Definitions, Monitoring, Examining and Investigating, Maintaining and Providig Records, Administrative Penalties and Fines, Patterns and Practices  


  • RULE NO: RULE TITLE
    69L-24.003: Definitions
    69L-24.004: Monitoring, Examining and Investigating
    69L-24.005: Maintaining and Providig Records
    69L-24.006: Administrative Penalties and Fines
    69L-24.007: Patterns and Practices
    NOTICE OF CHANGE
    Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 35 No. 25, June 26, 2009 issue of the Florida Administrative Weekly.

    These changes are in response to written comments submitted by the staff of the Joint Administrative Procedures Committee and also includes technical changes.

    69L-24.003 Definitions.

    The following definitions shall apply in the rule chapter:

    (1) through (5) No change.

    (6) “Department Rules” – any and all rules adopted by the Department of Financial Services in its administration of Chapter 440 that apply to insurers or other regulated entities

    (7) No change.

    (8) “Examination” – a process whereby the practices of regulated entities are examined to verify compliance with Chapter 440, Florida Statutes and Department Rules. The term “examination” is synonymous with the term “audit”.

    (9) through (10) No change.

    (11) “Form DFS-F2-DWC-1” – Form DFS-F2-DWC-1 (First Report of Injury or Illness), effective 03/2009, or an electronic equivalent as required in Rule 69L-56.301, F.A.C.

    (12) “Investigation” – a Department review that is conducted to verify compliance with Chapter 440, Florida Statutes and Department Rules.

    (13) “Pattern or Practice” – a repeated or customary act(s) of non-compliance with any single provision of Chapter 440, Florida Statutes or Department Rules on an individual claim or on multiple claims.

    (14) “Regulated Entity” – any insurer as defined in Section 440.02(38), F.S., employer, service company, servicing agent, third-party administrator, claims handling entity, self-serviced self-insured employer or fund, submitter of forms or data on behalf of an insurer, or managing general agent that is responsible for handling or adjusting claims, or fulfilling an insurer’s responsibility to transmit workers’ compensation data to the Department.

    (15) “Violation” – any finding of non-compliance with Chapter 440, Florida Statutes or Department Rules.

     

    69L-24.004 Monitoring, Examining and Investigating.

    (1) The Department shall monitor, examine, or investigate the performance of regulated entities to ensure compliance with Chapter 440, Florida Statutes and Department Rules as often as is deemed necessary.

    (a) No change.

    (b) Examining or investigating includes, but is not limited to, the review of a regulated entity’s processes and shall be based upon:

    1. The regulated entity’s performance in prior examinations and/or investigations, or

    2. Information obtained through the monitoring process

    (2) Monitoring, examining, or investigating includes, but is not limited to, the review of the following:

    (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 Rules 69L-3.001 through 69L-3.025, F.A.C.,

    (d) Timeliness and accuracy of electronic transactions required by Rules 69L-56.001 through 69L-56.500, F.A.C.,

    (e) Denial of claims,

    (f) Delay in provision of benefits,

    (g) Harassment, coercion or intimidation of any party,

    (h) Evidence of the mailing and wording of the fraud statement pursuant to Section 440.105(7), F.S.,

    (i) Timeliness of the response to a Petition for Benefits,

    (j) Timeliness of the compliance with a Judge of Compensation Claim’s order,

    (k) Timeliness of the compliance with a Department rule or order,

    (l) Compliance with CPS batch timeframes,

    (m) Claims-handling practices,

    (n) Timeliness of medical authorizations, which includes authorizations submitted on Form DFS-F5-DWC-25 (Florida Workers’ Compensation Uniform Medical Treatment/Status Reporting Form), effective 1/31/08, incorporated in paragraph 69L-7.602(2)(d), F.A.C.

    (o) Mailing of Form DFS-F2-DWC-65 (Important Workers’ Compensation Information for Florida’s Employers), effective 8/2004, or Form DFS-F2-DWC-66 (Informacion Importante De Seguro De Indemnizacion Por Accidentes De Trabajo Para Los Empleadores De La Florida), effective 8/2004, as incorporated in Rule 69L-3.0036, F.A.C., to the employer,

    (p) The date that Forms DFS-F2-DWC-60 or DFS-F2-DWC-61 (Important Workers’ Compensation Information for Florida’s Workers’ brochure or Informacion Importante De Seguro De Indeminzacion Por Accidentes De Trabajo Para Los Trabajadores De La Florida), as incorporated in Rule 69L-3.0035, F.A.C., were mailed to the injured worker, and

    (q) Mailing of the Employee Notification Letter, as incorporated in subsection 69L-26.004(6), F.A.C., to the injured worker.

    (3) Reports resulting from an examination or investigation conducted under Chapter 440, Florida Statutes and Department Rules, are confidential and exempt from Section 119.07(1), F.S., pursuant to Section 624.319, F.S., until the examination or investigation ceases to be active.

     

    69L-24.005 Maintaining and Providing Records.

    (1) through (2) No change.

    (2)(a) The date of notification or knowledge of the injury. “Notification” and “knowledge” are defined in Rules 69L-3.002(23) and 69L-56.002(40), F.A.C.

    (b) The date of initial disability, the eighth day of disability and knowledge of the eighth day of disability,

    (c) The date each indemnity payment was mailed to the injured worker, the amount of the payment, and the period of time that was covered in the payment,

    (d) The date that 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 paragraph 69L-7.602(2)(a), (b), (c), and (e), F.A.C., were received from the health care provider pursuant to paragraph 69L-7.602(1)(m), F.A.C.

    (e) The date that 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, were paid, disallowed, or denied,

    (f) The date that 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, were mailed or transmitted to the Department,

    (g) The date that Forms DFS-F2-DWC-60 (Important Workers’ Compensation Information for Florida’s Workers’ brochure) or DFS-F2-DWC-61 (Informacion Importante De Seguro De Indeminzacion Por Accidentes De Trabajo Para Los Trabajadores De La Florida) were mailed to the injured worker,

    (h) The date that Form DFS-F2-DWC-65 (Important Workers’ Compensation Information for Florida’s Employers), effective 8/2004, or Forms DFS-F2-DWC-66 (Informacion Importante Del Seguro De Indemnizacion Por Accidentes De Trabajo Para Los Empleadores De La Florida), effective 8/2004, as incorporated in Rule 69L-3.0036, F.A.C., was mailed to the employer,

    (i) The date that the Employee Notification Letter, as incorporated in subsection 69L-26.004(60), F.A.C., was mailed to the injured worker,

    (j) No change.

    (k) Electronic Data Interchange (EDI) transactions and requirements pursuant to Rules 69L-56.001 through 69L-56.500, F.A.C.

    (l) through (m) No change.

     

    69L-24.006 Administrative Penalties and Fines.

    The Department shall utilize the monitoring, examination, or investigation processes to ensure compliance with Chapter 440, Florida Statutes 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) No change.

    (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 Late                 Penalty 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 Forms 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 Late                 Penalty 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. through 5. No change.

    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) No change.

    (a)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-7.602(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. No change.

    (b) through (c) No change.

    (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_______.

     

    69L-24.007 Pattern or Practice.

    (1) through (2) No change.

    (3)(a) The Department shall issue a non-willful violation for a pattern or practice of unreasonable claims handling for any monitoring, examining, or investigating review activity listed in subsection 69L-24.004(2), F.A.C. 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. Any penalty imposed under this paragraph for a non-willful violation shall not duplicate a penalty imposed under another provision of Chapter 440, F.S., or Department Rules governing Florida Workers’ Compensation law.

    (b) 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. If the performance falls below 90% compliance during an audit, examination or investigation, except as otherwise stated in Chapter 440, F.S., Florida Statutes and Department Rules, the Department shall assess a penalty pursuant to subsection (3) herein.

    The remainder of the reads as previously published.