Florida

February 21, 2012: Florida News: CFO Jeff
Atwater Announces Arrest of North Port
Man on charges of Workers’ Compensation
Claim Fraud and Grand Theft

February 04, 2012: Florida News: Florida
CFO Jeff Atwater Announces Arrest of
‘Straw Owner,’ Clinic Operator for Violating
Clinic Law, Filing Fraudulent PIP Claims

January 12, 2012: Florida News: Published in
2011 Annual Report

December 06, 2011: Florida News
CFO Jeff Atwater Appoints Law
Enforcement Veteran to Lead the Division of
Insurance Fraud

December 01, 2011: Florida: News:
TALLAHASSEE—Florida Chief Financial
Officer Jeff Atwater announced today the
conviction of a North Carolina man in a $2.7
million workers’ compensation insurance
scam.

November 04, 2011: Florida: News:
Florida Chief Financial Officer Jeff Atwater
announced today the arrests of five insurance
fraud suspects for their involvement in a
staged accident scheme in Orlando

October 01, 2011: fee schedule
WORKERS' COMPENSATION FEE
SCHEDULES
Fee Schedules for Doctors, Hospitals,
Physicians’ Fee Schedule Codes, In Office
Surgery, etc.

September 2011: News:

•The Division has published its 2011 Annual
Report and it is now available under
Publications and Reimbursement Manuals or
at: http://www.myfloridacfo.
com/WC/pdf/DWC-Annual-Report-2011.pdf
[4MB PDF] The Annual Report contains a
summary of the Division's activities and
accomplishments for FY 2010-2011.
•Rule 69L-34, Florida Administrative Code
(F.A.C), has been adopted and became
effective on September 06, 2011. The rule
text and Form DFS-F6-DWC-2000 may be
obtained via the links provided below.•Rule
Chapter 69L-34, F.A.C. (rule text)
•Form DFS-F6-DWC-2000 [55K PDF]

Medical Control

The employer has the right to direct the injured employee to a physician for
initial treatment. The treating physician may not refer to another healthcare
provider without prior authorization from the employer/insurer. Upon
written request of the injured employee, the employer/insurer shall give the
employee the opportunity for one (1) change of physician during the course
of any one (1) injury or accident. The injured employee is entitled to select
that physician from a list of no fewer than three (3) employer/insurer-
authorized physicians who are not professionally related. The employee may
select his/her own pharmacy or select a pharmacy from the Express Scripts
pharmacy network. Emergency medical care does not require preapproval and
should be secured at the nearest location.

SB 1012

“prohibit the use of “SILENT PPOS’” bill to level the playing field between
physicians and managed care companies was recently signed into law by
Florida Gov. Charlie Crist (R). SB1012 imposes clear and reasonable
guidelines on resolving overpayment or underpayment of physician services
(including a 12-month time limit on seeking refunds from physicians) and
enforcing assignment of benefits declarations by patients for in-network
physicians. The bill also prohibits silent PPOs unless the contract expressly
authorizes this arrangement, and it requires transparency in the process of
selling or purchasing information on the networks a physician belongs to and
their level of payment.

Out-of-State Hospitals.

Hospital services provided outside of the state of Florida shall be reimbursed
the amount agreed upon by the hospital and the insurer pursuant to obtaining
authorization as required by Section V of this Manual, or if no amount has
been pre-approved, the hospital shall be reimbursed the greater of:
1. The amount of reimbursement established under the workers’
compensation statute of the jurisdiction where the hospital is located; or
2. The MRA as determined using this Manual, including the limitations on
reimbursement for radiology, clinical laboratory, and physical, occupational
and speech therapies which are determined according to the Florida Workers’
Compensation Health Care Provider Reimbursement Manual incorporated by
reference in rules 69L-7.020 and 69L-7.501, F.A.C.

(Higher Fees For Trauma Centers)

“Trauma Center” means a hospital approved for certification as a trauma
center pursuant to rule 64E-2.06, F.A.C. A list of certified trauma centers is
available free of charge on the Department of Health website at http://www.
doh.state.fl.us/demo/Trauma/PDFs/TraumaCenterContacts.pdf.

Per Diem Schedule.

1. If the Total Gross Charges After Implant Carve-Out is $51,400.00 or less,
reimbursement shall be determined according to the
Rule 69L-7.501, F.A.C. Effective 10/01/07 Florida Workers’ Compensation
Reimbursement Manual for Hospitals, 2006 Edition 9
following per diem allowances:
a. Inpatient services provided by hospital:
(1) Surgical stay: $3,304.00 per day;
(2) Non-surgical stay: $1,960.00 per day.
b. Inpatient services provided by a trauma center, licensed pursuant to s.
395.4025, F.S.:
(1) Surgical stay: $3,305.00 per day;
(2) Non-surgical stay: $1,986.00 per day.
Determination of whether inpatient services are surgical or non-surgical shall
be based on the CMS-defined operative status for the ICD-9-CM primary
procedure code reported by the hospital in the appropriate Form Locator on
the hospital billing form in accordance with 69L-7.602, F.A.C.
The CMS-defined operative status of ICD-9-CM primary procedure codes
shall be determined by reference to an authoritative resource for CMS
information, such as Length of Stay (LOS) by Diagnosis and Operation,
United States, published and copyrighted by Solucient LLC, and
recommended for use by hospitals and insurers by the Division and the
Agency. Appendix C of Solucient’s LOS manual contains a list of ICD-9-CM
procedure codes and their CMS-defined operative status.
Except as otherwise provided in this Manual, hospitals shall be reimbursed
pursuant to the surgical per diem schedule for each admission wherein the
ICD-9-CM primary procedure code is designated as either “operative” or
“mixed.”
Solucient’s LOS manuals may be obtained from Solucient, LLC, 1007 Church
Street, Suite 700, Evanston, Illinois 60201 or (800) 568-3282.
c. If, after segregation of the surgical implant charges, the charges for any day
of hospitalization are less than the applicable per diem allowance established
in this section, the hospital shall be reimbursed the per diem allowance for the
day(s) rather than the lesser amount
Rule 69L-7.501, F.A.C. Effective 10/01/07 Florida Workers’ Compensation
Reimbursement Manual for Hospitals, 2006 Edition 10
charged by the hospital.
2. The insurer shall not reimburse a per diem allowance for the day of
discharge.
3. When a discharge occurs within 24 hours of admission to a hospital facility,
reimbursement shall not exceed the applicable per diem allowance for a single
day, unless the hospital indicates that the injured employee expired within the
24 hours. When discharge occurs within 24 hours of admission and the injured
employee expired, the insurer shall reimburse the hospital either the
applicable per diem allowance, or seventy-five percent (75%) of the hospital’
s charges, whichever is greater.
4. The insurer shall not disallow a per diem allowance for any day of an
inpatient stay unless the documentation in the medical record does not
support the medical necessity for each of the estimated number of days that
were pre-certified, or the actual length of stay exceeds the estimated days that
were pre-certified by the insurer and the medical record does not substantiate
the medical necessity for the additional inpatient day(s).
E. Stop-Loss Reimbursement.
If the Total Gross Charges After Implant Carve-Out exceeds $51,400.00, the
hospital shall be reimbursed seventy-five percent (75%) of the Total Gross
Charges After Implant Carve-Out, except as otherwise provided in this
Manual.
Subject to any minimum partial payments required by Section XI herein, the
insurer shall deny, disallow, or adjust payment for charges included in the
Total Gross Charges After Implant Carve-Out that do not correspond to the
hospital’s Charge Master or are for undocumented or medically unnecessary
services or supplies as determined in accordance with Sections XI and XII of
this Manual. If any downward adjustment of the Total Gross Charges After
Implant Carve-Out, pursuant to Sections XI and XII of this Manual, reduces
the Total Gross Charges After Implant Carve-Out to $51,400.00 or less,
reimbursement for the Total Gross Charges After Implant Carve-Out shall be
pursuant to the applicable Per Diem Schedule.
Rule 69L-7.501, F.A.C. Effective 10/01/07

REIMBURSEMENT TOPICS”: BILLING AND REPORTING MEDICAL
SERVICES AND TREATMENT
There are no statutory time-frame requirements for submitting a medical bill
to a workers’ compensation insurer. However, the provider should submit a
bill as soon as possible after the services are rendered. The sooner the medical
bill is submitted to the insurer, the sooner the provider is reimbursed for the
service(s) rendered and the insurer meets their requirement for timely
payment of the bill. As the medical condition determines the injured
employee’s entitlement to continuing medical treatment, it also determines
other benefits to which the injured employee is entitled, e.g. compensation
payment benefits, retraining benefits, etc. Therefore, it is important that the
insurer receive the necessary medical reports and bills quickly to ensure the
injured employee receives appropriate benefits in a timely manner.

Physician and other licensed practitioner services, including oral and
maxillofacial services, are reported and billed on the form DFS-F5-DWC-9
(CMS 1500); Medical Supplies and Drugs dispensed by pharmacies and
durable medical equipment suppliers are reported and billed on the form DFS-
F5-DWC-10 (Statement of Charges for Drugs and Medical Equipment and
Supplies Form); Dental services are reported and billed on the form DFS-F5-
DWC-11 (ADA Claims Form); Facility services (to include hospital, ASC,
Nursing Homes, and Home Health Care) are reported on the form DFS-F5-
DWC-90 (UB-04)

. Reimbursement is based on the policy in effect on the date of service for the
specific provider type rendering the billed services. The Florida Workers’
Compensation system has established maximum reimbursement allowances
(MRAs) for each provider type eligible to render services under this program:
physicians, recognized practitioners, pharmacies, hospitals, and Ambulatory
Surgical Centers. Nursing Homes, Home Health Agencies, and durable medical
equipment (DME) providers are reimbursed under a contractual agreement
between the provider and the insurer at the time of authorization for the
service.

The workers’ compensation insurer may disallow reimbursement for services
when the provider fails to submit the DFS-F5-DWC-25 which documents the
request for authorization of the billed services as required by rule. An insurer
may also disallow reimbursement for services when the provider fails to
submit those documents listed in the reimbursement manual(s) or other forms
of documentation specifically requested by the insurer in writing at the time
of authorization. Examples may be:
Itemized statement
Operative reports for surgical procedures
Implant certification/documentation
DWC-25, when required by rule
Documentation to support medical necessity of care, services or treatment
Medication administration records

A provider may be reimbursed an amount greater or lesser than the listed
MRA if the provider and workers’ compensation insurer enter into a written
reimbursement contract.

. A workers’ compensation insurer is required by statute to pay, disallow, or
deny reimbursement of an accurately completed medical bill within 45 days of
receipt. Additionally, the insurer shall provide written notification of the
reimbursement decision (Explanation of Bill Review, EOBR) to the provider,
pursuant to Rule 69L-7.602, F.A.C.

All treatment, care and attendance services are to be billed by the recognized
health care provider who directly rendered the billable service. However, Rule
69L- 7.602(4)(b)(3) Special Billing Requirements Section requires recognized
practitioners who are salaried employees of an authorized treating physician
to bunder the employing physician’s alpha-numeric Florida Department of
Health licensenumber or unique license number

Valid CPT/HCPCS codes not listed in the current fee schedule are reimbursed
as ‘By Report’ codes. Submit the medical documentation to the insurer for
insurer pricing and reimbursement.

NOTICE OF DENIAL OF PAYMENT FOR AUTHORIZED OR
EMERGENCY MEDICAL TREATMENT AND SERVICES

If the provider bills for rendered services, authorized by the employer or
workers’ compensation insurer or rendered as emergency treatment, and the
insurer determines that the condition for which the services were rendered is
not covered under the Florida Workers’ Compensation system, the insurer is
responsible for reimbursing the provider for such services until the insurer
issues a Notice of Denial to the provider and all interested parties on the
Form DFS-F2-DWC-12, informing the provider that further treatment is not
authorized and is not reimbursable, s.440.2
An injured employee shall not be responsible for the payment of medical
treatment for a compensable condition. Therefore, a provider may not bill or
refer an injured employee to a collection agency for the payment of services
unpaid by the workers’ compensation insurer, s.440.13(14)(a),(c), F.S.

A provider may bill an injured employee the required $10.00 co-payment for
each office visit after the injured employee has reached MMI. The provider
may also bill the injured employee for any care or treatment rendered for a
non-related condition, a condition deemed non-compensable by the workers’
compensation insurer or, or when the insurer applies apportionment to
reimbursement, s.440.13(14)(c),F.S