To amend the rule to adopt the 2008 Edition of the Florida Workers’ Compensation Health Care Provider Reimbursement Manual and implement the 2008 conversion factors issued by the Centers for Medicare and Medicaid Services, as approved by the Three ...

DEPARTMENT OF FINANCIAL SERVICES
Division of Worker's Compensation

RULE NO: RULE TITLE
69L-7.020: Florida Workers' Compensation Health Care Provider Reimbursement Manual
PURPOSE AND EFFECT: To amend the rule to adopt the 2008 Edition of the Florida Workers’ Compensation Health Care Provider Reimbursement Manual and implement the 2008 conversion factors issued by the Centers for Medicare and Medicaid Services, as approved by the Three Member Panel, pursuant to Section 440.13(12), Florida Statutes. Additional proposed amendments to the rule will adopt the CPT® 2008 Current Procedural Terminology Professional Edition, Copyright 2007, American Medical Association and the “Healthcare Common Procedure Coding System, Medicare’s National Level II Codes, HCPCS 2008”, American Medical Association, Twentieth Edition, Copyright 2007, Ingenix Publishing Group. The 2008 Edition of the Florida Workers’ Compensation Health Care Provider Reimbursement Manual also provides new language addressing issues relating to co-payments, insurer reimbursement responsibilities, and reimbursement disputes. Specifically, it states that while health care providers are entitled to collect a $10.00 co-payment from injured workers who have reached maximum medical improvement, such co-payments are not in addition to any maximum reimbursement allowance or fee agreement, and that the reimbursement amount otherwise payable by the insurer shall be reduced by the amount of the co-payment. It further specifies that such co-payments do not apply in cases involving emergency care or service to injured employees. The 2008 Manual also provides new language recognizing National Correct Coding Initiative Edits as an appropriate resource for insurer use in the bill review process. On the subject of reimbursement disputes, new language provides that where an insurer has disallowed or adjusted payment for services rendered pursuant to an authorized workers’ compensation managed care arrangement, a health care provider may not elect to petition the Department of Financial Services pursuant to Section 440.13, Florida Statutes.
SUMMARY: Addresses proposed revisions to the Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2008 Edition, implements the 2008 conversion factors issued by the Centers for Medicare and Medicaid Services, provides guidelines detailing the circumstances under which providers may collect co-payments from claimants, provides new language recognizing the National Correct Coding Initiative Edits as an appropriate resource for insurer use in the bill review process, and provides that a health care provider may not elect to petition the Department to resolve a reimbursement dispute where services were rendered pursuant to an authorized workers’ compensation managed care arrangement.
SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS: No Statement of Estimated Regulatory Cost was prepared.
Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.
SPECIFIC AUTHORITY: 440.13(14)(b), 440.591 FS.
LAW IMPLEMENTED: 440.13(7), (12), (14)(c) FS.
IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE HELD AT THE DATE,TIME AND PLACE SHOWN BELOW(IF NOT REQUESTED, THIS HEARING WILL NOT BE HELD):
DATE AND TIME: Friday, November 21, 2008, 10:00 a.m.
PLACE: 104J Hartman Bldg., 2012 Capital Circle S. E., Tallahassee, Florida
Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 5 days before the workshop/meeting by contacting: Sam Willis at [phone]. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Sam Willis, Office of Medical Services, Division of Workers’ Compensation, Department of Financial Services, 200 East Gaines Street, Tallahassee, Florida 32399-4226, phone [phone]

THE FULL TEXT OF THE PROPOSED RULE IS:

69L-7.020 Florida Workers’ Compensation Health Care Provider Reimbursement Manual.

(1) The Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 20087 Edition, is adopted by reference as part of this rule.  The manual contains the Maximum Reimbursement Allowances determined by the Three-Member Panel, pursuant to Section 440.13(12), F.S., and establishes reimbursement policies, guidelines, codes and maximum reimbursement allowances for services and supplies provided by health care providers.  Also, the manual includes reimbursement policies and payment methodologies for pharmacists and medical suppliers.

(2) The CPT^® 20087 Current Procedural Terminology Professional Edition, Copyright 20076, American Medical Association; the Current Dental Terminology, CDT-2007/2008, Copyright 2006, American Dental Association; and in part for D codes and for injectable J codes, and for other medical services and supply codes, the “Healthcare Common Procedure Coding System, Medicare’s National Level II Codes, HCPCS 20087”, American Medical Association, Twentieth Nineteenth Edition, Copyright 20076, Ingenix Publishing Group, are adopted by reference as part of this rule.  When a health care provider performs a procedure or service which is not listed in the Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 20087 Edition incorporated above, the provider must use a code contained in the CPT^®-20087, CDT-2007/2008 or HCPCS-20087 as specified in this section.

(3) The Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 20087 Edition incorporated above, is available for inspection during normal business hours at the Florida Department of Financial Services, Document Processing Section, 200 East Gaines Street, Tallahassee, Florida 32399-0311, or via the Department’s web site at http://www.fldfs.com/wc.

Specific Authority 440.13(14)(b), 440.591 FS. Law Implemented 440.13(7), (12), (14)(c) FS. History–New 10-1-82, Amended 3-16-83, 11-6-83, 5-21-85, Formerly 38F-7.20, Amended 4-1-88, 7-20-88, 6-1-91, 4-29-92, 2-18-96, 9-1-97, 12-15-97, 9-17-98, 9-30-01, 7-7-02, Formerly 38F-7.020, 4L-7.020, Amended 12-4-03, 1-1-04, 7-4-04, 5-9-05, 9-4-05, 11-16-06, 10-18-07,________.

NAME OF PERSON ORIGINATING PROPOSED RULE: Sam Willis, Office of Medical Services, Division of Workers’ Compensation
NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Alex Sink, Chief Financial Officer, Department of Financial Services
DATE PROPOSED RULE APPROVED BY AGENCY HEAD: August 8, 2008
DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAW: August 22, 2008