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THE FLORIDA WORKERS COMPENSATION SYSTEM

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

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THE FLORIDA WORKERS COMPENSATION SYSTEM

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    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:

    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

    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

    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.

    17. TEMPORARY TOTAL DISABILITY s.440.15(2)(a), F.S.

    18. PERMANENT IMPAIRMENT RATING s.440.15(3)(d), F.S.

    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.)

    20. PERMANENT IMPAIRMENT RATING s.440.15(3)(d), F.S.

    21. SUBSEQUENT INJURY; APPORTIONMENT s.440.15(5)(b), F.S.

    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

    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

    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

    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.

    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.

    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.

    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.

    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

    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…

    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…

    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.

    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.

    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.

    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.

    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.

    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:

    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.

    40. Fraud Statement

    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

    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

    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)

    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

    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

    47. Definitions

    48. Definitions

    49. Definitions

    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.”

    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

    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.

    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. “

    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. )

    61. SUBSEQUENT INJURY; APPORTIONMENT s.440.15(5)(b), F.S.

    62. OCCUPATIONAL DISEASES s.440.151(1)(a), F.S.

    63. OCCUPATIONAL DISEASES s.440.151(2), F.S.

    64. PAYMENT OF MEDICAL BILLS s.440..20, F.S.

    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.

    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.”

    67. DFS-F5-DWC-25 -- Florida Workers’ Compensation Uniform Medical Treatment/Status Reporting Form (adopted for use July 4, 2004)

    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.”

    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

    70. Insurers and providers shall utilize ONLY the Form DWC-25 for physician reporting of the injured employee’s medical treatment / status.

    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.

    73.

    74.

    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.”

    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)

    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.”

    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.”

    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…”

    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…”

    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

    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. “

    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…”

    84.

    86.

    93. EXPERT MEDICAL ADVISOR (EMA)

    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

    96. EXPERT MEDICAL ADVISORS Rule 69LA-30.003, F.A.C.

    97. EXPERT MEDICAL ADVISORS Qualifications (continued)

    98. EXPERT MEDICAL ADVISORS Rule 69LA-30.004, F.A.C.

    99. EXPERT MEDICAL ADVISORS Rule 69LA-30.007, F.A.C.

    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.”

    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.”

    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 .

    108. EXPERT MEDICAL ADVISORS Rule 69LA-30.008(5), F.A.C.

    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

    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

    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

    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 ?

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