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Instrucciones para Proveedores de Atención Médica
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Instrucciones para Proveedores de Atención Médica

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  • 1. THE FLORIDA WORKERS’ COMPENSATION SYSTEM TUTORIAL for EXPERT MEDICAL ADVISORS
  • 2. This tutorial will provide the reader with highlights from each of the pertinent medical sections of the Florida Statutes. The Department of Financial Services’ - Division of Workers’ Compensation’s internet site offers a complete copy of Chapter 440, F.S. on the home web page: http://www.fldfs.com/wc . (Click on “Ch. 440 FL Statutes” located in the topics listed on the left side of the home page.)
  • 3. Through this program…
    • THE EXPERT MEDICAL ADVISOR WILL BE ABLE TO UNDERSTAND HIS/HER RESPONSIBILITIES FOR PROVIDING EXPERT OPINION TO FACILITATE THE RESOLUTION OF MEDICAL CARE ISSUES AND DISPUTES PENDING BEFORE THE DIVISION OR A JUDGE OF COMPENSATION CLAIMS
  • 4. The Florida Workers’ Compensation System Goals provide for the following:
    • A Self Executing System
    • Quick Efficient Delivery of Medical Benefits
    • Medically Necessary Treatment
    • Facilitation of Return to Work
  • 5. WHAT ARE WORKERS’ COMPENSATION BENEFITS?
    • MEDICAL -
    • MEDICALLY NECESSARY
    • MEDICAL CARE
    • INDEMNITY -
    • WAGE REPLACEMENT BENEFITS
    • REEMPLOYMENT -
    • VOCATIONAL REHABILITATION BENEFITS TO FACILITATE EARLY RETURN TO SUITABLE GAINFUL EMPLOYMENT
  • 6. WHAT IS THE ROLE OF THE PHYSICIAN WHO RENDERS CARE AND SERVICES TO INJURED WORKERS IN THE FLORIDA WORKERS’ COMPENSATION SYSTEM?
  • 7. THE ROLE OF THE PHYSICIAN
    • TO ESTABLISH AN ACCURATE DIAGNOSIS
    • The Clinical Evaluation must be based on History/Physical/Diagnostics, Diagnosis & Treatment, Studies and Consultations
    • TO PRESCRIBE “MEDICALLY NECESSARY” TREATMENT
    • Definition - s.440.13(1)(m), F.S.
    • The Proposed Treatment Plan MUST BE submitted on
    • Form DFS-F5-DWC-25 (DWC-25)
    • TO COMMUNICATE THE PATIENT’S FUNCTIONAL STATUS
    • Identify Medical Restrictions/Limitations relating to work & full time or transitional duty
    • Prescribe Restrictions/Limitations and submit to the insurer on DWC-25
  • 8. STANDARDS OF CARE s.440.13(16), F.S.
    • Treatment is inherently scientifically logical
    • Treatment focuses on clinical dysfunction
    • High intensity, short duration treatment approach
    • Treatment plan, therapies, medication, functional limitations/restrictions periodic review
    • Additionally, the treatment plan is reviewed upon receiving information from other health care providers [no less than] every 30 days
    The health care provider’s care and treatment shall be based on the following standards of care.
  • 9. STANDARDS OF CARE (continued) s.440.13(16), F.S.
    • Treatment MATCHES physiologic and clinical problem
    • Treatment SHALL match type, intensity, duration of service necessary for identified problem
    • Restrictions / Limitations are based on objective RELEVANT medical findings
    • Restrictions / Limitations are reviewed continuously and at EACH and EVERY visit
    • Return to work (RTW) is an integral part of the treatment plan
  • 10. THE ROLE OF THE PHYSICIAN (continued)
      • WHEN PROVIDING SPECIFIC LIMITATIONS / RESTRICTIONS
      • The health care provider shall identify:
        • Specific Parameters (i.e. load, frequency, duration, position)
        • Measured inabilities
        • Detriments to recovery
        • Imminent danger to self or others
        • Alternative methods of function
        • THE HEALTH CARE PROVIDER IS TO IDENTIFY THE EMPLOYEE’S PHYSICAL LIMITATIONS, AND ADDRESS RETURN TO WORK STATUS
  • 11. STANDARDS OF CARE (continued) s.440.13(16), F.S. The Standards of Care shall be followed in providing medical care under Chapter 440: (a) Abnormal anatomical findings alone, in the absence of objective relevant medical findings, shall not be an indicator of injury or illness , a justification for the provision of remedial medical care or the assignment of restrictions, or the foundation for limitations.
  • 12. (b) At all times during evaluation and treatment, the provider shall act on the premise that returning to work is an integral part of the treatment plan . The assignment of restrictions and limitations shall be reviewed with each patient exam and upon receipt of new information…
    • The health care provider shall report changes in restrictions and limitations on the Form DWC-25.
    STANDARDS OF CARE (continued) s.440.13(16), F.S.
  • 13. STANDARDS OF CARE (continued) s.440.13(16), F.S. (c) Reasonable, necessary medical care of injured employees shall in all situations: 1. Utilize a high intensity, short duration treatment approach 2. Include reassessment of treatment plans, regimes, therapies, prescriptions, and functional limitations or restrictions prescribed by the provider every 30 days 3. Be focused on treatment of the individual employees specific clinical dysfunction or status
  • 14. STANDARDS OF CARE (continued) s.440.13(16), F.S. All treatment shall be inherently scientifically logical, and the evaluation or treatment procedure must match the documented physiologic and clinical problem. Treatment shall match the type, intensity, and duration of service required by the problem identified.
    • The carrier may disallow reimbursement for a procedure when the treatment procedure does not match the problem identified.
  • 15. THE ROLE OF THE PHYSICIAN (continued)
    • TO ESTABLISH THE DATE OF MAXIMUM MEDICAL MPROVEMENT
    • MMI is reached when no further recovery is anticipated or when maximum improvement is a reasonable medical probability [s.440.02(10), F.S.]
    • TO DOCUMENT THE PERMANENT IMPAIRMENT RATING (PIR)
      • The physician shall:
      • calculate PIR at the time of MMI
      • identify anatomical/functional abnormalities or losses resulting from work-related injury or illness
      • identify the injured workers’ permanent restrictions/limitations
  • 16. PERMANENT IMPAIRMENT RATING s.440.15(3)(b), F.S. Pursuant to the Florida Statutes, only physicians licensed under Florida Statute Chapters, as appropriate (considering the nature of the injury), are authorized to render an opinion regarding the permanent impairment rating of an injured employee: 458 Medical 469 Osteopathic 460 Chiropractors 461 Podiatrists 463 Optometrists 466 Dentists
  • 17. TEMPORARY TOTAL DISABILITY s.440.15(2)(a), F.S. “… once the employee reaches the maximum number of weeks allowed, or the employee reaches the date of maximum medical improvement, whichever occurs earlier, temporary disability benefits shall cease and the injured worker’s permanent impairment shall be determined.”
    • Once the physician determines the employee has achieved maximum medical improvement, the physician SHALL calculate the permanent impairment rating.
    When does the healthcare provider assign MMI & PIR?
  • 18. PERMANENT IMPAIRMENT RATING s.440.15(3)(d), F.S. After the employee has been certified by a doctor as having reached maximum medical improvement… the certifying doctor shall evaluate the condition of the employee and assign an impairment rating, using the impairment schedule on the following slide.
    • Maximum medical improvement and impairment rating shall be reported by the physician to the carrier on the Form DWC-25.
  • 19.
    • “ The certifying doctor shall issue a written report to the employee and the carrier certifying that maximum medical improvement has been reached…and providing any other information required by the department by rule.”
    • (report MMI/PIR on Form DWC-25, specifying permanent restrictions / limitations pursuant to 69L-7.602, F.A.C.)
    “ The carrier shall establish an overall maximum medical improvement date and permanent impairment rating, based on all such reports.” PERMANENT IMPAIRMENT RATING/ MAXIMUM MEDICAL IMPROVEMENT s.440.15(3)(d)1., F.S.
  • 20. PERMANENT IMPAIRMENT RATING s.440.15(3)(d), F.S. If the certification and evaluation are performed by a doctor other than the employee’s treating doctor, the certification and evaluation must be submitted to the treating doctor, the employee, and the carrier within 10 days after the evaluation. The treating doctor must indicate to the carrier agreement or disagreement with the other doctor’s certification and evaluation.
    • The certifying doctor who is not the employee’s treating doctor must submit a completed Form DWC-25 to the treating doctor, the employee and the carrier within 10 days after the evaluation.
  • 21. SUBSEQUENT INJURY; APPORTIONMENT s.440.15(5)(b), F.S. The degree of permanent impairment or disability attributable to the accident or injury shall be compensated in accordance with this section, apportioning out the preexisting permanent condition based on the anatomical impairment rating attributable to the preexisting condition.
  • 22. RATING PERMANENT IMPAIRMENT s.440.15(3)(b), F.S.
    • AMA, 3RD EDITION
    • for DOI: prior to 07/01/90
    • MINNESOTA GUIDE
    • for DOI: 07/01/90 to 06/20/93
    • 1993 Florida Impairment Rating Guide (FIRG)
    • for DOI: 06/21/93 to 01/07/97
    • 1996 FL Uniform P.I.R. Schedule
    • for DOI: 01/08/97 and thereafter
    Impairment Rating The health care provider shall use the following resources to calculate a permanent impairment rating (based on the date of injury or accident – DOI):
  • 23. Chapter 440, Florida Statutes, identifies the employer, health care provider and insurer/ carrier duties and responsibilities related to the provision of care for Florida injured workers. The health care provider should review the following excerpts to be familiar with the Florida Statutes pertaining to medical services. Florida Statutes
  • 24.
    • 440.02 Definitions.
    • 440.09 Coverage.
    • 440.093 Mental and nervous injuries.
    • 440.102 Drug-free workplace program requirements.
    • 440.105 Prohibited activities; reports; penalties; limitations. (Fraud)
    • 440.13 Medical services and supplies; penalty for violations; limitations
    Florida Statutes
  • 25.
    • 440.134 Workers’ compensation managed care arrangement
    • 440.15(3) Permanent impairment benefits/ rating
    • 440.15(5) Subsequent injury; apportionment
    • 440.151 Occupational diseases
    • 440.20 Time for payment of compensation and medical bills; penalties for late payment
    • 440.491 Reemployment of injured workers; rehabilitation
    Florida Statutes
  • 26.
    • (10) “Date of maximum medical improvement” means the date after which further recovery from, or lasting improvement to, an injury or disease can no longer reasonably be anticipated, based upon reasonable medical probability.
    • (15)(a) Employee – means any person who receives remuneration from an employer for the performance of any work or service while engaged in any employment …and includes, but is not limited to, aliens and minors.
    Florida Statutes s.440.02 Definitions
  • 27.
    • (1) Major Contributing Cause – means the cause which is more than 50% responsible for the injury as compared to all other causes combined for which treatment or benefits are sought.
    • (1) Pain or other subjective complaints alone, in the absence of objective relevant medical findings, are not compensable.
    • (1) Objective relevant medical findings are those objective findings that correlate to the subjective complaints of the injured employee and are confirmed by physical examination findings or diagnostic testing.
    Florida Statutes s.440.09 Coverage The following factors impact whether an injury or illness is compensable under Florida’s workers’ compensation.
  • 28.
    • (1)(a) Subsequent Injury – No compensation or benefits for any subsequent injury the employee suffers as a result of an original work injury unless the original injury is the major contributing cause of the subsequent injury.
    • (1)(b) If a work injury combines with a preexisting disease or condition to cause or prolong disability or need for treatment, the employer must pay compensation or benefits only to the extent that the work injury remains more than 50% responsible for the injury as compared to all other causes combined.
    • MAJOR CONTRIBUTING CAUSE must be demonstrated by medical evidence only.
    Florida Statutes s.440.09 Coverage (continued)
  • 29.
    • (3) Compensation is not payable if the injury was occasioned primarily by the intoxication of the employee; by the influence of any drugs not prescribed by a physician; or by the willful intention of the employee to injure or kill himself, herself, or another.
    • (7)(c) If the injured worker refuses to submit to a drug test , it shall be presumed in the absence of clear and convincing evidence to the contrary that the injury was occasioned primarily by the influence of drug.
    Florida Statutes s.440.09 Coverage (continued)
  • 30.
    • The treatment must be based on objective RELEVANT medical findings
    • The work-related injury must be the MAJOR CONTRIBUTING CAUSE
    • The diagnosis must be determined by MEDICAL EVIDENCE only
    • Pain and/or a subjective complaint without objective RELEVANT medical findings is NOT COMPENSABLE
    Review of Coverage s.440.09(1)(a)(b), F.S.
  • 31.
    • (1) A mental or nervous injury due to stress, fright, or excitement only is not an injury by accident arising out of the employment. A physical injury resulting from mental or nervous injuries unaccompanied by physical trauma requiring medical treatment shall not be compensable under this chapter.
    • (2) Mental and nervous injuries occurring as a manifestation of an injury compensable under this chapter shall be demonstrated by clear and convincing medical evidence…The compensable physical injury must be and remain the major contributing cause …Compensation is not payable for the mental, psychological or emotional injury arising out of depression…
    Florida Statutes s.440.093 Mental and nervous injuries
  • 32.
    • (3) Subject to the payment of permanent benefits under s.440.15, in no event shall temporary benefits for a compensable mental or nervous injury be paid for more than 6 months after the date of maximum medical improvement for the injured employee’s physical injury or injuries…
    Florida Statutes s.440.093 Mental and nervous injuries (cont.)
  • 33.
    • (1)(c) “Drug” means alcohol, including a distilled spirit, wine, a malt beverage or an intoxicating liquor; an amphetamine; a cannabinoid; cocaine; phencyclidine (PCP); a hallucinogen; methaqualone; an opiate; a barbiturate ; a benzodiazepine; a synthetic narcotic; a designer drug; or a metabolite of any of the substances listed. An employer may test an individual for any or all of such drugs.
    Florida Statutes s.440.102 Drug-free workplace program requirements
  • 34.
    • (5)(e)2. A specimen for a drug test may be taken or collected by …a physician, a physician assistant, a registered professional nurse, a licensed practical nurse, or a nurse practitioner or a certified paramedic who is present at the scene of an accident for the purpose of rendering emergency medical service or treatment.
    • (5)(m) An employer shall pay the cost of all drug tests , initial and confirmation, which the employer requires of employees . An employee or job applicant shall pay the costs of any additional drug tests not required by the employer.
    Florida Statutes s.440.102 Drug-free workplace program requirements
  • 35.
    • (5)(p) All authorized remedial treatment, care and attendance provided by a health care provider to an injured employee before medical and indemnity benefits are denied under this section must be paid for by the carrier or self-insured. However, the carrier or self-insurer must have given reasonable notice to all affected health care providers that payment for treatment, care and attendance provided to the employee after a future date certain will be denied.
    Florida Statutes s.440.102 Drug-free workplace program requirements
  • 36.
    • (1)(a) … any professional practitioner licensed or regulated by the Department of Health…or any employee thereof, having knowledge or who believes that a fraudulent act or any other act or practice which, upon conviction, constitutes a felony or misdemeanor under this chapter is being or has been committed shall send to the Division of insurance Fraud, Bureau of Workers’ Compensation Fraud, a report or information pertinent to such knowledge or belief and such additional information relative thereto as the bureau may require.
    Florida Statutes s.440.105 Prohibited activities; reports; penalties; limitations
  • 37.
    • (4)(c) It shall be unlawful for any physician licensed under chapter 458, osteopathic physician licensed under chapter 469L, chiropractic physician licensed under chapter 460, podiatric physician licensed under chapter 461, optometric physician licensed under chapter 463, or any practitioner licensed under the laws of this state to knowingly and willfully assist, conspire with, or urge any person to fraudulently violate any of the provisions of this chapter .
    Florida Statutes s.440.105 Prohibited activities; reports; penalties; limitations
  • 38.
    • Fraud Statement - An injured employee or any other party making a claim under this chapter shall provide his or her personal signature attesting that he or she has reviewed, understands, and acknowledges the following statement:
    Florida Statutes s.440.105(7) Fraud Statement “ Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234.”
  • 39.
    • ( 2) A party who makes claims for services provided to the claims-handling entity on a recurring basis may make one personally signed attestation to the claims-handling entity as required by Section 440.105(7), F.S., which will satisfy the requirement for all claims submitted to the claims-handling entity for the calendar year in which the attestation is submitted.
    Florida Administrative Code Rule 69L-3.0047, F.A.C. Fraud Statement
    • Health Care Providers must submit a signed fraud statement once per calendar year to each insurer / carrier from which they are requesting reimbursement.
  • 40.
    • Fraud Statement
    Florida Statutes 440.105(7) If the injured employee or other party refuses to sign the document attesting that he or she has reviewed, understands, and acknowledges the statement, benefits, or payments under this chapter shall be suspended until such signature is obtained.
    • The insurer may disallow payment for a medical bill if the health care provider fails to have a signed Fraud Statement on file with the insurer.
  • 41. Each subsection of the following Florida Statutes is presented in detail to familiarize the health care provider with the Florida Statutes pertinent to treatment rendered to injured workers in the Florida Workers’ Compensation system. Florida Statutes 440.13 Medical Services
  • 42.
    • DEFINITIONS
    • 440.13(1)(d): Health care provider certification
    • 440.13(1)(h): Health care provider who renders care pursuant to a prescription or under the supervision of a physician
    • 440.13(1)(l): Medical necessity
    • 440.13(1)(q): Physician
    Florida Statutes 440.13 Medical Services
  • 43.
    • 440.13(2)(d): Carrier right to transfer care
    • 440.13(3)(a): Provider certification; Authorization prior to provision of care
    • 440.13(3)(b): Emergency care; authorization
    • 440.13(3)(c): Provider referrals
    • 440.13(3)(g): Employee liability for payment
    Florida Statutes 440.13 Medical Services
  • 44.
    • 440.13(3)(d) & (i): Carrier authorization
    • 440.13(4)(a): Form DFS-F5-DWC-25
    • 440.13(4)(b) Provision of medical records
    • 440.13(4)(c): Physician-patient privilege
    • 440.13(5)(a): Independent medical examinations (IME)
    Florida Statutes 440.13 Medical Services
  • 45.
    • 440.13(5)(d): IME No-show provisions
    • 440.13(7)(a): Reimbursement disputes
    • 440.13(8)(b) Overutilization; statute or rule violations; health care provider penalties/sanctions
    • 440.13(9): Expert Medical Advisors
    • 440.13(10): Witness (deposition) fees
    Florida Statutes 440.13 Medical Services
  • 46.
    • 440.13(12): Reimbursement allowances
    • 440.13(13): Removal of physicians from the list of certified health care providers
    • 440.14(14)(c): Co-payment after assignment of MMI
    • 440.13(15): Practice Parameters
    • 440.13(16): Standards of Care - reasonable necessary medical care
    Florida Statutes 440.13 Medical Services
  • 47.
    • Definitions
    Florida Statutes 440.13(1)
    • “ Carrier” means, for purposes of this section, insurance carrier, self-insurance fund or individually self-insured employer, or assessable mutual insurer.
    • “ Certified health care provider” means a health care provider who has been certified by the Division or who has entered an agreement with a licensed managed care organization to provide treatment to injured workers under this section. Certification of such health care provider must include documentation that the health care provider has read and is familiar with the portions of the statute, impairment guides, practice parameters, protocols of treatment, and rules which govern the provision of remedial treatment, care, and attendance.
  • 48.
    • Definitions
    Florida Statutes 440.13(1)
    • “ Health care provider” means a physician or any recognized practitioner who provides skilled services pursuant to a prescription or under the supervision or direction of a physician and who has been certified by the Division as a health care provider…
    • (l) “Medically necessary” or “medical necessity” means any medical service or medical supply which is used to identify or treat an illness or injury, is appropriate to the patient’s diagnosis and status of recovery, and is consistent with the location of service, the level of care provided, and applicable practice parameters…The service must not be of an experimental, investigative, or research nature.
  • 49.
    • Definitions
    Florida Statutes 440.13(1) (o) “Pattern or practice of overutilization” means repetition of instances of overutilization within a specific medical case or multiple cases by a single health care provider. (q) “Physician” or “doctor” means a physician licensed under chapter 458, an osteopathic physician licensed under chapter 469L, a chiropractic physician licensed under chapter 460, a podiatric physician licensed under chapter 461, an optometrist licensed under chapter 463, or a dentist licensed under chapter 466, each of whom must be certified by the Division… (r) “Reimbursement dispute” means any disagreement between a health care provider or health care facility and carrier concerning payment for medical treatment.
  • 50. CARRIER TRANSFER OF CARE s. 440.13(2)(d), F.S.
    • The carrier has the right to transfer the care of an injured employee from the attending health care provider if an independent medical examination determines that the employee is not making appropriate progress in recuperation .
  • 51. CERTIFICATION & INSURER AUTHORIZATION Non-Emergency Care s. 440.13(3)(a), F.S.
    • Conditions of eligibility for reimbursement
    • The health care provider must have:
      • Certification from the Division and
      • Insurer/Carrier authorization prior to provision of services
    • Notice of Injury : Filing the DWC-1 is the
    • responsibility of the Employer.
  • 52.
    • “ Certified Health Care Provider” means a health care provider who has been certified by the Division or who has entered an agreement with a licensed managed care organization to provide treatment to injured workers under Chapter 440, pursuant to s.440.13(1)(d), Florida Statutes.”
    CERTIFIED HEALTH CARE PROVIDER
  • 53.
    • The physician must meet the qualifications specified in Rule 69L-29, F.A.C.
    • The physician must submit an accurately completed application for Health Care Provider Certification to the Division
    • The application may be printed from the following link:
    • http://www.fldfs.com/wc/pdf/DFS-3160-0020.pdf
    CERTIFIED HEALTH CARE PROVIDER How does a physician become a “Certified Health Care Provider”?
  • 54. CERTIFICATION & INSURER AUTHORIZATION EMERGENCY CARE s.440.13(3)(b), F.S.
    • For emergency care & services:
    • Pre-authorization & use of a certified HCP is not required
    • The HCP must notify the carrier by
    • close of 3rd business day
    • The treatable condition must arise from work-related accident
  • 55. Emergency is defined. . .
    • In s. 395.002(9), F.S.
    • As an acute, severe (includes pain), causes impairment, death, or dysfunction
    • And covers screening, exam, evaluation, care, treatment, or surgery to relieve / alleviate symptoms
    +
  • 56. EXPERIMENTAL, INVESTIGATIVE OR RESEARCH IN NATURE
    • Effective October 1, 2003 , the insurer / carrier has statutory authority to determine if a treatment procedure is experimental, investigative or research in nature.
    • Effective October 1, 2003, all requests for determination of coverage for treatment procedures that may be experimental, investigative or research in nature shall be submitted by the health care provider to the carrier.
    How does a health care provider gain approval for treatment that may be deemed experimental, investigative or research in nature?
  • 57. PROVIDER REFERRALS s.440.13(3)(c),F.S.
    • “ A health care provider may not refer the employee to another health care provider, diagnostic facility, therapy center, or other facility without prior authorization from the carrier, except when emergency care is rendered. “
    • Referrals must be made to another certified health care provider , unless the referral is for emergency treatment.
  • 58.
    • “ The employee is not liable for payment of medical treatment or services provided pursuant to this section except as otherwise provided in this section. “ s.440.13(3)(g), F.S.
    • )
    “… providers have recourse against the employer or carrier for payment for services rendered in accordance with this chapter.” s.440.13(14)(a), F.S. EMPLOYEE LIABILITY FOR PAYMENT Can the injured employee be billed for services provided in relation to a compensable work injury?
  • 59. PAYMENT OF MEDICAL FEES s.440.13(14)(a), F.S. “ Except for emergency care treatment, fees for medical services are payable only to a health care provider certified and authorized to render remedial treatment, care or attendance under this chapter… A health care provider may not collect or receive a fee from an injured employee within this state, except as otherwise provided by this chapter… Such providers have recourse against the employer or carrier for payment for services rendered in accordance with this chapter.”
  • 60. PAYMENT OF MEDICAL FEES Patient Copayment s.440.13(14)(c), F.S. “ Notwithstanding any other provision of this chapter, following overall maximum medical improvement from an injury compensable under this chapter, the employee is obligated to pay a copayment of $10 per visit for medical services . The copayment shall not apply to emergency care provided to the employee.” When may the healthcare provider collect payment from the injured employee?
  • 61. SUBSEQUENT INJURY; APPORTIONMENT s.440.15(5)(b), F.S. “ If a compensable injury, disability, or need for medical care, or any portion thereof, is a result of aggravation or acceleration of a preexisting condition, or is the result of merger with a preexisting condition, only the disabilities and medical treatment associated with such compensable injury shall be payable under this chapter …”
    • The carrier may reduce reimbursement for medical services by the percentage of impairment or disability attributed to the preexisting condition.
  • 62. OCCUPATIONAL DISEASES s.440.151(1)(a), F.S. … in no case shall an employer be liable for compensation under the provisions of this section unless such disease has resulted from the nature of the employment in which the employee was engaged under such employer…and the nature of the employment was the major contributing cause of the disease . Major contributing cause must be shown by medical evidence only, as demonstrated by physical examination findings and diagnostic testing.
  • 63. OCCUPATIONAL DISEASES s.440.151(2), F.S. Whenever used in this section the term “occupational disease” shall be construed to mean only a disease which is due to causes and conditions which are characteristic of and peculiar to a particular trade, occupation, process , or employment than for the general public. “Occupational disease” means only a disease for which there are epidemiological studies showing that exposure to the specific substance involved, at the levels to which the employee was exposed, may cause the precise disease sustained by the employee.
  • 64. PAYMENT OF MEDICAL BILLS s.440..20, F.S. “ (2)(b) The carrier must pay, disallow, or deny all medical, dental, pharmacy, and hospital bills submitted to the carrier in accordance with department rule no later than 45 calendar days after the carrier’s receipt of the bill. “ (4) If the carrier is uncertain of its obligation to provide all benefits or compensation, the carrier shall immediately and in good faith commence investigation of the employee’s entitlement to benefits under this chapter and shall admit or deny compensability within 120 after the initial provision of compensation or benefits… How long does an insurer/carrier have to pay a bill?
  • 65.
    • “ A carrier must respond to a written request for authorization from an authorized health care provider by close of the third business day after receipt of the request.”
    • Prior authorization is NOT REQUIRED for EMERGENCY SERVICES.
    INSURER / CARRIER AUTHORIZATION s.440.13(3)(d), F.S. How long does an insurer/carrier have to authorize or disallow a physician’s written request for treatment?
  • 66.
    • “ A carrier must respond to a written request for specialist consultations, surgical operations, physiotherapeutic or occupational therapy procedures, X-ray examinations or special diagnostic or laboratory tests that cost more than $1000 within 10 days after receipt of the request.”
    • Completion and submission of the DFS-F5-DWC-25 is considered a written request for authorization of treatment.
    INSURER / CARRIER AUTHORIZATION (continued) s.440.13(3)(i), F.S.
  • 67.
    • DFS-F5-DWC-25 -- Florida Workers’ Compensation Uniform Medical Treatment/Status Reporting Form
    • (adopted for use July 4, 2004)
    A copy of the DWC-25 can be obtained from the Division website at the following link: http://www.fldfs.com/wc/pdf/DWC-25.pdf FORM DWC-25 Rule 69L-7.602, F.A.C.
  • 68.
    • “ Any health care provider providing necessary remedial treatment, care, or attendance to any injured worker shall submit treatment reports to the carrier in a format prescribed by the department .”
    • The format prescribed by the department is the Form DFS-F5-DWC-25 (DWC -25) .
    FORM DWC-25 s.440.13(4)(a), F.S.
  • 69.
    • “ A claim for medical or surgical treatment is not valid or enforceable …unless, by the close of the third business day following the first treatment, the physician providing treatment furnishes to the employer or carrier…”
    • a Form DWC-25
    FORM DWC-25 s.440.13(4)(a), F.S. An insurer/carrier may disallow payment for services if the health care provider does not submit a Form DWC-25, pursuant to Rule 69L-7.602, F.A.C.
  • 70.
    • Insurers and providers shall utilize ONLY the Form DWC-25 for physician reporting of the injured employee’s medical treatment / status.
    • Any other reporting form MAY NOT be used in lieu of or supplemental to the Form DWC-25
    FORM DWC-25 Rule 69L-7.602, F.A.C. Therefore, the physician is not required to complete any other insurer/carrier forms.
  • 71.
    • Must be signed by the authorized physician
    • Does not replace physician notes, medical records or required billing forms
    • Information must be consistent with medical notes, medical records, diagnostic testing, etc.
    • Becomes a part of the patient’s medical record maintained by the physician
    • Must be submitted to the employer upon request
    FORM DWC-25 Rule 69L-7.602, F.A.C. The Form DWC-25:
  • 72.
    • Health Care Providers who render direct billable services shall submit to the carrier a medical bill for reimbursement of services using the Form DFS-F5-DWC-9 (CMS 1500) regardless of employment arrangement.
    A copy of the DFS-F5-DWC-9 can be obtained from the CMS website: http://www.cms.hhs.gov/cmsforms/ FORMS SUBMITTED TO CARRIER Rule 69L-7.602, F.A.C.
  • 73.
    • Health care providers who willfully refuse to provide medical records or discuss the medical condition of the injured employee are subject to the penalties set forth in s.440.13(8)(b), F.S.
    “ Upon the request of the department , each medical report or bill obtained or received by the employer, the carrier, or the injured employee…, including any report of an examination, diagnosis , or disability evaluation, must be produced by the health care provider to the department pursuant to rules adopted by the department.” PROVISION OF MEDICAL RECORDS s.440.13(4)(b), F.S. Medical records must be produced upon request.
  • 74. “ The health care provider shall also furnish to the injured employee or his or her attorney and the employer or carrier or its attorney, on demand, a copy of his or her office chart, records, and reports , and may charge the injured employee no more than 50 cents per page for copying the records and the actual direct cost to the health care provider or health care facility for x rays, microfilm, or any other nonpaper records..” PROVISION OF MEDICAL RECORDS s.440.13(4)(b), F.S.
  • 75.
    • “ An employee who reports an injury or illness alleged to be work-related waives any physician-patient privilege with respect to any condition or complaint reasonably related to the condition for which the employee claims compensation.”
    “ Release of medical information by the health care provider or other physician does not require the authorization of the injured employee.” PHYSICIAN-PATIENT PRIVILEGE s.440.13(4)(c), F.S. A “release of information” is not required for the health care provider to release medical records, unless otherwise specified in the Florida Statutes.
  • 76.
    • The physician performing the IME shall complete:
    • A physical examination of the injured employee
    • A review of medical records
    • Determination of functional limitations and restrictions
    • Calculation of Permanent Impairment Rating if at Maximum Medical Improvement
    • Report to Carrier and Employee (a Form DWC-25 and written medical report)
    INDEPENDENT MEDICAL EXAMINATIONS (IME) s.440.13(5)(a), F.S.
  • 77.
    • “ In any dispute concerning overutilization, medical benefits, compensability, or disability under this chapter, the carrier or the employee may select an independent medical examiner.”
    INDEPENDENT MEDICAL EXAMINATIONS (IME) s.440.13(5)(a), F.S.
    • Although a physician may be certified as an EMA, when an IME is requested the EMA is functioning as health care provider, not as an EMA.
  • 78.
    • “ If the parties agree, the examiner may be a health care provider treating or providing other care to the employee.”
    • “ The independent medical examiner may not provide follow-up care if such recommendation for care is found to be medically necessary.”
    INDEPENDENT MEDICAL EXAMINATIONS (IME) s.440.13(5)(a), F.S.
  • 79.
    • “ The employer and employee shall be entitled to only one independent medical examination per accident and not one independent medical examination per medical specialty.”
    • “ The party requesting and selecting the independent medical examination shall be responsible for all expenses associated with said examination…”
    INDEPENDENT MEDICAL EXAMINATIONS (IME) s.440.13(5)(a), F.S.
  • 80.
    • “ If the employee fails to appear for the independent medical examination scheduled by the employer or carrier …the employee is barred from recovering compensation for any period during which he or she has refused to submit to such examination.”
    • “ Further, the employee shall reimburse the employer or carrier 50 percent of the physician’s cancellation or no-show fee…”
    IME NO-SHOW PROVISIONS FOR PAYMENT s.440.13(5)(d), F.S.
  • 81.
    • What is a health care provider to do if he/she is improperly reimbursed for services?
    • A health care provider may file a petition for reimbursement dispute resolution with the Division, pursuant to s.440.13(7), F.S. and Rule 69LA-31, F.A.C.
    • The form for filing a Petition for Resolution of Reimbursement Dispute may be printed from the following link: http://www.fldfs.com/wc/pdf/DFS-3160-0023.pdf
    REIMBURSEMENT DISPUTES s.440.13(7), F.S.
  • 82.
    • “ Any health care provider…who elects to contest the disallowance or adjustment of payment by a carrier under subsection (6) must, within 30 days after receipt of notice of disallowance or adjustment of payment, petition the Division to resolve the dispute.”
    • “ The petition must be accompanied by all documents and records that support the allegations contained in the petition. Failure of a petitioner to submit such documentation to the Division results in dismissal of the petition. “
    REIMBURSEMENT DISPUTES s.440.13(7), F.S.
  • 83.
    • All insurer/carrier’s are responsible to perform utilization review.
    • “ Carriers shall review all bills, invoices, and other claims for payment submitted by health care providers in order to identify overutilization and billing errors…”
    • “ If a carrier finds that overutilization of medical services or a billing error has occurred…it must disallow or adjust payment for such services…”
    CARRIER UTILIZATION REVIEW s.440.13(6), F.S.
  • 84. “ “ If the Division determines that a health care provider has engaged in a pattern or practice of overutilization or a violation of this chapter or rules adopted by the Division, including a pattern or practice of providing treatment in excess of the practice parameters or protocols of treatment, it may impose one or more…penalties.” OVERUTILIZATION, STATUTE OR RULE VIOLATIONS, HCP PENALTIES / SANCTIONS s.440.13(8)(b), F.S.
  • 85. DIVISION OF WORKERS’ COMPENSATION JURISDICTION s.440.13(11)(c), F.S. “ The Division has exclusive jurisdiction to decide any matters concerning reimbursement, to resolve any overutilization dispute under subsection (7), and to decide any question concerning overutilization under subsection (8) which question or dispute arises after January 1, 1994.”
  • 86.
    • An order barring the provider from payment under this chapter.
    • Deauthorization of care under review.
    • Denial of payment for care rendered in the future.
    • Decertification of a health care provider as an expert medical advisor …
    • A fine assessed by the Division not to exceed $5000 per instance of overutilization or violation.
    • Notification of and review by the appropriate licensing authority.
    POTENTIAL PROVIDER PENALTIES s.440.13(8)(b), F.S.
  • 87. WITNESS (Deposition) FEES s.440.13(10), F.S. “ Any health care provider who gives a deposition shall be allowed a witness fee. The amount charged by the witness may not exceed $200 per hour . An expert witness who has never provided direct professional services to a party but has merely reviewed medical records and provided an expert opinion or has provided only direct professional services that were unrelated to the workers’ compensation case may not be allowed a witness fee in excess of $200 per day . “ What reimbursement is made to the health care provider acting as a witness?
  • 88. PROVIDER AUDITS s.440.13(11)(a), F.S. “ The Division of Workers’ Compensation may investigate health care providers to determine whether providers are complying with this chapter and with rules adopted by the Division…If the Division finds that a health care provider has improperly billed, overutilized, or failed to comply with Division rules or the requirements of this chapter…may impose penalties as set forth in subsection (8) or other sections of this chapter. What happens to the health care provider who fails to comply with the laws and rules that apply to Florida workers’ compensation?
  • 89. REIMBURSEMENT FOR MEDICAL SERVICES s.440.13(12)(a), F.S. “ The panel (Three Member Panel) shall determine statewide schedules of maximum reimbursement allowances for medically necessary treatment, care, and attendance provided by physicians …and durable medical equipment.” “ An individual physician , hospital… shall be reimbursed either the agreed-upon contract price or the maximum reimbursement allowance in the appropriate schedule .” How is the reimbursement schedule determined?
  • 90. “ 4. Maximum reimbursement for a physician licensed under chapter 458 or 469L shall be increased to 110 percent of the reimbursement allowed by Medicare , using appropriate codes and modifiers or the medical reimbursement level adopted by the three-member panel as of January 1, 2003, whichever is greater .” “ 5. Maximum reimbursement for surgical procedures shall be increased to 140 percent of the reimbursement allowed by Medicare or the medical reimbursement level adopted by the three member panel as of January 1, 2003, whichever is greater .” REIMBURSEMENT FOR MEDICAL SERVICES s.440.13(12)(b), F.S.
  • 91. REIMBURSEMENT Rule 69L-7.020, F.A.C. “ The Florida Workers’ Compensation Health Care Provider Reimbursement Manual , 2005 Edition…contains reimbursement policies , guidelines, codes and maximum reimbursement allowances for services and supplies provided by health care providers.”
    • The appropriate Health Care Provider Reimbursement Manual is determined by the manual in effect on the date the service is provided.
    Where can a health care provider locate the maximum reimbursement allowances for services?
  • 92. REIMBURSEMENT Rule 69L-7.020, F.A.C. Reimbursement manuals may be viewed on or printed from the Division website: www.fldfs.com/wc
  • 93. EXPERT MEDICAL ADVISOR (EMA)
    • How does a physician become a Florida workers’ compensation Expert Medical Advisor?
    • What are the Expert Medical Advisor’s duties and responsibilities within the Florida Workers’ Compensation system?
    • Who can select the Expert Medical Advisor?
  • 94. EXPERT MEDICAL ADVISORS s.440.13(9), F.S.
    • The physician must meet the qualifications specified in Rule 69LA-30.003, F.A.C.
    • The physician must submit a completed application for Expert Medical Advisor Certification to the Division.
    • The application may be printed from the following link:
    • http://www.fldfs.com/wc/pdf/DFS-3160-0021.pdf
    How does a physician become an Expert Medical Advisor?
  • 95. Expert Medical Advisor certification requires that the physician attest to knowledge of the Florida Statutes related to workers’ compensation, specifically Sections 440.02, 440.09, 440.093, 440.102, 440.105, 440.13, 440.134, 440.15(3), 440.15(5), 440.151, 440.20 and 440.091 and knowledge of the Florida Administrative Code Rules 69L-7.602 and 69L-7.020 or complete this tutorial. EXPERT MEDICAL ADVISOR CERTIFICATION Rule 69LA-30, F.A.C.
  • 96. EXPERT MEDICAL ADVISORS Rule 69LA-30.003, F.A.C. To be certified as an Expert Medical Advisor, a physician shall meet the following qualifications:
    • Must have been certified as a health care provider by the Division for not less than 12 months prior to the date of application; and
    • Must hold valid licensure , issued by the Florida Department of Health, with “clear and active” status; and
    • Must hold specialty-board certification or specialty-board eligibility; and
  • 97. EXPERT MEDICAL ADVISORS Qualifications (continued)
    • Must demonstrate experience in the assignment of permanent impairment ratings greater than zero (0%); and
    • Must demonstrate experience in performing independent medical examinations ; and
    • Must have completed twenty hours of continuing medical education , specifically related to the practitioner’s field of specialty, within two years prior to the date of application; and
    • Must possess knowledge of the Florida Statutes and Florida Administrative Code related to workers’ compensation.
  • 98. EXPERT MEDICAL ADVISORS Rule 69LA-30.004, F.A.C.
    • Throughout the certification period, the Expert Medical Advisor shall notify the Division:
    • If specialty-board certification has expired
    • If Florida Department of Health license status is changed from “clear and active”
    • Of any change in address or contact information
  • 99. EXPERT MEDICAL ADVISORS Rule 69LA-30.007, F.A.C. “ Upon receiving notice of selection by the Division or judge of compensation claims as an Expert Medical Advisor the physician shall disclose any conflict of interest related to the case for which the physician was selected and shall decline selection as an Expert Medical Advisor.” CONFLICT OF INTEREST
    • An Expert Medical Advisor shall decline selection as an EMA if a conflict of interest exists.
  • 100. EXPERT MEDICAL ADVISORS s.440.13(9), F.S.
    • An EMA may ONLY be contracted by the Division or Judges of Compensation Claims
    • EMAs are contracted to settle disputes related to:
    • - Reimbursement allowances
    • - Differing health care provider opinions
    • - Medical necessity of services rendered
  • 101. EXPERT MEDICAL ADVISORS s.440.13(9), F.S.
    • “ The Division shall certify expert medical advisors in each specialty to assist the Division and the judges of compensation claims…”
    • “ As a prerequisite for certification or recertification, the Division shall require , at a minimum, that the expert medical advisor have specialized workers’ compensation training or experience under the workers’ compensation system of this state and board certification or board eligibility .”
  • 102. EXPERT MEDICAL ADVISORS s.440.13(9), F.S.
    • “ The Division shall contract with one or more entities that employ, contract with, or otherwise secure expert medical advisors to provide peer review or expert medical consultation, opinions, and testimony to the Division or to a judge of compensation claims in connection with resolving disputes relating to reimbursement, differing opinions of health care providers, and health care and physician services rendered under this chapter, including utilization issues.”
  • 103. EXPERT MEDICAL ADVISORS s.440.13(9), F.S.
    • “ Expert medical advisors contracting with the Division shall, as a term of such contract, agree to provide consultation or services in accordance with the timetables set forth in this chapter and to abide by rules adopted by the Division …pertaining to procedures for review of services rendered by health care providers and preparation of reports and testimony or recommendations for submission to the Division or the judge of compensation claims.”
  • 104. EXPERT MEDICAL ADVISORS s.440.13(9), F.S.
    • “ If there is a disagreement in the opinions of the health care providers…The opinion of the expert medical advisor is presumed to be correct unless there is clear and convincing evidence to the contrary as determined by the judge of compensation claims.”
    • “ The expert medical advisor appointed to conduct the evaluation shall have free and complete access to the medical records of the employee.”
  • 105. EXPERT MEDICAL ADVISORS s.440.13(9)(d), F.S.
    • “ The expert medical advisor must complete his or her evaluation and issue his or her report to the Division or to the judge of compensation claims within 15 days after receipt of all medical records . The expert medical advisor must furnish a copy of the report to the carrier and to the employee.”
    • The expert medical advisor shall submit an accurately completed Form DWC-25 to the insurer/ carrier by close of the following business day when a patient physical examination is performed.
  • 106. EXPERT MEDICAL ADVISORS s.440.13(9)(f), F.S.
    • “ The party ordering the services of an expert medical advisor to resolve a dispute must compensate the advisor for his or her time in accordance with a schedule adopted by the Division.”
    “ If the employee prevails in a dispute …based on the expert medical advisor’s findings, the employer or carrier shall pay for the costs…” “ The Division may assess a penalty not to exceed $500 against any carrier that fails to timely compensate an advisor in accordance with this section.”
  • 107. EXPERT MEDICAL ADVISORS s.440.13(9)(f), F.S.
    • The party ordering the services of an expert medical advisor to resolve a dispute must compensate the advisor for his or her time .
    If the employee prevails in a dispute …based on the expert medical advisor’s findings, the employer or carrier shall pay for the costs… Who reimburses for the services of an Expert Medical Advisor?
    • An Expert Medical Advisor shall submit his/her bill on an invoice approved by the Judge of Compensation Claims or the Division.
  • 108. EXPERT MEDICAL ADVISORS Rule 69LA-30.008(5), F.A.C. REIMBURSEMENT SCHEDULE FOR SERVICES CONTRACTED BY: Judges of Compensation Claims - $300.00 per hour for no more than 8 hours per case Division of Workers’ Compensation - $200.00 per hour for no more than 8 hours per case
  • 109. REMOVAL OF PHYSICIANS FROM Division LIST OF CERTIFIED HEALTH CARE PROVIDERS s.440.13(13), F.S. “ The Division shall remove from the list of physicians … authorized to provide remedial treatment, care and attendance under this chapter the name of any physician…found after reasonable investigation to have : (a) Engaged in professional or other misconduct or incompetency in connection with medical services rendered under this chapter; The Division may remove a provider from the Division’s list of certified health care providers or Expert Medical Advisors.
  • 110. REMOVAL OF PHYSICIANS FROM Division LIST (continued) s.440.13(13), F.S. (b) Exceeded the limits of his…professional competence… or to have made materially false statements regarding his…qualifications in his…application; (c) Failed to transmit copies of medical reports to the employer or carrier, or failed to submit full and truthful medical reports of all his…findings to the employer or carrier as required…; (d) Solicited, or employed another to solicit for himself …professional treatment, examination, or care of an injured employee in connection with any claim…;
  • 111. REMOVAL OF PHYSICIANS FROM Division LIST (continued) s.440.13(13), F.S. (e) Refused to appear before, or to answer upon request of, the Division…any legal question, or to produce any relevant book or paper concerning his…conduct under any authorization granted to him…under this chapter; (f) Self-referred in violation of this chapter or other laws of this state; or (g) Engaged in a pattern or practice of overutilization or a violation of this chapter or rules adopted by the Division…
  • 112.
    • 440.134(1)(g): Definition of WCMCA
    • 440.134(1)(i): Definition of medical care coordinator
    • 440.134(1)(j): Definition of provider network
    • 440.134(1)(k): Definition of primary care provider
    Florida Statutes 440.134 WC Managed Care Arrangements The following list provides the statutes related to Workers’ Compensation Managed Care Arrangements, including a brief description for each subsection.
  • 113.
    • 440.134(4): AHCA authorization as WCMCA
    • 440.134(6): Plan of Operation elements - WCMCA
    • 440.134(7): Provision of Records to insurer/ carrier - WCMCA
    • 440.134(8): Training and education of HCP and Administrative Staff
    Florida Statutes 440.134 WC Managed Care Arrangements (continued)
  • 114.
    • Complete information regarding Workers’ Compensation Managed Care Arrangements may be viewed at the Division’s home webpage (listed under CH. 440, FL Statutes) at the following link:
    • www.fldfs.com/wc
    Florida Statutes 440.134 WC Managed Care Arrangements (continued)
  • 115. Florida Administrative Code Rules pertaining to Medical Services
    • Chapter 69L
    • Rule 69L-3.0047 = Fraud Statement
    • Rule 69L-7.602 = Billing, Filing and Reporting of Medical Services
    • Rule 69L-7.020 = Health Care Provider Reimbursement Manual
  • 116. Florida Administrative Code Rules pertaining to Medical Services
    • Chapter 69L
    • Rule 69LA-29 - Health Care Provider Certification
    • Rule 69LA-30 - Expert Medical Advisor Certification
    • Rule 69LA-31 - Reimbursement Disputes
  • 117. Florida Administrative Code
    • Florida Administrative Code rules may be viewed at or printed from the following Internet address:
    • http://fac.dos.state.fl.us/
  • 118. ? QUESTIONS ? Contact the Specialist On-Call (850) 413-1613 Workers’ Compensation Medical Services Unit
  • 119. CONGRATULATIONS! YOU HAVE SUCCESSFULLY COMPLETED THE EXPERT MEDICAL ADVISOR TUTORIAL
  • 120. This concludes the Florida Workers’ Compensation Tutorial for Expert Medical Advisors. Completion of this tutorial fulfills the Expert Medical Advisor certification criteria requiring the physician to attest to familiarity with the rules and statutes relating to the provision of benefits and services in the Florida Workers’ Compensation system.