Florida Division of Workers Compensation Breakout Session

1. Florida Division of Workers� Compensation Breakout Session Presenters: Andrew Sabolic Robin Ippolito Eric Lloyd and Anna Ohlson Linda Yon

2. Year in Review Administrative Rules Employer/Contractor Workshops Claims EDI Release 3 SB 50A analysis on �Compensability� Stop-Work Order Legislation in Other States Revised DWC Website Workers� Compensation System Guide

3. What is on the Horizon? Administrative Rules Health Care Provider Violation Health Care Provider Certification Revisions to Health Care Reimbursement Dispute Rule Use and Effectiveness of the DWC-25 Revision to Broken Arm Poster, Injured Employee Brochure, and Employer Brochure 2010 Legislative Session Effect of Federal Health Care Plan on Workers� Compensation Insurer and Health Care Provider Training Use of Data to Help Mitigate Workers� Compensation Exposure

4. Thank You! Questions

5. Florida Division of Workers CompensationRobin Ippolito, Bureau Chief, Monitoring & Audit

6. Bureau of Monitoring & Audit Monitoring and audit of carrier practices in claims handling Monitoring carrier compliance through CPS Administration of PT supplemental payments by Division Self insurance regulation

7. Topics:Overview of Rule 69L-24 F.A.C., Insurer Standards and PracticesCurrent Audit FocusOverview of Rule 69L-5, F.A.C., Rules for Self-Insurers under the Workers� Compensation Act

8. 69L 24, F.A.C.Rule Purpose Monitor and enforce self execution of workers compensation system Provide uniform guidelines for timely and accurate data reporting, penalties for noncompliance Revised to implement s. 440.525, F.S.

9. 69L-24.004 and 24.005, F.A.C. Broad audit authority granted under s. 440.525 F.S. Authorized to audit any and all periods going back to the last prior audit. May audit as often as warranted.

10. Items reviewed on audit (a) timeliness and accuracy of indemnity and/or medical payments, (b) timeliness and accuracy of the filing of medical bill data, (c) timeliness and accuracy of all forms required to be reported pursuant to Rule 69L-3, F.A.C.,

11. (d) timeliness and accuracy of electronic transactions required by Rule 69L-56, F.A.C., (e) denial of claims, (f) delay in provision of benefits,

12. (g) harassment, coercion or intimidation of any party, (h) evidence of the mailing and wording of the fraud statement pursuant to s. 440.105(7), F.S., (i) timeliness of the response to a Petition for Benefits,

13. (j) timeliness of the compliance with a Judge of Compensation Claim�s order, (k) timeliness of the compliance with a Department rule, order or directive, (l) compliance with CPS batch timeframes,

14. (m) claims-handling practices, (n) timeliness of medical authorizations (o) mailing of Form DFS-F2-DWC-65 (Important Workers� Compensation Information for Florida�s Employers) or Form DFS-F2-DWC-66 to the employer,

15. (p) the date that Forms DFS-F2-DWC-60 or 61 (Important Workers� Compensation Information for Florida�s Workers�) brochure were mailed to the injured worker, and (q) mailing of the Employee Notification Letter to the injured worker.

20. 69L-24.006, F.A.C.Penalty cap After the insurer has accepted all penalties� and the total amount of untimely filing penalties for that month exceeds $10,000 the penalty for each untimely filing not included in the calculation of the penalty up to $10,000, shall be recalculated and assessed a penalty of $25.00 per untimely filing for that specific month.

21. Insurers that incur untimely filing penalties issued through CPS in excess of $10,000 for three or more specific months in a calendar year shall conduct quarterly self audits� for a one year period.

22. Any insurer that has been assessed penalties in excess of $10,000 for a calendar month since January 1, 2008� will have their penalty amount recalculated pursuant to subparagraph (1)(b)3. herein.

23. Medical Late Filing Penalties Number of Days Late Penalty for Untimely Filing 1-30 calendar days late $5 31-60 calendar days late $10 61-90 calendar days late $25 91 or greater calendar days late $50 Rejected Not Resubmitted $50

26. 69L-24.007 F.A.C., Patterns and Practices A pattern or practice constitutes a willful violation if the regulated entity that committed the pattern or practice: Did so intentionally and with knowledge of the act�s unlawfulness or with disregard to the unlawfulness of the act; or,

28. The penalties shall be $20,000 for a single willful violation, not exceed an aggregate of $100,000 for all pattern or practice violations arising out of the same action.

29. The Department may issue a non-willful violation for a pattern or practice of unreasonable claims handling for any monitoring, examining, or investigating review activity listed in Rule 69L-24.004(2), F.A.C., or for any other pattern or practice identified by the Department.

30. For each such non-willful violation, a penalty of $2,500 shall be assessed against the insurer by the Department, with such fines not exceeding an aggregate of $10,000 for all pattern or practice violations arising out of the same action.

31. The Department will calculate a regulated entity�s performance in order to determine if a non-willful violation will be assessed for a pattern or practice of unreasonable claims handling.

32. If the performance falls below 90% compliance during an audit, examination or investigation, except as otherwise stated in Chapter 440 and other applicable Florida Statutes and Department Rules, the Department may assess a penalty pursuant to paragraph (3) herein.

34. 69L-5, F.A.C.Rules for Self-Insurers under the Workers� Compensation Act

37. Key Revisions Increase in the minimum net worth requirement from $1,000,000 to $10,000,000

38. Security Deposit Investment grade = $100,000Non-Investment grade = greater of outstanding loss reserves or reserves forecasted to one year in future

39. Excess Insurance Specific excess retention is increased from $350,000 to $500,000 or 1% of the entities net worth

40. Summary Focus on identifying and improving poor claims-handling practices through enforcement, education, and training Establish performance standards and uniform guidelines for penalties

43. Robin Ippolito, Bureau Chief (850) 413-1775 Robin.Ippolito@myfloridacfo.com

44. Before you start the presentation, do you want to introduce the new Web Page or do you want to do that at the end? Otherwise, I just usually give some introductory remarks about some of what I plan to cover, such as: Status of Reimbursement Manuals How to handle reimbursement disputes Inter-relationship of proposed treatment plans, authorization and the DWC-25 Standards of Care Before you start the presentation, do you want to introduce the new Web Page or do you want to do that at the end? Otherwise, I just usually give some introductory remarks about some of what I plan to cover, such as: Status of Reimbursement Manuals How to handle reimbursement disputes Inter-relationship of proposed treatment plans, authorization and the DWC-25 Standards of Care

45. REIMBURSEMENT MANUALS Hospital Manual, 2006 Ed. (Effective 10/01/2007) Rule 69L-7.501, Florida Administrative Code (F.A.C.) Ambulatory Surgical Centers Reimbursement Manual, 2006 Ed. (Effective 08/19/2007) Rule 69L-7.100, F.A.C. Health Care Provider Reimbursement Manual, 2008 Ed. (Effective 02/04/2009) Rule 69L-7.020, F.A.C. INPATIENT: Per diem increased for both acute care hospitals and trauma centers; Stop Loss (revised to exceed $51,400 based on gross charges of non-surgical admissions or Total Gross Charges After Implant Carve Out) � reimbursed at 75% of hospital charges for medically necessary services (except implants); Implants reimbursed based on a cost plus formula (p. 11): implant device itself gets 60% mark-up, associated disposable instrumentation (on the same invoice) gets 20% mark-up and S&H at cost. OUTPATIENT: Lab and x-rays performed up to 3 days prior to scheduled surgery reimbursed at 60% rather than according to non-hospital provider schedule. Problems have continued concerning the interpretation of �usual and customary charge�; however, Department held a public rule-making workshop on July 7, 2009, to discuss recommendation of the 3MP to adopt two Payment Adjustment Factors that could be applied to the Medicare Outpatient Prospective Payment System reimbursement to reach a geographic �usual and customary charge� methodology consistent with the One Beacon case of 2007. Please check our webpage to keep up with the progress on this rule during the next few months. INPATIENT: Per diem increased for both acute care hospitals and trauma centers; Stop Loss (revised to exceed $51,400 based on gross charges of non-surgical admissions or Total Gross Charges After Implant Carve Out) � reimbursed at 75% of hospital charges for medically necessary services (except implants); Implants reimbursed based on a cost plus formula (p. 11): implant device itself gets 60% mark-up, associated disposable instrumentation (on the same invoice) gets 20% mark-up and S&H at cost. OUTPATIENT: Lab and x-rays performed up to 3 days prior to scheduled surgery reimbursed at 60% rather than according to non-hospital provider schedule. Problems have continued concerning the interpretation of �usual and customary charge�; however, Department held a public rule-making workshop on July 7, 2009, to discuss recommendation of the 3MP to adopt two Payment Adjustment Factors that could be applied to the Medicare Outpatient Prospective Payment System reimbursement to reach a geographic �usual and customary charge� methodology consistent with the One Beacon case of 2007. Please check our webpage to keep up with the progress on this rule during the next few months.

46. Carrier Controls Over Medical Payout Section 440.13(6), Florida Statutes Review all bills, invoices, other claims Identify over-utilization & billing errors Must disallow or adjust * billing errors over-utilization violations of practice parameters/treatment protocols established under WC statute In previous slides we overviewed some of the reimbursement rules specifically promulgated by the Department that promote cost-containment; but it is important to emphasize that the implementation of cost-containment tools is primarily with the carrier as services are authorized and billed. The law requires carriers to identify billing errors and over-utilization as bills are received from providers, and that the disallowances or adjustments that ensue must comply with the rules of the Dept and the provisions in the law. But the review of services after they are rendered and before they are paid is just one aspect of utilization review that carriers are responsible to implement. The law requires prospective review by authorization of specific providers and services, review of and communication about treatment plans and what must happen when a treatment plan is not acceptable to the carrier � before care is even rendered. The law also enables the carrier to use independent medical examinations or peer consultants to make authorization and treatment plan approvals and transfers of care. As carriers have set up their procedures for handling authorizations, including continuous review and approval of proposed treatment plans submitted at least every 30 days on the DWC-25, the carrier can institute a systematic approach of �utilization control�. In previous slides we overviewed some of the reimbursement rules specifically promulgated by the Department that promote cost-containment; but it is important to emphasize that the implementation of cost-containment tools is primarily with the carrier as services are authorized and billed. The law requires carriers to identify billing errors and over-utilization as bills are received from providers, and that the disallowances or adjustments that ensue must comply with the rules of the Dept and the provisions in the law. But the review of services after they are rendered and before they are paid is just one aspect of utilization review that carriers are responsible to implement. The law requires prospective review by authorization of specific providers and services, review of and communication about treatment plans and what must happen when a treatment plan is not acceptable to the carrier � before care is even rendered. The law also enables the carrier to use independent medical examinations or peer consultants to make authorization and treatment plan approvals and transfers of care. As carriers have set up their procedures for handling authorizations, including continuous review and approval of proposed treatment plans submitted at least every 30 days on the DWC-25, the carrier can institute a systematic approach of �utilization control�.

47. Explanation of Bill Review (EOBR)(requirement per 69L-7.602(5)(q), F.A.C.) Only mechanism to convey notice of payment, adjustment, disallowance Statement referencing s. 440.13(7), F.S. Insurer name and specific contact EOBR codes and descriptors in (o) Name/mailing address of entity* carrier designates to receive service of petitions When the carrier adjusts, disallows or pays a bill, there are rules about how to convey that information to the HCP. The points (on the slide) are important because they ensure uniformity and clarity � and they initiate the HCPs right to an appeal of the carrier�s reimbursement decision, whether the decision is based on an alleged billing error or questions about the appropriate utilization of the medical resources . Eric, this may be an appropriate place to mention that carriers need to be sure that they are properly identified on their (servicing) agent�s EOBR. In following up on carrier compliance with our orders resulting for reimbursement determinations, we have found that many EOBRs do not properly identify the carrier that is ultimately responsible for the medical bill claims handling practices. When the carrier adjusts, disallows or pays a bill, there are rules about how to convey that information to the HCP. The points (on the slide) are important because they ensure uniformity and clarity � and they initiate the HCPs right to an appeal of the carrier�s reimbursement decision, whether the decision is based on an alleged billing error or questions about the appropriate utilization of the medical resources . Eric, this may be an appropriate place to mention that carriers need to be sure that they are properly identified on their (servicing) agent�s EOBR. In following up on carrier compliance with our orders resulting for reimbursement determinations, we have found that many EOBRs do not properly identify the carrier that is ultimately responsible for the medical bill claims handling practices.

48. Carrier Returns to HCP Rule 69L-7.602(5)(j)5, F.A.C. wrong form; required information missing; illegible or incorrect claimant identification; incorrect insurer, service company, TPA Obtain or return within 21 days of receipt written statement of reason for return not on an EOBR Process sufficient detail, verifiable by DWC Most everyone realizes that medical bills are to be paid within 45 days of receipt of the bill by the carrier. The exception to the payment timeframe is when bills are not properly submitted. The Billing Rule details what constitutes an improperly submitted bill and the carriers obligation in handling, so that all parties know the expectation and corrective action can be taken. This particular citation outlines the deficiencies that can result in returned bills and the carrier�s obligation to document handling in the event there are complaints about non-payments or untimely payments. Non-payments of medical bills (bills that are not disallowed, adjusted or paid based on an EOBR or have not been returned based on any of the above reasons for resubmission to the carrier) are handled by OMS also. In order for us to assist with non-payments, providers must provide OMS with a copy of the bill (with relevant attachments) and proof of delivery to the carrier. Most everyone realizes that medical bills are to be paid within 45 days of receipt of the bill by the carrier. The exception to the payment timeframe is when bills are not properly submitted. The Billing Rule details what constitutes an improperly submitted bill and the carriers obligation in handling, so that all parties know the expectation and corrective action can be taken. This particular citation outlines the deficiencies that can result in returned bills and the carrier�s obligation to document handling in the event there are complaints about non-payments or untimely payments. Non-payments of medical bills (bills that are not disallowed, adjusted or paid based on an EOBR or have not been returned based on any of the above reasons for resubmission to the carrier) are handled by OMS also. In order for us to assist with non-payments, providers must provide OMS with a copy of the bill (with relevant attachments) and proof of delivery to the carrier.

49. Reimbursement Dispute Petitions Rule 69L-31, F.A.C. (effective 11/28/2006) Petition Form (DFS Form 3160-0023)* Within 30 days of receipt of EOBR Copy to Carrier by USPS certified mail Notices of Deficiency (NOD) to Petitioners An increasing number of providers have taken advantage of the Reimbursement Dispute Resolution process since OMS returned to DWC in 2005. As the graph indicates, the number of petitions submitted has increased annually resulting in a 150% increase from the number of petitions submitted in FY 2005-2006 to those submitted in FY 2008-2009. This past FY, OMS streamlined our determination process so that if neither party to the dispute contested a determination within 21 days, it automatically became a Final Order of the Dept. That means that providers no longer have to wait for a second document ordering the carrier to make reimbursement and that within 30 days of receipt of the department�s determination, the carrier must notify OMS that correct payment has been made. Additionally, we follow-up on any Determination for which we have not received verification from the carrier. (This goes back to issue about SA/TPA properly identifying carrier on EOBR.) We are also working with the Bureau of Monitoring and Audit to consider how non-compliance with OMS determinations should be handled under their claims handling patterns and practices regulations.An increasing number of providers have taken advantage of the Reimbursement Dispute Resolution process since OMS returned to DWC in 2005. As the graph indicates, the number of petitions submitted has increased annually resulting in a 150% increase from the number of petitions submitted in FY 2005-2006 to those submitted in FY 2008-2009. This past FY, OMS streamlined our determination process so that if neither party to the dispute contested a determination within 21 days, it automatically became a Final Order of the Dept. That means that providers no longer have to wait for a second document ordering the carrier to make reimbursement and that within 30 days of receipt of the department�s determination, the carrier must notify OMS that correct payment has been made. Additionally, we follow-up on any Determination for which we have not received verification from the carrier. (This goes back to issue about SA/TPA properly identifying carrier on EOBR.) We are also working with the Bureau of Monitoring and Audit to consider how non-compliance with OMS determinations should be handled under their claims handling patterns and practices regulations.

50. Overview of FY 08-09 Determined 788 Dismissed 899 Why? Mostly� Failure to cure NOD Untimely Withdrawn by petitioner Over half of the petitions filed with OMS have to be dismissed. The largest portion (almost 45%) are dismissed because providers fail to cure a specific deficiency identified by the case reviewer through Notices of Deficiency to the petitioner (OMS provides specific information required for the petition to be accepted as valid) . For example, the petitioner does not serve a copy of the petition by certified mail on the carrier (or designated entity for the carrier ) or a copy of the related bill is not included with the petition. Slightly over a quarter of the dismissals are because the provider failed to submit the petition within 30 days of receipt of the EOBR from the carrier. These 2 categories account for about 70 percent of our dismissed petitions and can be rectified if attention is given by providers to these details. The 3rd most frequent reason for a dismissal is that the petition is withdrawn by the petitioner. This 15% represents resolution directly by the parties to the dispute in which the provider notifies OMS that it has received proper payment or has elected to settle the amount due.Over half of the petitions filed with OMS have to be dismissed. The largest portion (almost 45%) are dismissed because providers fail to cure a specific deficiency identified by the case reviewer through Notices of Deficiency to the petitioner (OMS provides specific information required for the petition to be accepted as valid) . For example, the petitioner does not serve a copy of the petition by certified mail on the carrier (or designated entity for the carrier ) or a copy of the related bill is not included with the petition. Slightly over a quarter of the dismissals are because the provider failed to submit the petition within 30 days of receipt of the EOBR from the carrier. These 2 categories account for about 70 percent of our dismissed petitions and can be rectified if attention is given by providers to these details. The 3rd most frequent reason for a dismissal is that the petition is withdrawn by the petitioner. This 15% represents resolution directly by the parties to the dispute in which the provider notifies OMS that it has received proper payment or has elected to settle the amount due.

51. This Chart reflects the distribution of petitions by provider type. Brown represents the submissions from physicians/other recognized practitioners; green represents those received from Ambulatory Surgery Centers; and gold represents those submitted by hospitals, which have consistently comprised the largest proportion of petitioners since the FY 05-06. It is interesting to note, albeit anecdotally, that hospital petitions have decreased somewhat since the current reimbursement schedule went into effect. As you recall, the inpatient provisions were substantially revised/clarified, including specific reimbursement for surgical implant devices. This Chart reflects the distribution of petitions by provider type. Brown represents the submissions from physicians/other recognized practitioners; green represents those received from Ambulatory Surgery Centers; and gold represents those submitted by hospitals, which have consistently comprised the largest proportion of petitioners since the FY 05-06. It is interesting to note, albeit anecdotally, that hospital petitions have decreased somewhat since the current reimbursement schedule went into effect. As you recall, the inpatient provisions were substantially revised/clarified, including specific reimbursement for surgical implant devices.

52. However, from here you can see that hospital outpatient services (based on U&C �methodology�) are the greater number of hospital petitions and represent almost the same volume as the ambulatory surgery center disputes. Eric, since this graph is based on Determinations issued (rather than all Petitions submitted), I just want to remind you that we have not been issuing OPH ( U&C) determinations throughout the last 2 FY. For OMS to have issued so many OPH Determinations, it has to mean that the disputes were subject to contracts not based on U&C or were the designated OPH services that are specified to be reimbursed by the schedule that applies to �non-hospital providers�. However, from here you can see that hospital outpatient services (based on U&C �methodology�) are the greater number of hospital petitions and represent almost the same volume as the ambulatory surgery center disputes. Eric, since this graph is based on Determinations issued (rather than all Petitions submitted), I just want to remind you that we have not been issuing OPH ( U&C) determinations throughout the last 2 FY. For OMS to have issued so many OPH Determinations, it has to mean that the disputes were subject to contracts not based on U&C or were the designated OPH services that are specified to be reimbursed by the schedule that applies to �non-hospital providers�.

53. Briefly, Just want to discuss the Health Care Provider�s responsibility when submitting a petition. Recall that 75% of Petitions are dismissed for technical reasons beyond the control of OMS. Remember that the Petitioner must be identified as a Health Care Provider. That means a licensee � whether a physician or other recognized practitioner or a facility. It is acceptable for the employer of a provider or the corporate entity that receives the actual payment to represent a Health Care Provider, but unless the party that actually rendered the services as a defined HCP under WC law is identified, the petition will be dismissed.Briefly, Just want to discuss the Health Care Provider�s responsibility when submitting a petition. Recall that 75% of Petitions are dismissed for technical reasons beyond the control of OMS. Remember that the Petitioner must be identified as a Health Care Provider. That means a licensee � whether a physician or other recognized practitioner or a facility. It is acceptable for the employer of a provider or the corporate entity that receives the actual payment to represent a Health Care Provider, but unless the party that actually rendered the services as a defined HCP under WC law is identified, the petition will be dismissed.

54. The �DATE OF THE EXPLANATION OF BILL REVIEW (EOBR) FROM THE CARRIER� is essential information and establishes that the HCP is timely contesting the carrier�s reimbursement. OMS is barred from assisting a HCP who does not file timely. We will take your word on timeliness as long as you tell us how you establish it and, if you don�t, we have a default mechanism whereby we establish it for you. However, if the petition is not in the mail to OMS within the 30 day period from receipt of the EOBR, OMS is barred from assisting the HCP. The next most important thing is that a HCP serve the copy of the petition on the carrier as instructed on the EOBR. If the carrier does not specify exactly where to serve the copy of the petition, the default address is to the party issuing the EOBR. However, if we can not verify that the proper party was served, we can not address the petition.The �DATE OF THE EXPLANATION OF BILL REVIEW (EOBR) FROM THE CARRIER� is essential information and establishes that the HCP is timely contesting the carrier�s reimbursement. OMS is barred from assisting a HCP who does not file timely. We will take your word on timeliness as long as you tell us how you establish it and, if you don�t, we have a default mechanism whereby we establish it for you. However, if the petition is not in the mail to OMS within the 30 day period from receipt of the EOBR, OMS is barred from assisting the HCP. The next most important thing is that a HCP serve the copy of the petition on the carrier as instructed on the EOBR. If the carrier does not specify exactly where to serve the copy of the petition, the default address is to the party issuing the EOBR. However, if we can not verify that the proper party was served, we can not address the petition.

55. Each question on the petition form is important for the petitioner to answer as clearly and concisely as possible. Specific answers make the review process a little more efficient .Each question on the petition form is important for the petitioner to answer as clearly and concisely as possible. Specific answers make the review process a little more efficient .

57. This list is a good reference for petitioners to ensure that there is no deficiency in supporting documentation.This list is a good reference for petitioners to ensure that there is no deficiency in supporting documentation.

58. RESPONSES TO REIMBURSEMENT DISPUTE PETITIONS Carrier response must be on : DFS Form 3160-0024 required element Within 10 days of receipt of service of petition Failure to respond constitutes waiver of all objections Copy to petitioner by verifiable delivery Self-explanatory Self-explanatory

59. We are somewhat surprised by the number of carriers that do not respond to petitions. On the other hand, it does occur that a carrier will actually realize that additional payment is due and automatically issue additional payment. It is at the point when we receive the Carrier Response that we know the identity the carrier if a DWC-1 (FROI) has not been filed with the DWC. We encourage HCPs to request withdrawal of their petition when appropriate payment is received prior to our Determination so that we can dismiss the case.We are somewhat surprised by the number of carriers that do not respond to petitions. On the other hand, it does occur that a carrier will actually realize that additional payment is due and automatically issue additional payment. It is at the point when we receive the Carrier Response that we know the identity the carrier if a DWC-1 (FROI) has not been filed with the DWC. We encourage HCPs to request withdrawal of their petition when appropriate payment is received prior to our Determination so that we can dismiss the case.

60. This is the carrier�s opportunity to give the other side of the story, including whether the dispute is correctly stated and if not, why not. This is the carrier�s opportunity to give the other side of the story, including whether the dispute is correctly stated and if not, why not.

61. Emphasis on copies of contracts.Emphasis on copies of contracts.

62. Two Forms Required in Florida Billing Form - specific to each health care provider type (DWC-9, 10, 11, or 90) Uniform Medical Treatment/Status Reporting Form � (DWC-25) every 30 days (or less, if significant event occurs) treating physicians (including ER), PA, ARNP Since the inception of the �Uniform Medical Treatment/Status Reporting Form�, providers routinely only submit their bills (with any required attachment such as an invoice for non-incidental supplies used during an office procedure or the itemized statement for hospital charges). Office notes and extensive medical records DO NOT have to accompany all bills as they may have in the past. However, physician and physician extenders must submit the �Uniform Medical Treatment/Status Reporting Form� ( DWC-25) also. This form does not replace medical records, of course, but it does provide all pertinent information from the medical record, plus specific information needed to administer the WC law, that the carrier needs to manage the case. It must be provided within 3 days of the initial service and within 24 hours of all subsequent encounters (at no more than 30 day intervals). Since the inception of the �Uniform Medical Treatment/Status Reporting Form�, providers routinely only submit their bills (with any required attachment such as an invoice for non-incidental supplies used during an office procedure or the itemized statement for hospital charges). Office notes and extensive medical records DO NOT have to accompany all bills as they may have in the past. However, physician and physician extenders must submit the �Uniform Medical Treatment/Status Reporting Form� ( DWC-25) also. This form does not replace medical records, of course, but it does provide all pertinent information from the medical record, plus specific information needed to administer the WC law, that the carrier needs to manage the case. It must be provided within 3 days of the initial service and within 24 hours of all subsequent encounters (at no more than 30 day intervals).

63. Standards of Care Section 440.13(16), F.S. Objective relevant medical findings Every 30 days reassess: Treatment plans, restrictions, limitations Early activation and restoration of function Utilize the DWC - 25 All physicians and adjusters need to be familiar with this portion of this statute. Everyone will be working from the same page if we keep the Standard of Care defined here as the focus of what is planned and authorized for injured employees.All physicians and adjusters need to be familiar with this portion of this statute. Everyone will be working from the same page if we keep the Standard of Care defined here as the focus of what is planned and authorized for injured employees.

64. The DWC-25 has been around for a number of years and depending on perspective, we hear praise and condemnation. The biggest point is that like just about anything, it could probably be improved because, while the form is only 2 pages, it requires 16 pages of instruction which can be a bit daunting. It is important to look at it objectively and realize that it really does provide the carrier with the essential information required to manage the medical care well, without a lot of burdensome paperwork � if it is utilized to its fullest. This 2 page form is the only other form that physician�s need complete and send to the carrier, except their bills. It must be submitted NLT 3 days after the first treatment and by the close of business of the next business day following each visit or a maximum of 30 days from the prior submission. It must be submitted by principle, consulting, referring physicians and those accepting transfer of care.The DWC-25 has been around for a number of years and depending on perspective, we hear praise and condemnation. The biggest point is that like just about anything, it could probably be improved because, while the form is only 2 pages, it requires 16 pages of instruction which can be a bit daunting. It is important to look at it objectively and realize that it really does provide the carrier with the essential information required to manage the medical care well, without a lot of burdensome paperwork � if it is utilized to its fullest. This 2 page form is the only other form that physician�s need complete and send to the carrier, except their bills. It must be submitted NLT 3 days after the first treatment and by the close of business of the next business day following each visit or a maximum of 30 days from the prior submission. It must be submitted by principle, consulting, referring physicians and those accepting transfer of care.

65. Remember that patient classifications are to be assigned to patients irrespective of the date of accident. They are intended to convey to insurers the complexity of services that will be required for optimal clinical management. They help to distinguish critical differences that influence the intensity, scope and cost of services. They help to identify clinical circumstances that affect treatment and other available benefits and assist in making authorization decisions.Remember that patient classifications are to be assigned to patients irrespective of the date of accident. They are intended to convey to insurers the complexity of services that will be required for optimal clinical management. They help to distinguish critical differences that influence the intensity, scope and cost of services. They help to identify clinical circumstances that affect treatment and other available benefits and assist in making authorization decisions.

66. Most import to remember that this document is a WRITTEN REQUEST FOR AUTHORIZATION!Most import to remember that this document is a WRITTEN REQUEST FOR AUTHORIZATION!

67. Section IV is where you provide anything the carrier might need to know from the physician perspective about return to work capabilities. Again, RTW has a lot to do with the cost of the case. It is information that must be exchanged between the treating physician and the employer/insurer and obviously applies to both on and off the job � and until the physician changes them.Section IV is where you provide anything the carrier might need to know from the physician perspective about return to work capabilities. Again, RTW has a lot to do with the cost of the case. It is information that must be exchanged between the treating physician and the employer/insurer and obviously applies to both on and off the job � and until the physician changes them.

68. If MMI has not been reached before, carriers need an estimate of Impairment Rating NLT 6 weeks before the expiration of temporary benefits so that any permanent benefit due can be calculated and the injured employee can be paid. If MMI has not been reached before, carriers need an estimate of Impairment Rating NLT 6 weeks before the expiration of temporary benefits so that any permanent benefit due can be calculated and the injured employee can be paid.

69. Remember that even when direct billable services are provided by other than a physician, the physician is required to sign the DWC-25.Remember that even when direct billable services are provided by other than a physician, the physician is required to sign the DWC-25.

70. On the Horizon Violations Rule - being drafted, not yet in rulemaking Hospital Manual � work shop held 7/7/09 OPPS/Payment Adjustment Factors Billing Rule � hearing held 7/7/09 New forms (presently billed on letterhead) Skilled Nursing Facilities Home Health HCP RM, upon consideration of Three Member Panel 2009 Conversion Factor HCP Certification � On-line tutorial and certification process Eric, not sure how we want to handle this if we have not scheduled Violations Rule for workshop. We can discuss. Eric, not sure how we want to handle this if we have not scheduled Violations Rule for workshop. We can discuss.

71. Questions about any of this�.contact MSU at 850-413-1613Questions about any of this�.contact MSU at 850-413-1613

72. Questions?

74. Linda Yon Sr. Management Analyst Supv. Bureau of Data Quality and Collection FL Division of Workers� Compensation

83. Therefore, not all MTC filing requirements set out in Rule 69L-56, F.A.C., can be equated to a DWC Form.A complete accounting of MTC�s required by FL is set out in Rule 69L-56, F.A.C., and in the �FL Claims EDI Event Table� (and �MTC Filing Instructions�)

85. Rule 69L-56 was recently revised effective May 17, 2009, primarily with regards to new POC filing requirements for PEO�s. Also, repealed section 69L-56.330 (electronic formats for reporting 8th day info for R1 submitters), and deleted the provision in 69L-56.301 that formerly allowed substitution of the Employer�s address for the Employee�s address protected under 119.071, F.S.

86. Per current statute, 440.185, F.S., the Division must collect certain identifying Employee data, including the employee�s SSN and mailing address. FL Statute 119.071(4)(d)8 requires the Division to protect the release of the address and other confidential information for certain classes of employees, if they (or their employer) write the Division and request that their information remain confidential.

87. Accordingly, new editing (implemented 8/12/09) will preclude EDI filings that report the employer�s address for the the employee�s address.

125. To avoid late filing penalties for an Electronic First Report of Injury or Illness, the EDI FROI/SROI should be triggered immediately upon the Claim Admin�s disposition of the claim (payment or denial).

126. This will allow time for correction of potential errors and resubmission and subsequent receipt/acceptance by the Division within the filing due dates specified in Rule 69L-56, F.A.C.

143. The Benefits segment should reflect current values at the time of transmission, based upon the Benefit Type Codes paid on the claim (snapshot).

288. EMPLOYER PAID BENEFITS

289. EMPLOYER PAID BENEFITS

290. EMPLOYER PAID BENEFITS

293. But if the 00/IP is sent late and at the time of filing, the ee has been disabled for 22 days or more, then the 2xx segment for employer paid salary for the waiting week (�Days 1 thru 7�) should be included on the IP (if the employer has not been reimbursed.) Here, �Days 1 thru 7� paid by the Empr would constitute salary in lieu of compensation the Claim Administrator would have otherwise had to pay.

294. If BTC 2xx was not included on the IP and it was later confirmed the employee was disabled for 22 or more days and the waiting week is actually payable/reportable�

295. �the addition of BTC 2xx on the next R3 filing will be accepted without an intervening MTC to �introduce� the 2xx benefits (where the Start Date of the 2xx benefit segment is the earliest Start Date of benefits reported.)

296. A 00/EP filing must contain only 2xx benefits segment(s). 

299. Benefit Type Codes 210, 230, 242, 250, 251, 270 should be used if the Claim Admin. knows the specific benefit type for which the injured worker was paid salary in lieu of comp (Benefit Type Amount Paid is req�d for these BTC�s.) If the specific benefit type is unknown, BTC 240 should be used.

306. Employer Paid Salary In Lieu of Compensation Indicator (DN-273) should be reported as �Y� only if Employer is currently paying salary in lieu of comp. If Employer discontinues salary and Claim Admin. picks up payment, the Indicator should be set to �N�.

307. If the Claim Administrator reimburses the employer for salary paid in lieu compensation, and the employer is no longer paying salary, the Reduced Benefit Amount Code �R� � Reclassification should be sent to explain why the 2xx Benefits segment is no longer on the current transaction.

308. In situations where the employer actually paid salary in lieu of comp (for more than just the waiting week), but the 00/IP was filed late and the Claim Admin. has already fully reimbursed the employer, there will never be a 2xx segment on any EDI transaction. As a result, �

309. � the Claim Admin. will need to supply other documentation to satisfy the CPS Specialist that salary was initially paid, after which an EDI Team member can update DWC�s system to reflect that the initial payment of indemnity was salary in lieu of comp.

310. For paper DWC-1 or R1 EDI filings: If salary in lieu of comp was incorrectly reported or mis-coded when the record was first established, rather than sending Reduced Benefit Amount Code �R� to reconcile the problem, contact the EDI Team to modify the initial filing information on the DWC database.

311. Recap: For R3 EDI filings: The claim administrator must file an MTC 02 to report corrected initial payment information. If there have been intervening EDI transactions that accepted, an EDI Team member may need to manually update Integrated after confirming the information on the accepted MTC 02.

313.

315. EP after IP