69L-34.003. Elective Referral of Alleged Health Care Provider Violation

(1) Any person who elects to submit a report of a violation, as defined in this rule chapter, directly to the Division’s Office of Medical Services, shall use the Health Care Provider Violation Referral Form, DFS-F6-DWC-2000 http://www.flrules.org/Gateway/reference.asp?No=Ref-00278 (Effective: August 2011), (hereinafter “Referral Form”), which is hereby incorporated by reference. The Referral Form is available via the Division’s web site at http://www.myfloridacfo.com/wc/provider/index.html.

(2) Such person shall submit to the Division a separate Referral Form, DFS-F6-DWC-2000 http://www.flrules.org/Gateway/reference.asp?No=Ref-00278 (Effective: August 2011), and all supportive documentation for each alleged violation.

(3) Such person shall serve a copy of the Referral Form, DFS-F6-DWC-2000 http://www.flrules.org/Gateway/reference.asp?No=Ref-00278 (Effective: August 2011), and all supportive documentation on the Provider utilizing a verifiable delivery process, such as United States Postal Service certified mail or a similar process offered by a common carrier.

(4) Supportive documentation of a specific violation may include, but is not limited to, the following documents or records:

(a) All DFS-F5-DWC-25 forms submitted by the Provider for the authorization of treatment provided or prescribed for the date(s) of service under review and the Carrier’s response to each request for authorization. Form DFS-F5-DWC-25 (Florida Workers’ Compensation Uniform Medical Treatment/Status Reporting Form) is incorporated by reference in paragraph 69L-7.710(2)(d), F.A.C.

(b) Electronic or written correspondence between the Carrier and the Provider regarding the medical necessity of treatment prescribed or rendered on the date(s) of service under review.

(c) All carrier notices of disallowance or adjustment of reimbursement within the meaning of section 440.13(7), F.S., for the date(s) of service and treatment under review (e.g., Explanations of Bill Reviews or EOBRs).

(d) A copy of each medical bill for the date(s) of service under review, which lists the line item service disallowed or adjusted on the basis of overutilization, or improper billing, or a billing error.

(e) Peer review report(s) substantiating a standard of care violation, including overutilization of services, for the date(s) of service under review with specific reference to the practice guidelines upon which the peer review finding is based.

(f) Electronic or written request(s) sent to the Provider for a refund of reimbursement for line item service(s) that constituted overutilization or an improper billing or a billing error.

(g) Electronic or written request(s) sent to the Provider for medical records and information or for the submission of Form DFS-F5-DWC-25.

(h) Electronic or written correspondence notifying the Provider of the Carrier’s responsibility for the payment of medical services rendered for authorized treatment pursuant to the applicable reimbursement manual and the Provider’s inability to balance bill the injured worker.

(i) Copies of collection letters sent to the injured worker from the Provider or a collection agent acting on behalf of the Provider, seeking payment for covered medical services authorized by the Carrier.

(j) A copy of a Determination, issued by the Division, finding that the Provider improperly billed and is not entitled to additional reimbursement or the amount of reimbursement due is less than the amount the Carrier reimbursed for the billed service(s).

(5) Reporting of violations under this rule does not remove or satisfy the Carrier’s mandatory reporting obligation under rules 69L-7.710 and 69L-34.002, F.A.C.

Rulemaking Authority 440.13(4)(c), (7)(e), 440.591 FS. Law Implemented 440.13(4), (8), (11), (13), (15), 440.192 FS. History–New 9-6-11.