THE FLORIDA WORKERS’ COMPENSATION SYSTEM

THE FLORIDA WORKERS’ COMPENSATION SYSTEM TUTORIAL for EXPERT MEDICAL ADVISORS

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 thetopics listed on the left side of the home page.)

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 Through this program…

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

MEDICAL - MEDICALLY NECESSARY MEDICAL CARE INDEMNITY - WAGE REPLACEMENT BENEFITS REEMPLOYMENT - VOCATIONAL REHABILITATION BENEFITS TO FACILITATE EARLY RETURN TO SUITABLE GAINFUL EMPLOYMENT WHAT ARE WORKERS’ COMPENSATION BENEFITS?

WHAT IS THE ROLE OF THE PHYSICIAN WHO RENDERS CARE AND SERVICES TO INJURED WORKERS IN THE FLORIDA WORKERS’ COMPENSATION SYSTEM?

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 IdentifyMedical Restrictions/Limitations relating to work & full time or transitional duty Prescribe Restrictions/Limitations and submit to the insurer on DWC-25 THE ROLE OF THE PHYSICIAN

STANDARDS OF CARE s.440.13(16), F.S. The health care provider’s care and treatment shall be based on the following standards of care. • 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

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

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 ROLE OF THE PHYSICIAN(continued) • THE HEALTH CARE PROVIDER IS TO IDENTIFY THE EMPLOYEE’S PHYSICAL LIMITATIONS, AND ADDRESS RETURN TO WORK STATUS

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.

STANDARDS OF CARE (continued) s.440.13(16), F.S. (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. (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

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.

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 THE ROLE OF THE PHYSICIAN(continued)

PERMANENT IMPAIRMENT RATINGs.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

TEMPORARY TOTAL DISABILITYs.440.15(2)(a), F.S. When does the healthcare provider assign MMI & PIR? “…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.

PERMANENT IMPAIRMENT RATINGs.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.

“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.) PERMANENT IMPAIRMENT RATING/ MAXIMUM MEDICAL IMPROVEMENTs.440.15(3)(d)1., F.S. “The carrier shall establish an overall maximum medical improvement date and permanent impairment rating, based on all such reports.”

PERMANENT IMPAIRMENT RATINGs.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.

SUBSEQUENT INJURY;APPORTIONMENTs.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.

RATING PERMANENT IMPAIRMENTs.440.15(3)(b), F.S. The health care provider shall use the following resources to calculate a permanent impairment rating(based on the date of injury or accident – DOI): • 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

Florida Statutes 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.

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

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

(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

(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.

(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 CAUSEmust be demonstrated by medical evidence only. Florida Statutes s.440.09 Coverage(continued)

(3) Compensation isnot 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)

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.

(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 injurymust 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

(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.)

(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

(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

(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

(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 actor 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

(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

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.”

(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.

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.

Florida Statutes 440.13 Medical Services 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.

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

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

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

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

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

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.

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.

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.

The carrier has theright to transfer the careof 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. CARRIER TRANSFER OF CAREs.440.13(2)(d), F.S.

THE FLORIDA WORKERS’ COMPENSATION SYSTEM