69L-7.602: Florida Workers' Compensation Medical Services Billing, Filing and Reporting Rule
PURPOSE AND EFFECT: The proposed rule (which applies to dates of injury occurring on or after October 1, 2003) clarifies that an insurer must provide health care providers with prior notification of a decision to apply apportionment in the payment of reimbursement for medical services. The amendment provides that an insurer shall, at the time of authorization or, if the decision to apportion the reimbursement is made after authorization, but prior to the rendering of services, provide each health care provider with written or electronic notification of its decision to apply apportionment in the payment of reimbursement for medical service(s). The proposed rule also deletes subsection (7) of the rule which addresses administrative penalties and fines for untimely payments to health care providers or the disposition of other medical bills. These penalty provisions are transferred to Rule Chapter 69L-24, F.A.C.
SUMMARY: The proposed rule clarifies that insurers are required to provide notification to health care providers in cases where payment of reimbursement for medical services will be subject to apportionment. This proposed change also deletes a penalties provision that has previously been moved to Rule Chapter 24, F.A.C.
SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS AND LEGISLATIVE RATIFICATION:
The Agency has determined that this will have an adverse impact on small business or likely increase directly or indirectly regulatory costs in excess of $200,000 in the aggregate within one year after the implementation of the rule. A SERC has been prepared by the agency.
The Agency has determined that the proposed rule is not expected to require legislative ratification based on the statement of estimated regulatory costs or if no SERC is required, the information expressly relied upon and described herein: A preliminary economic analysis prepared by the agency estimates that the each carrier will incur programming costs of $1125 in order to comply with the proposed amendment to Rule 69L-7.602, F.A.C. Multiplied by the 418 carriers with workers’ compensation as an authorized line of business in Florida, the estimated aggregate programming costs is $470,250.
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), 440.15(3)(b), (d), 440.185(5), 440.525(2), 440.591, 440.593(5) FS.
LAW IMPLEMENTED: 440.09, 440.13(2)(a), (3), (4), (6), (11), (12), (14), (16), 440.15(3)(b), (d), (5), 440.185(5), (9), 440.20(6), 440.525(2), 440.593 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: Friday, August 3, 2012, 2:00 p.m.
PLACE: Room 102, Hartman Building, 2012 Capital Circle Southeast, Tallahassee, Florida
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 or Eric.Lloyd@myfloridacfo.com
Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this program, please advise the Department at least 5 calendar days before the program by contacting the person listed above.
THE FULL TEXT OF THE PROPOSED RULE IS:
69L-7.602 Florida Workers’ Compensation Medical Services Billing, Filing and Reporting Rule.
(1) through (4) No changes.
(5) Insurer Responsibilities.
(a) No change.
(b)1. At the time of authorization for medical service(s) or upon receipt of notification of emergency care, an insurer shall notify each health care provider, in writing, of data elements or supporting documentation that are necessary for reimbursement determinations that are in addition to the requirements of this rule and the applicable reimbursement manual.
2. This subparagraph applies to dates of injury occuring on or after October 1, 2003. At the time of authorization for medical service(s), or upon receipt of notification of emergency care, an insurer shall issue a written or electronic notice to each health care provider stating whether the insurer will, when paying reimbursement for the medical service(s) for a compensable injury, apportion out the percentage of need for the care attributable to a pre-existing condition pursuant to Section 440.15(5), F.S. If the insurer decides to apportion out the percentage of need for the care attributable to the pre-existing condition after authorization, the insurer shall issue a written or electronic notice to each health care provider stating that it will apply such apportionment, pursuant to Section 440.15(5), F.S., to the reimbursement for the authorized medical service(s). Compliance with this subparagraph is independent of and does not satisfy the notification requirement pursuant to Rule 69L-3.017, F.A.C.
(c) through (v) No change.
(6) No change.
(7) Insurer Administrative Penalties and Administrative Fines for Untimely Health Care Provider-Payment or Disposition of Medical Bills.
(a) The Department shall impose insurer administrative penalties for failure to comply with the payment, adjustment, disallowance or denial requirements pursuant to Section 440.20(6)(b), F.S. Timely performance standards for timely payments, adjustments and payments, disallowances or denials, reported on Forms DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11 and DFS-F5-DWC-90, shall be calculated and applied on a monthly basis for each separate form category that was received within a specific calendar month. Such insurer penalties shall be determined according to the penalty schedule in paragraph (7)(b) of this rule.
(b) Pursuant to Section 440.185(9), F.S., the Department shall impose insurer administrative fines for failure to comply with the submission, filing or reporting requirements of this rule. Insurer administrative fines shall be applied as follows:
1. Calculated on a monthly basis for each separate form category (Forms DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11 and DFS-F5-DWC-90) received and accepted by the Division within a specific calendar month; and
2. Insurers are required to report all medical reports timely pursuant to paragraph (5)(e) of this rule. Insurers that fail to submit a minimum of 95% of all medical reports timely are subject to an administrative fine. Each untimely filed medical report which falls below the 95% requirement is subject to the following penalty schedule:
a. 1 – 30 calendar days late $5.00;
b. 31 – 60 calendar days late $10.00;
c. 61 – 90 calendar days late $25.00;
d. 91 or greater calendar days late $100.00.
3. Each medical report that does not pass the electronic reporting edits shall be rejected by the Division and considered not filed pursuant to paragraph (5)(e) of this rule. If the medical report remains rejected and not corrected, resubmitted and accepted by the Division for greater than 90 days, an administrative fine shall be assessed in the amount of $100.00 for each such medical report. Rejected and not resubmitted medical reports will not be included in the 95% timely reporting requirement.
4. Untimely filed medical reports for a given month will be excluded from the administrative fine set forth in subparagraph (7)(b)3. above as falling within the performance standard between 100% and 95% in the following order:
a. Medical Reports filed 1 – 30 calendar days late; then
b. Medical Reports filed 31 – 60 calendar days late; then
c. Medical Reports filed 61 – 90 calendar days late; then
d. Medical Reports filed 91+ calendar days late.
Rulemaking Authority 440.13(4), 440.15(3)(b), (d), 440.185(5), 440.525(2), 440.591, 440.593(5) FS. Law Implemented 440.09, 440.13(2)(a), (3), (4), (6), (11), (12), (14), (16), 440.15(3)(b), (d), (5), 440.185(5), (9), 440.20(6), 440.525(2), 440.593 FS. History–New 1-23-95, Formerly 38F-7.602, 4L-7.602, Amended 7-4-04, 10-20-05, 6-25-06, 3-8-07, 1-12-10,________.