69L-34.001: Definitions
69L-34.002: Mandatory Carrier Reporting
69L-34.003: Referral of Alleged Health Care Provider Violation
69L-34.004: Timeliness of Referral
69L-34.005: Referral Investigation
69L-34.006: Invalid Referrals
PURPOSE AND EFFECT: The purpose and effect of this proposed rule is to:
1. Clarify that the mandatory reporting of all instances of overutilization to the Division of Workers’ Compensation (“Division”) shall be accomplished by means of the Carrier’s compliance with the Division’s medical claims information filing requirements in subsections 69L-7.602(5) and (6), Florida Administrative Code (F.A.C.), Florida Workers’ Compensation Medical Services Billing, Reporting and Filing Rule; and
2. Introduce an elective reporting process by which any person may report to the Division, a Health Care Provider’s violation of Chapter 440, Florida Statutes (F.S.), and applicable administrative rules.
SUMMARY: The proposed rule chapter provides that Carriers satisfy their mandatory reporting requirements under Section 440.13(8), F.S., “Pattern or Practice of Overutilization,” by filing the required medical claims data elements and any other medical billing and payment information required by the Division in accordance with the provisions of subsections (5) and (6) of Rule 69L-7.602, F.A.C., “Florida Workers’ Compensation Medical Billing, Filing and Reporting Rule,” or denies authorization of a recommended medical benefit by issuing a Notice of Denial Form, DFS-F2-DWC-12, pursuant to Rule 69L-3.012, F.A.C. The proposed rule chapter also incorporates new form DFS-F6-DWC-2000, titled, “Health Care Provider Violation Referral Form,” that provides Carriers with a discretionary method of reporting Health Care Provider violations to augment the mandatory process that occurs in accordance with the provisions of Rule 69L-7.602, F.A.C.
SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS: The proposed rule chapter is not anticipated to have an adverse impact on economic growth or to increase regulatory costs.
Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.
RULEMAKING AUTHORITY: 440.13(4)(c), (7)(e), 440.591 FS.
LAW IMPLEMENTED: 440.13, 440.13(1), 440.13(1)(k), (4), (7), (8), (11), (13), (14), (16), 440.192 FS.
IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE HELD AT THE DATE,TIME AND PLACE SHOWN BELOW(IF NOT REQUESTED, THIS HEARING WILL NOT BE HELD):
DATE AND TIME: Thursday, June 23, 2011, 9:00 a.m.
PLACE: 104J Hartman Building, 2012 Capital Circle Southeast, Tallahassee, Florida
Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 5 days before the workshop/meeting by contacting: Eric Lloyd, (850)413-1689 or Eric.Lloyd@myfloridacfo.com. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Eric Lloyd, Program Administrator, Office of Medical Services, Division of Workers’ Compensation, Department of Financial Services, 200 East Gaines Street, Tallahassee, Florida 32399-4232, (850)413-1689, Eric.Lloyd@myfloridacfo.com
THE FULL TEXT OF THE PROPOSED RULE IS:
69L-34.001 Definitions.
As used in this Rule Chapter:
(1) “Carrier” is as defined in Section 440.13(1)(c), Florida Statutes (F.S.).
(2) “Division” means The Department of Financial Services Division of Workers’ Compensation.
(3) “Health Care Provider” (hereinafter referred to as “Provider”) is as defined in Section 440.13(1)(h), F.S., and includes those that consent to the jurisdiction of the Division pursuant to Section 440.13(3)(f), F.S.
(4) “Supportive Documentation” is defined as all documents and records that support an allegation of a violation pursuant to this Rule Chapter.
(5) “Verifiable delivery process” is defined as the ability to document a common carrier’s pick- up date or a United States Postal Services postmark date.
(6) “Violation” is defined as a Provider’s non-compliance with Chapter 440, F.S. and Division rules, which shall include: failing to submit medical records and reports pursuant to Section 440.13(4)(a) and (c), F.S., or pursuant to subsection 69L-7.602(4), F.A.C.; failing to refund an overpayment of reimbursement, pursuant to Section 440.13(11)(a), F.S.; collecting or receiving payment from an injured worker in violation of Section 440.13(14)(a), F.S.; failing to follow standards of care, pursuant to Section 440.13(16), F.S., including overutilization of services; or failing to properly bill medical services, pursuant to Rule 69L-7.602, F.A.C. Recommending treatment that would constitute overutilization, in and of itself, is not an instance of overutilization.
(7) “Improper billing and billing errors” means the failure of a Provider to comply with the Division’s billing and reporting requirements pursuant to Rule 69L-7.602, F.A.C., and the applicable reimbursement manual(s).
Rulemaking Authority 440.13(4)(c), (7)(e), 440.591 FS. Law Implemented 440.13, 440.13(1)(k) FS. History–New__________.
69L-34.002 Mandatory Carrier Reporting.
A Carrier shall have met the requirements to report to the Division, pursuant to Section 440.13(8), F.S., all instances of overutilization and improper billing and billing errors, including all instances in which the Carrier disallows or adjusts payment, by timely filing the required medical claims data elements with the Division, as required in subsections 69L-7.602(5) and (6), F.A.C., or denies authorization of a recommended medical benefit by issuing a Notice of Denial Form DFS-F2-DWC-12, pursuant to Rule 69L-3.012, F.A.C.
Rulemaking Authority 440.13(4)(c), (7)(e), 440.591 FS. Law Implemented 440.13(8) FS. History–New__________.
69L-34.003 Elective Referral of Alleged Health Care Provider Violation.
(1) Any person who elects to submit a report of a violation, as defined in this rule chapter, directly to the Division’s Office of Medical Services, shall use the Health Care Provider Violation Referral Form, DFS-F6-DWC-2000 (Effective:________), (hereinafter “Referral Form”), which is hereby incorporated by reference. The Referral Form is available via the Division’s web site at http://www.myfloridacfo.com/wc/provider/index.html.
(2) Such person shall submit to the Division a separate Referral Form, DFS-F6-DWC-2000 (Effective:________), and all supportive documentation for each alleged violation.
(3) Such person shall serve a copy of the Referral Form, DFS-F6-DWC-2000 (Effective:________), and all supportive documentation on the Provider utilizing a verifiable delivery process, such as United States Postal Service certified mail or a similar process offered by a common carrier.
(4) Supportive documentation of a specific violation may include, but is not limited to, the following documents or records:
(a) All DFS-F5-DWC-25 forms submitted by the Provider for the authorization of treatment provided or prescribed for the date(s) of service under review and the Carrier’s response to each request for authorization. Form DFS-F5-DWC-25 is hereby incorporated by reference.
(b) Electronic or written correspondence between the Carrier and the Provider regarding the medical necessity of treatment prescribed or rendered on the date(s) of service under review.
(c) All carrier notices of disallowance or adjustment of reimbursement within the meaning of Section 440.13(7), F.S., for the date(s) of service and treatment under review (e.g., Explanations of Bill Reviews or EOBRs).
(d) A copy of each medical bill for the date(s) of service under review, which lists the line item service disallowed or adjusted on the basis of overutilization, or improper billing, or a billing error.
(e) Peer review report(s) substantiating a standard of care violation, including overutilization of services, for the date(s) of service under review with specific reference to the practice guidelines upon which the peer review finding is based.
(f) Electronic or written request(s) sent to the Provider for a refund of reimbursement for line item service(s) that constituted overutilization or an improper billing or a billing error.
(g) Electronic or written request(s) sent to the Provider for medical records and information or for the submission of Form DFS-F5-DWC-25.
(h) Electronic or written correspondence notifying the Provider of the Carrier’s responsibility for the payment of medical services rendered for authorized treatment pursuant to the applicable reimbursement manual and the Provider’s inability to balance bill the injured worker.
(i) Copies of collection letters sent to the injured worker from the Provider or a collection agent acting on behalf of the Provider, seeking payment for covered medical services authorized by the Carrier.
(j) A copy of a Determination, issued by the Division, finding that the Provider improperly billed and is not entitled to additional reimbursement or the amount of reimbursement due is less than the amount the Carrier reimbursed for the billed service(s).
(5) Reporting of violations under this rule does not remove or satisfy the Carrier’s mandatory reporting obligation under Rules 69L-7.602 and 69L-34.002, F.A.C.
Rulemaking Authority 440.13(4)(c), (7)(e), 440.591 FS. Law Implemented 440.13(7), (8), (11), (14), (16), 440.192 FS. History– New__________.
69L-34.004 Timeliness of a Referral.
(1) A properly completed Referral Form, DFS-F6-DWC-2000 (Effective:________), filed with Supportive Documentation, must be received by the Division no later than 180 days after the issuance of an EOBR, as defined in Rule 69L-7.602, F.A.C., or another form of initial notification sent from the Carrier to the Provider identifying the occurrence of an alleged violation.
(2) The EOBR or initial notification of the occurrence of an alleged violation shall be via an electronic or written notice sent to the Provider.
Rulemaking Authority 440.13(4)(c), (7)(e), 440.591 FS. Law Implemented 440.13(8) FS. History–New__________.
69L-34.005 Referral Investigation.
(1) The Division is authorized to conduct an investigation of an alleged violation based upon any of the following results:
(a) An audit of medical bill data filed with the Division; or
(b) The receipt of a completed Referral Form, DFS-F6-DWC-2000 (Effective:________), and all Supportive Documentation; or
(c) A combination of paragraphs (a) and (b) above.
(2) The Carrier and the Provider shall submit to the Division, within forty-five (45) days of receipt of a document request from the Division, all additional documentation requested by the Division as a part of its investigation. If any of the requested documentation is not included in the Carrier’s or the Provider’s response to the Division’s document request, the Carrier or the Provider shall submit a specific written explanation as to the reason(s) the documentation was not included.
(3) If either the Carrier or the Provider fails to timely submit the requested documentation or specific written explanation as to the reason the additional documentation can not be provided, the Division, in its exclusive jurisdiction pursuant to Section 440.13(11)(c), F.S., is authorized to close the investigation or issue its findings based on the documentation filed with the Referral Form and any responses appurtenant thereto that were timely received.
(4) The Division shall not issue a penalty for violations under this Rule Chapter except following an investigation pursuant to this rule; however, if the Division finds a Provider has engaged in a violation, administrative penalties, fines or other sanctions shall be issued in accordance with Section 440.13(8), (11) and (13), F.S.
Rulemaking Authority 440.13(4)(c), (7)(e), 440.591 FS. Law Implemented 440.13(1),(8), (11), (13) FS. History–New_________.
69L-34.006 Invalid Referrals.
(1) A Carrier shall not submit a Referral Form, DFS-F6-DWC-2000 (Effective:________), to the Division to report an alleged violation related to:
(a) A reimbursement dispute pending a Determination, pursuant to Section 440.13(7), F.S.; or
(b) A petition for medical benefits pending before a Judge of Compensation Claims.
(2) A referral related to issues identified in subsection (1) is invalid and shall not be investigated.
Rulemaking Authority 440.13(4)(c), (7)(e), 440.591 FS. Law Implemented 440.13(7), (8), 440.192 FS. History–New__________.