Florida Senate - 2012 COMMITTEE AMENDMENT
Bill No. SB 668
Barcode 409686
LEGISLATIVE ACTION
Senate . House
Comm: RE .
02/23/2012 .
.
.
.
—————————————————————————————————————————————————————————————————
—————————————————————————————————————————————————————————————————
The Committee on Health Regulation (Garcia) recommended the
following:
1 Senate Substitute for Amendment (766998) (with title
2 amendment)
3
4 Delete everything after the enacting clause
5 and insert:
6 Section 1. Paragraph (a) of subsection (3) and paragraph
7 (c) of subsection (12) of section 440.13, Florida Statutes, are
8 amended, paragraph (k) is added to subsection (3), paragraphs
9 (d) and (e) of subsection (12) are redesignated as paragraphs
10 (c) and (d), respectively, present subsections (15) through (17)
11 are renumbered as subsections (16) through (18), respectively,
12 and a new subsection (15) is added to that section, to read:
13 440.13 Medical services and supplies; penalty for
14 violations; limitations.—
15 (3) PROVIDER ELIGIBILITY; AUTHORIZATION.—
16 (a) As a condition for to eligibility for payment under
17 this chapter, a health care provider who renders services must
18 be a certified health care provider and must receive
19 authorization from the carrier before providing treatment. This
20 paragraph does not apply to emergency care. An employer or a
21 carrier may not refuse to authorize a physician to treat an
22 injured employee solely because the physician is a dispensing
23 practitioner, as defined in s. 465.0276. The department shall
24 adopt rules to administer implement the certification of health
25 care providers.
26 (k) If a physician who is a dispensing practitioner as
27 defined in s. 465.0276 receives authorization from an employer
28 or a carrier to treat a claimant pursuant to paragraph (a), the
29 physician may dispense and fill prescriptions for medicines
30 under this chapter. For purposes of dispensing and filling
31 prescriptions for medicines, the department, employer, or
32 carrier, or an agent or representative of the department,
33 employer, or carrier, may not select the pharmacy, pharmacist,
34 or dispensing practitioner that the claimant must use.
35 (12) CREATION OF THREE-MEMBER PANEL; GUIDES OF MAXIMUM
36 REIMBURSEMENT ALLOWANCES.—
37 (c) As to reimbursement for a prescription medication, the
38 reimbursement amount for a prescription shall be the average
39 wholesale price plus $4.18 for the dispensing fee, except where
40 the carrier has contracted for a lower amount. Fees for
41 pharmaceuticals and pharmaceutical services shall be
42 reimbursable at the applicable fee schedule amount. Where the
43 employer or carrier has contracted for such services and the
44 employee elects to obtain them through a provider not a party to
45 the contract, the carrier shall reimburse at the schedule,
46 negotiated, or contract price, whichever is lower. No such
47 contract shall rely on a provider that is not reasonably
48 accessible to the employee.
49 (15) REIMBURSEMENT FOR PRESCRIPTION MEDICATION.—The
50 reimbursement amount for prescription medication shall be the
51 average wholesale price plus $4.18 for the dispensing fee,
52 unless the carrier and the provider seeking reimbursement have
53 directly contracted with each other for a lower reimbursement
54 amount.
55 (a) If a prescription has been repackaged or relabeled, the
56 provider shall give a $15 credit to the insurance carrier or
57 self-insured employer for each prescription that costs more than
58 $25. The credit shall be reflected in the Explanation of Bill
59 Review provided by the carrier or employer. The credit does not
60 apply if the carrier and the provider seeking reimbursement have
61 directly contracted with each other for a lower reimbursement
62 amount.
63 (b) A physician or the physician’s assignee may not hold an
64 ownership interest in a licensed pharmaceutical repackaging
65 entity and may not set or cause to be set a repackaged
66 pharmaceutical average wholesale price.
67 (c) An insurance carrier or self-insured employer that
68 improperly denies or delays payment of a valid claim for
69 reimbursement of a prescription medication is subject to an
70 administrative fine of $250 per instance of improper
71 reimbursement. If the department determines that a carrier or
72 employer has improperly denied or delayed reimbursement claims
73 more than 15 times in any one calendar year, the administrative
74 penalty increases to $1,000 per instance of improper
75 reimbursement. If the department determines that a carrier or
76 employer has improperly denied or delayed reimbursement claims
77 more than 100 times in any one calendar year, the insurer or
78 employer must show cause to the department as to why its
79 certificate of authority to underwrite workers’ compensation
80 insurance should not be revoked or suspended. The penalties in
81 this paragraph are not exclusive and are in addition to remedies
82 provided under part IX of chapter 626.
83 (d) Pursuant to subsection (7), a provider may challenge a
84 disallowance, denial, or adjustment of payment by filing a
85 petition for dispute resolution with the department within 30
86 days after receiving the final Explanation of Bill Review issued
87 by the insurance carrier or self-insured employer. The carrier
88 or self-insured employer must clearly state on the face of the
89 final Explanation of Bill Review when the 30-day period for
90 filing a petition for dispute resolution with the department
91 commences.
92 Section 2. This act shall take effect July 1, 2012.
93
94 ================= T I T L E A M E N D M E N T ================
95 And the title is amended as follows:
96 Delete everything before the enacting clause
97 and insert:
98 A bill to be entitled
99 An act relating to workers’ compensation medical
100 services; amending s. 440.13, F.S.; prohibiting an
101 employer or carrier from refusing to authorize a
102 physician who is a prescribing physician; prohibiting
103 the Department of Financial Services, the employer, or
104 the carrier from selecting a claimant’s pharmacy;
105 revising requirements for determining the amount of a
106 reimbursement for prescription medications;
107 prohibiting a physician from having an ownership
108 interest in a pharmacy repackaging entity or setting
109 pharmaceutical wholesale prices; providing penalties
110 for an employer or carrier’s improper delay or denial
111 of payment and procedures for a provider to challenge
112 a disallowance, denial, or adjustment of payment;
113 providing an effective date.