providers
361	disagree that the employee is able to return to work, the
362	department agency may, and the judge of compensation claims
363	shall, upon his or her own motion or within 15 days after
364	receipt of a written request by either the injured employee, the
365	employer, or the carrier, order the injured employee to be
366	evaluated by an expert medical advisor. The opinion of the
367	expert medical advisor is presumed to be correct unless there is
368	clear and convincing evidence to the contrary as determined by
369	the judge of compensation claims. The expert medical advisor
370	appointed to conduct the evaluation shall have free and complete
371	access to the medical records of the employee. An employee who
372	fails to report to and cooperate with such evaluation forfeits
373	entitlement to compensation during the period of failure to
374	report or cooperate.
375	(d)  The expert medical advisor must complete his or her
376	evaluation and issue his or her report to the department agency
377	or to the judge of compensation claims within 15 days after
378	receipt of all medical records. The expert medical advisor must
379	furnish a copy of the report to the carrier and to the employee.
380	(e)  An expert medical advisor is not liable under any
381	theory of recovery for evaluations performed under this section
382	without a showing of fraud or malice. The protections of s.
383	766.101 apply to any officer, employee, or agent of the
384	department agency and to any officer, employee, or agent of any
385	entity with which the department agency has contracted under
386	this subsection.
387	(f)  If the department agency or a judge of compensation
388	claims orders the services of a certified expert medical advisor
389	to resolve a dispute under this section, the party requesting
390	such examination must compensate the advisor for his or her time
391	in accordance with a schedule adopted by the department agency.
392	If the employee prevails in a dispute as determined in an order
393	by a judge of compensation claims based upon the expert medical
394	advisor's findings, the employer or carrier shall pay for the
395	costs of such expert medical advisor. If a judge of compensation
396	claims, upon his or her motion, finds that an expert medical
397	advisor is needed to resolve the dispute, the carrier must
398	compensate the advisor for his or her time in accordance with a
399	schedule adopted by the department agency. The department agency
400	may assess a penalty not to exceed $500 against any carrier that
401	fails to timely compensate an advisor in accordance with this
402	section.
403	(11)  AUDITS.--
404	(a)  The department Agency for Health Care Administration
405	may investigate health care providers to determine whether
406	providers are complying with this chapter and with rules adopted
407	by the department agency, whether the providers are engaging in
408	overutilization, whether providers are engaging in improper
409	billing practices, and whether providers are adhering to
410	practice parameters and protocols established in accordance with
411	this chapter. If the department agency finds that a health care
412	provider has improperly billed, overutilized, or failed to
413	comply with department agency rules or the requirements of this
414	chapter, including, but not limited to, practice parameters and
415	protocols established in accordance with this chapter, it must
416	notify the provider of its findings and may determine that the
417	health care provider may not receive payment from the carrier or
418	may impose penalties as set forth in subsection (8) or other
419	sections of this chapter. If the health care provider has
420	received payment from a carrier for services that were
421	improperly billed, that constitute overutilization, or that were
422	outside practice parameters or protocols established in
423	accordance with this chapter, it must return those payments to
424	the carrier. The department agency may assess a penalty not to
425	exceed $500 for each overpayment that is not refunded within 30
426	days after notification of overpayment by the department agency
427	or carrier.
428	(b)  The department shall monitor carriers as provided in
429	this chapter and the Office of Insurance Regulation shall audit
430	insurers and group self-insurance funds as provided in s.
431	624.3161, to determine if medical bills are paid in accordance
432	with this section and rules of the department and Financial
433	Services Commission, respectively. Any employer, if self-
434	insured, or carrier found by the department or Office of
435	Insurance Regulation not to be within 90 percent compliance as
436	to the payment of medical bills after July 1, 1994, must be
437	assessed a fine not to exceed 1 percent of the prior year's
438	assessment levied against such entity under s. 440.51 for every
439	quarter in which the entity fails to attain 90-percent
440	compliance. The department shall fine or otherwise discipline an
441	employer or carrier, pursuant to this chapter or rules adopted
442	by the department, and the Office of Insurance Regulation shall
443	fine or otherwise discipline an insurer or group self-insurance
444	fund pursuant to the insurance code or rules adopted by the
445	Financial Services Commission, for each late payment of
446	compensation that is below the minimum 95-percent performance
447	standard. Any carrier that is found to be not in compliance in
448	subsequent consecutive quarters must implement a medical-bill
449	review program approved by the department or office, and an
450	insurer or group self-insurance fund is subject to disciplinary
451	action by the Office of Insurance Regulation.
452	(c)  The department agency has exclusive jurisdiction to
453	decide any matters concerning reimbursement, to resolve any
454	overutilization dispute under subsection (7), and to decide any
455	question concerning overutilization under subsection (8), which
456	question or dispute arises after January 1, 1994.
457	(d)  The following department agency actions do not
458	constitute agency action subject to review under ss. 120.569 and
459	120.57 and do not constitute actions subject to s. 120.56:
460	referral by the entity responsible for utilization review; a
461	decision by the department agency to refer a matter to a peer
462	review committee; establishment by a health care provider or
463	entity of procedures by which a peer review committee reviews
464	the rendering of health care services; and the review
465	proceedings, report, and recommendation of the peer review
466	committee.
467	(12)  CREATION OF THREE-MEMBER PANEL; GUIDES OF MAXIMUM
468	REIMBURSEMENT ALLOWANCES.--
469	(a)  A three-member panel is created, consisting of the
470	Chief Financial Officer, or the Chief Financial Officer's
471	designee, and two members to be appointed by the Governor,
472	subject to confirmation by the Senate, one member who, on
473	account of present or previous vocation, employment, or
474	affiliation, shall be classified as a representative of
475	employers, the other member who, on account of previous
476	vocation, employment, or affiliation, shall be classified as a
477	representative of employees. The panel shall determine statewide
478	schedules of maximum reimbursement allowances for medically
479	necessary treatment, care, and attendance provided by
480	physicians, hospitals, ambulatory surgical centers, work-
481	hardening programs, pain programs, and durable medical
482	equipment. The maximum reimbursement allowances for inpatient
483	hospital care shall be based on a schedule of per diem rates, to
484	be approved by the three-member panel no later than March 1,
485	1994, to be used in conjunction with a precertification manual
486	as determined by the department, including maximum hours in
487	which an outpatient may remain in observation status, which
488	shall not exceed 23 hours. All compensable charges for hospital
489	outpatient care shall be reimbursed at 75 percent of usual and
490	customary charges, except as otherwise provided by this
491	subsection. Annually, the three-member panel shall adopt
492	schedules of maximum reimbursement allowances for physicians,
493	hospital inpatient care, hospital outpatient care, ambulatory
494	surgical centers, work-hardening programs, and pain programs. An
495	individual physician, hospital, ambulatory surgical center, pain
496	program, or work-hardening program shall be reimbursed either
497	the agreed-upon contract price or the maximum reimbursement
498	allowance in the appropriate schedule.
499	(b)  It is the intent of the Legislature to increase the
500	schedule of maximum reimbursement allowances for selected
501	physicians effective January 1, 2004, and to pay for the
502	increases through reductions in payments to hospitals. Revisions
503	developed pursuant to this subsection are limited to the
504	following:
505	1.  Payments for outpatient physical, occupational, and
506	speech therapy provided by hospitals shall be reduced to the
507	schedule of maximum reimbursement allowances for these services
508	which applies to nonhospital providers.
509	2.  Payments for scheduled outpatient nonemergency
510	radiological and clinical laboratory services that are not
511	provided in conjunction with a surgical procedure shall be
512	reduced to the schedule of maximum reimbursement allowances for
513	these services which applies to nonhospital providers.
514	3.  Outpatient reimbursement for scheduled surgeries shall
515	be reduced from 75 percent of charges to 60 percent of charges.
516	4.  Maximum reimbursement for a physician licensed under
517	chapter 458 or chapter 459 shall be increased to 110 percent of
518	the reimbursement allowed by Medicare, using appropriate codes
519	and modifiers or the medical reimbursement level adopted by the
520	three-member panel as of January 1, 2003, whichever is greater.
521	5.  Maximum reimbursement for surgical procedures shall be
522	increased to 140 percent of the reimbursement allowed by
523	Medicare or the medical reimbursement level adopted by the
524	three-member panel as of January 1, 2003, whichever is greater.
525	(c)  As to reimbursement for a prescription medication, the
526	reimbursement amount for a prescription shall be the average
527	wholesale price plus $4.18 for the dispensing fee, except where
528	the carrier has contracted for a lower amount. Fees for
529	pharmaceuticals and pharmaceutical services shall be
530	reimbursable at the applicable fee schedule amount. Where the
531	employer or carrier has contracted for such services and the
532	employee elects to obtain them through a provider not a party to
533	the contract, the carrier shall reimburse at the schedule,
534	negotiated, or contract price, whichever is lower. No such
535	contract shall rely on a provider that is not reasonably
536	accessible to the employee.
537	(d)  Reimbursement for all fees and other charges for such
538	treatment, care, and attendance, including treatment, care, and
539	attendance provided by any hospital or other health care
540	provider, ambulatory surgical center, work-hardening program, or
541	pain program, must not exceed the amounts provided by the
542	uniform schedule of maximum reimbursement allowances as
543	determined by the panel or as otherwise provided in this
544	section. This subsection also applies to independent medical
545	examinations performed by health care providers under this
546	chapter. In determining the uniform schedule, the panel shall
547	first approve the data which it finds representative of
548	prevailing charges in the state for similar treatment, care, and
549	attendance of injured persons. Each health care provider, health
550	care facility, ambulatory surgical center, work-hardening
551	program, or pain program receiving workers' compensation
552	payments shall maintain records verifying their usual charges.
553	In establishing the uniform schedule of maximum reimbursement
554	allowances, the panel must consider:
555	1.  The levels of reimbursement for similar treatment,
556	care, and attendance made by other health care programs or
557	third-party providers;
558	2.  The impact upon cost to employers for providing a level
559	of reimbursement for treatment, care, and attendance which will
560	ensure the availability of treatment, care, and attendance
561	required by injured workers;
562	3.  The financial impact of the reimbursement allowances
563	upon health care providers and health care facilities, including
564	trauma centers as defined in s. 395.4001, and its effect upon
565	their ability to make available to injured workers such
566	medically necessary remedial treatment, care, and attendance.
567	The uniform schedule of maximum reimbursement allowances must be
568	reasonable, must promote health care cost containment and
569	efficiency with respect to the workers' compensation health care
570	delivery system, and must be sufficient to ensure availability
571	of such medically necessary remedial treatment, care, and
572	attendance to injured workers; and
573	4.  The most recent average maximum allowable rate of
574	increase for hospitals determined by the Health Care Board under
575	chapter 408.
576	(e)  In addition to establishing the uniform schedule of
577	maximum reimbursement allowances, the panel shall:
578	1.  Take testimony, receive records, and collect data to
579	evaluate the adequacy of the workers' compensation fee schedule,
580	nationally recognized fee schedules and alternative methods of
581	reimbursement to certified health care providers and health care
582	facilities for inpatient and outpatient treatment and care.
583	2.  Survey certified health care providers and health care
584	facilities to determine the availability and accessibility of
585	workers' compensation health care delivery systems for injured
586	workers.
587	3.  Survey carriers to determine the estimated impact on
588	carrier costs and workers' compensation premium rates by
589	implementing changes to the carrier reimbursement schedule or
590	implementing alternative reimbursement methods.
591	4.  Submit recommendations on or before January 1, 2003,
592	and biennially thereafter, to the President of the Senate and
593	the Speaker of the House of Representatives on methods to
594	improve the workers' compensation health care delivery system.
595
596	The agency and the department, as requested, shall provide data
597	to the panel, including, but not limited to, utilization trends
598	in the workers' compensation health care delivery system. The
599	department agency shall provide the panel with an annual report
600	regarding the resolution of medical reimbursement disputes and
601	any actions pursuant to subsection (8) s. 440.13(8). The
602	department shall provide administrative support and service to
603	the panel to the extent requested by the panel.
604	(13)  REMOVAL OF PHYSICIANS FROM LISTS OF THOSE AUTHORIZED
605	TO RENDER MEDICAL CARE.--The department agency shall remove from
606	the list of physicians or facilities authorized to provide
607	remedial treatment, care, and attendance under this chapter the
608	name of any physician or facility found after reasonable
609	investigation to have:
610	(a)  Engaged in professional or other misconduct or
611	incompetency in connection with medical services rendered under
612	this chapter;
613	(b)  Exceeded the limits of his or her or its professional
614	competence in rendering medical care under this chapter, or to
615	have made materially false statements regarding his or her or
616	its qualifications in his or her application;
617	(c)  Failed to transmit copies of medical reports to the
618	employer or carrier, or failed to submit full and truthful
619	medical reports of all his or her or its findings to the
620	employer or carrier as required under this chapter;
621	(d)  Solicited, or employed another to solicit for himself
622	or herself or itself or for another, professional treatment,
623	examination, or care of an injured employee in connection with
624	any claim under this chapter;
625	(e)  Refused to appear before, or to answer upon request
626	of, the department agency or any duly authorized officer of the
627	state, any legal question, or to produce any relevant book or
628	paper concerning his or her conduct under any authorization
629	granted to him or her under this chapter;
630	(f)  Self-referred in violation of this chapter or other
631	laws of this state; or
632	(g)  Engaged in a pattern of practice of overutilization or
633	a violation of this chapter or rules adopted by the department
634	agency, including failure to adhere to practice parameters and
635	protocols established in accordance with this chapter.
636	Section 3.  Section 440.125, Florida Statutes, is amended
637	to read:
638	440.125  Medical records and reports; identifying
639	information in employee medical bills; confidentiality.--Any
640	medical records and medical reports of an injured employee and
641	any information identifying an injured employee in medical bills
642	which are provided to the department, pursuant to s. 440.13, are
643	confidential and exempt from the provisions of s. 119.07(1) and
644	s. 24(a), Art. I of the State Constitution, except as otherwise
645	provided by this chapter. The department may share any such
646	confidential and exempt records, reports, or information
647	received pursuant to s. 440.13 with the Agency for Health Care
648	Administration and the Department of Education in furtherance of
649	their official duties under ss. 440.13 and 440.134. The agency
650	and the department shall maintain the confidential and exempt
651	status of such records, reports, and information received.
652	Section 4.  This act shall take effect July 1, 2008.

CODING: Words stricken are deletions; words underlined are additions.