69L-24.006. Administrative Penalties and Fines

The Department shall utilize the monitoring, examination, or investigation processes to ensure compliance with chapter 440, F.S. and Department Rules. The Department may assess administrative penalties and fines for violations. Violations within this rule are described in general language. The use of general language shall not be construed to expand or modify the statute. Violations are not necessarily described herein using the language that would be used to formally assert the violation in any specific case.

(1) Indemnity Violations.

(a) Late payments of compensation. In order to ensure insurer compliance under chapter 440, F.S., the Department shall monitor, examine, and investigate the performance of insurers. The Department shall assess penalties for late payments of compensation that are below a minimum 95 percent timely payment performance standard. The insurer shall pay to the Workers’ Compensation Administration Trust Fund a penalty of:

1. Fifty dollars per number of installments of compensation below the 95 percent timely payment performance standard and equal to or greater than a 90 percent timely payment performance standard.

2. One hundred dollars per number of installments of compensation below a 90 percent timely payment performance standard.

(b) Late filing of forms.

1. Employers shall be fined for each Form DFS-F2-DWC-1 (First Report of Injury or Illness), effective 03/2009, as incorporated in rule 69L-3.025, F.A.C., which is not filed timely with the insurer or claims-handling entity as follows:

Number of Days LatePenalty for Untimely Filing

1-7 calendar days late$100 per form

8-14 calendar days late$200 per form

15-21 calendar days late$300 per form

22-28 calendar days late$400 per form

Over 28 calendar days late$500 per form

2. The Division, through CPS, will calculate the penalties in order starting with the form with the greatest number of days late first. Insurers shall be fined for each Form DFS-F2-DWC-1 (First Report of Injury or Illness), effective 03/2009, as incorporated in rule 69L-3.025, F.A.C., or an electronic equivalent as required in rule 69L-56.301, F.A.C., form which is not timely filed with the Department. Penalties shall be calculated for all the Form DFS-F2-DWC-1 or an electronic equivalent as required in rule 69L-56.301, F.A.C., that have been received by the Department in a specific CPS batch month as follows:

Number of Days LatePenalty for Untimely Filing

1-7 calendar days late$100 per form

8-14 calendar days late$200 per form

15-21 calendar days late$300 per form

22-28 calendar days late$400 per form

Over 28 calendar days late$500 per form

3. After the insurer has accepted all penalties and submitted the batch to the Division for a specific month and the total amount of untimely filing penalties for that month exceeds $10,000 as calculated under subparagraphs (1)(b)1. and 2. herein, 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.

4. 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, in addition to penalties assessed, conduct quarterly self audits of their Form DFS-F2-DWC-1 filings to the Department documenting compliance by the insurer with the reporting requirements for Form DFS-F2-DWC-1, and submit the results of those audits to the Department documenting compliance with the reporting requirements for Form DFS-F2-DWC-1 for a one year period.

5. Any insurer that has been assessed penalties in excess of $10,000 for a calendar month since January 1, 2008, until the effective date of this rule chapter, for untimely filing of Form DFS-F2-DWC-1, will have their penalty amount recalculated pursuant to subparagraph (1)(b)3. herein. If the insurer has already paid penalties to the Department for the untimely filing of Form DFS-F2-DWC-1, the Department shall refund the difference between the penalties paid and those recalculated under subparagraph (1)(b)3. herein, to the insurer, unless the insurer owes any outstanding, unpaid penalties to the Department. The outstanding, unpaid penalties must be paid in full prior to any refund being issued by the Department.

6. If the electronic equivalent of the First Report of Injury or Illness as required in rule 69L-56.301, F.A.C., is assigned an Application Acknowledgement Code of Transaction Accepted (TA) within 30 days after the Claim Administrator, as defined in rule 69L-56.002, F.A.C., is first approved and required by the Division to send electronic First Reports of Injury or Illness to the Division pursuant to paragraph 69L-56.300(1)(d), F.A.C., the insurer, as defined in section 440.02(38), F.S., shall not be assessed a filing penalty pursuant to subparagraph 69L-24.006(1)(b)2., F.A.C., based on the filing requirements established in rule subsections 69L-56.301(1) and (2), F.A.C. After the completion of the 30 day period referenced above, all electronic First Reports of Injury or Illness must be assigned an Application Acknowledgement Code of Transaction Accepted (TA) by the Division within the required filing timeframes established in subsections 69L-56.301(1) and (2), F.A.C., to be considered timely filed.

(2) Medical Violations.

(a) Insurer Administrative Penalties and Administrative Fines for Untimely Health Care Provider-Payment or Disposition of Medical Bills.

1. The Department shall assess administrative penalties for failure to comply with the payment, adjustment, disallowance, or denial requirements pursuant to section 440.20(6)(b), F.S. To evaluate the data for timely performance standards for timely payments, adjustments and payments, disallowances or denials, reported on Forms DFS-F5-DWC-9 (Health Insurance Claim Form/CMS-1500), DFS- F5-DWC-10 (Statement of Charges for Drugs and Medical Supplies Form and Instructions), DFS-F5-DWC-11 (American Dental Association Dental Claim Form), and DFS-F5-DWC-90 (Hospital Billing Form (UB-04), or their electronic equivalents, as incorporated in paragraphs 69L-7.710(2)(a), (b), (c) and (e), F.A.C., the Department shall calculate penalties on a monthly basis for each separate form/category type that was received and accepted by the Department within a specific calendar month.

2. Pursuant to section 440.20(6)(b), F.S., the Department shall calculate and assess administrative fines according to the following guidelines:

a. For medical services provided on or after January 1, 2004, insurers shall pay, disallow, or deny all medical, dental, pharmacy, and hospital bills properly submitted to the insurer pursuant to Department rule no later than 45 calendar days after the insurer’s receipt of the bill pursuant to paragraph 69L-7.710(5)(k), F.A.C. The Department shall assess penalties for payments, disallowances, or denials of medical, dental, pharmacy, and hospital bills that are below a minimum 95 percent timely performance standard. The insurer shall pay a penalty of:

I. $25 for each bill below the 95 percent timely performance standard, but meeting a 90 percent timely performance standard.

II. $50 for each bill below a 90 percent timely performance standard.

(b) Insurer Administrative Penalties and Fines for Untimely Filing of Medical Bills.

1. Insurers that fail to submit a minimum of 95% of all medical bills timely for a specific month are subject to an administrative fine. Insurers shall be fined for medical bills which are not timely filed with the Department in accordance with the following procedure. For all untimely medical bills falling below the 95% requirement for a specific month, the Division, through CPS, will calculate the penalties for the untimely medical bills in order starting with the greatest number of days late first. Penalties for late filed medical bills shall be calculated in the batch month in which the medical bills are actually received by the Department, not the batch month in which the medical bills were required to be timely submitted, as follows:

Number of Days LatePenalty 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

2. After the insurer has accepted all penalties and submitted the batch to the Division for a specific month and the total amount of untimely filing penalties for that month exceeds $10,000 as calculated under subparagraph (2)(b)1., herein, 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 $5.00 per untimely filing for that specific month.

3. 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, in addition to penalties assessed, conduct quarterly self audits of their medical bill filings to the Department documenting compliance by the insurer with the reporting requirements for medical bills, and submit the results of those audits to the Department documenting compliance with the reporting requirements for medical bills for a one year period.

4. Any insurer that has been assessed penalties in excess of $10,000 for a calendar month since January 1, 2008, until the effective date of this rule chapter, for untimely filing of medical bills, will have their penalty amount recalculated in accordance with subparagraph (2)(b)2., herein. If the insurer has already paid penalties to the Department for the untimely filing of medical bills, the Department shall refund the difference between the penalties paid and those recalculated under subparagraph (2)(b)2., herein, to the insurer, unless the insurer owes any outstanding, unpaid penalties to the Department. The outstanding, unpaid penalties must be paid in full prior to any refund being issued by the Department.

(c) Insurer Administrative Penalties and Fines for Rejected and not Resubmitted Medical Bills.

1. Insurers are required to timely correct medical bills that are rejected by the Department.

2. If the medical bill remains rejected and the insurer does not correctly resubmit the bill within 90 calendar days of the original rejected date, an administrative fine shall be assessed against the insurer in the amount of $50 for each such medical bill.

(d) The provisions of subsection 69L-7.602(7), F.A.C., become null and void and are supplanted by penalty provisions in this amended rule 69L-24.006, F.A.C., effective upon adoption of this amended rule chapter 69L-24, F.A.C.

Rulemaking Authority 440.13(11), 440.185(10), 440.20(6), 440.525(4), 440.591, 440.593(4) FS. Law Implemented 440.13(11), 440.185, 440.20(6), (8), 440.525, 440.593 FS. History–New 1-12-10.