The Department proposes rule amendments to clarify requirements and procedures for resolution of medical reimbursement disputes.

 

DEPARTMENT OF FINANCIAL SERVICES

Division of Workers’ Compensation

RULE NOS.:RULE TITLES:

69L-31.002Definitions

69L-31.003Petition Form

69L-31.004Carrier Response Form

69L-31.005Petition Requirements

69L-31.006Consolidation of Petitions

69L-31.007Service of Petition on Carrier and Affected Parties

69L-31.008Computation of Time

69L-31.009Carrier Response Requirements

69L-31.010Effect of Non-Response by Carrier

69L-31.011Complete Record

69L-31.012Joint Stipulation of the Parties

69L-31.013Petition Withdrawal

69L-31.014Overutilization Issues Raised in Reimbursement Dispute Resolution

PURPOSE AND EFFECT: The Department proposes rule amendments to clarify requirements and procedures for resolution of medical reimbursement disputes.

SUMMARY: Modification of the processes related to resolution of reimbursement disputes by the Florida Department of Financial Services pursuant to section 440.13(7)(e), F.S.

SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS AND LEGISLATIVE RATIFICATION:

The Agency has determined that this will not have an adverse impact on small business or likely increase directly or indirectly regulatory costs in excess of $200,000 in the aggregate within one year after the implementation of the rule. A SERC has not been prepared by the Agency.

The Agency has determined that the proposed rule is not expected to require legislative ratification based on the statement of estimated regulatory costs or if no SERC is required, the information expressly relied upon and described herein: A preliminary economic analysis conducted by the Department indicated that the proposed rules will not have an adverse impact or result in regulatory costs in excess of $1 million within five years, as established in section 120.541(2)(a), F.S.

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.

RULEMAKING AUTHORITY: 440.13(7), (7)(e), 440.591, FS.

LAW IMPLEMENTED: 440.13(7), (9), (11), FS.

A HEARING WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:

DATE AND TIME: Wednesday, January 8, 2020, 9:30 a.m. Eastern Time

PLACE: Room 155, 1579 Summit Lake Drive, Tallahassee, FL 32317

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: Theresa Pugh, telephone: [phone], email: [e-mail]. 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). 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: Theresa Pugh, Program Administrator – Medical Services Section, Bureau of Monitoring and Auditing (please see contact information in paragraph above).

 

THE FULL TEXT OF THE PROPOSED RULE IS:

 

69L-31.002 Definitions.

The definitions that follow and those in section 440.13(1), F.S., apply to capitalized terms used in this rule chapter:

(1) “Notice of Disallowance or Adjustment” means a document that identifies the amount of disallowance or adjustment of payment that corresponds with the medical bill submitted by the Health Care Provider;

(2) “Petitioner” means the Health Care Provider, or entity acting on behalf of the Health Care Provider, submitting a Petition Form to contest Carrier disallowance or adjustment of payment.

(3) “Petition Form” means the Petition for Resolution of Reimbursement Dispute Form, DFS-F6-DWC-3160-0023, incorporated in Rule 69L-31.003, F.A.C.

(4) “Response Form” means the Carrier Response to Petition for Resolution of Reimbursement Dispute Form, DFS-F6-DWC 3160-0024, incorporated in Rule 69L-31.004, F.A.C.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7) FS. History–New.

 

69L-31.003 Petition for Resolution of Reimbursement Dispute Form and Requirements.

(1) The Petition for Resolution of Reimbursement Dispute Form, DFS-F6-DWC-3160-0023, revised MM/YYYY, (DFS Form 3160-0023, effective September 8, 2006) is hereby incorporated by reference herein. This form may be obtained on the Department’s website Internet at

https://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Forms/Default.htm http://www.myfloridacfo.com/wc/forms.html or by contacting the Department at [phone].

(2) A petition to contest Ccarrier disallowance or adjustment of payment pursuant to section 440.13(7)(a), F.S., must be made on the Petition for Resolution of Reimbursement Dispute Form. The Department will not accept any other form or document in lieu of the Petition Form. Instructions for submission of the Petition Form are included on the bottom of the Petition Form. Any submission seeking to contest the disallowance or adjustment of payment by a carrier pursuant to section 440.13(7)(a), F.S., must include a completed Petition for Resolution of Reimbursement Dispute Form.

(3) The Petitioner must submit the Petition Form to the Department within the timeframe set forth in section 440.13(7)(a), F.S., and must include with the Petition Form the documents listed below that support the allegations contained in the Petition Form:

(a) A copy of each Notice of Disallowance or Adjustment received from the Carrier and, if applicable, proof of the date of receipt, as required by subsection 69L-31.008(1), F.A.C.;

(b) A copy of all medical bill(s) or request(s) for reimbursement sent to the Carrier for which payment was disallowed or adjusted by the Carrier on each Notice of Disallowance or Adjustment;

(c) A copy of all documentation submitted to the Carrier in support of the medical service(s), bill(s), or request(s) for reimbursement that are subject to the dispute;

(d) If the services in the Notice of Disallowance or Adjustment were provided pursuant to a contract, documentation substantiating the contract was in effect for the line item(s) in dispute and the provision which governs reimbursement for the services;

(e) If the Medical Necessity of the services in the Notice of Disallowance or Adjustment are being disputed, any relevant section(s) of evidence-based practice guidelines the Petitioner relied upon to support the Medical Necessity of the services in the contested line item(s) (in the absence of, or deviation from, the evidence-based practice guidelines, the Petitioner may provide a signed document from the Health Care Provider who provided the services in the contested line item(s) in the Notice of Disallowance or Adjustment describing the Medical Necessity of the services);

(f) If the authorization for the services in the Notice of Disallowance or Adjustment are being disputed, all of the Petitioner’s documentation, records, and correspondence related to the authorization or request for authorization; and

(g) Any additional documents or records that support the allegations contained in the Petition Form. 

(4) If the Petitioner does not submit a completed Petition Form, accompanied by all of the required items, the Department will notify the Petitioner of the deficiency in submission. The Petitioner will have twenty (20) calendar days from receipt of the notice of deficiency to cure the deficiency by providing to the Department the items specified in the Department’s notice along with proof of proper service of the curative documentation upon the Carrier. If the Department does not receive the curative documentation and proof of service of the curative documentation upon the Carrier within twenty (20) calendar days after Petitioner’s receipt of the notice of deficiency, the petition will be dismissed with prejudice.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7) 440.13(7)(a), 440.13(11) FS. History–New 11-28-06, Formerly 59A-31.003, Amended    .

 

69L-31.004 Carrier Response to Petition for Resolution of Reimbursement Dispute Form and Requirements.

(1) The Carrier Response to Petition for Resolution of Reimbursement Dispute Form, DFS-F6-DWC-3160-0024, revised MM/YYYY, (DFS Form 3160-0024, effective September 8, 2006) is hereby incorporated by reference herein. This form may be obtained on the Department’s website Internet at https://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Forms/Default.htm http://www.myfloridacfo.com/wc/forms.html or by contacting the Department at [phone].

(2) The Carrier Response to Petition for Resolution of Reimbursement Dispute Form shall be considered a required element of the requested documentation to the Department under section 440.13(7)(b), F.S. The Carrier Response to Petition for Resolution of Reimbursement Dispute Form is shall be the only form accepted by the Department upon which a Ccarrier may submit to the Department its response, pursuant to section 440.13(7)(b), F.S., to a Petition Form for Resolution of Reimbursement Dispute. Instructions for submission of the Response Form are included on the bottom of the Response Form.

(3) The Carrier must submit the Response Form, accompanied by all supporting documentation, to the Department in accordance with the timeframe set forth in section 440.13(7)(b), F.S.

(a) If EOBR code 10 or 11 (used to deny payment because the service rendered is for a non-compensable injury or illness) was used as a reason to deny payment for the line item(s) the Petitioner contends was improperly denied, a copy of the Form DFS-F2-DWC-12, Notice of Denial, adopted in Rule 69L-3.025, F.A.C., that was sent to the injured worker and Health Care Provider pursuant to Rule 69L-56.4012, F.AC., must be included as part of the supporting documentation.

(b) If the Carrier relied upon evidence-based practice guidelines to support the disallowance of payment for the Medical Necessity of services in the Notice of Disallowance or Adjustment, the Carrier may submit the relevant section(s) of the evidence-based practice guidelines, along with a signed document from the Carrier’s medical director confirming that the relevant section(s) of the evidence-based practice guidelines is the reason for the disallowance or adjustment of payment. Absent any relevant section(s) of evidence-based practice guidelines, the Carrier may provide a Peer Review to support the disallowance of payment for the Medical Necessity of services in the contested line item(s) in the Notice of Disallowance or Adjustment.

(c) If the Carrier disallowed or adjusted the payment in the Notice of Disallowance or Adjustment because the Petitioner was not authorized to provide the services, all of the Carrier’s documentation, correspondence, and records evidencing authorization was not given to the Health Care Provider prior to the dates of service(s) or all of the Carrier’s documentation, records, and correspondence evidencing the Carrier responded to the request for authorization in accordance with paragraphs (3)(d) or (3)(i) of section 440.13, F.S.

(4) Using a delivery method that provides confirmation of the date of delivery, the Carrier must provide to the Petitioner, at the Petitioner’s mailing address provided on the Petition Form, a copy of the Response Form and all supporting documentation submitted to the Department in response to the Petition Form.  The Carrier must document the delivery tracking information in such detail that the Department can verify the Petitioner’s receipt of the Response Form and supporting documentation.

(5) Any submission by a Ccarrier pursuant to section 440.13(7)(b), F.S., that does not include a completed Carrier Response to Petition for Resolution of Reimbursement Dispute Form, accompanied by all required items, will shall result in the issuance of a notice of deficiency by the Department. The A Ccarrier will shall have twenty (20) ten (10) calendar days from receipt of the notice of deficiency to cure the deficiency by providing to the Department the items specified in the Department’s notice along with proof of proper service of the curative documentation upon the Petitioner identified in the Department’s notice of deficiency. Failure to timely cure the deficiency and provide proof of service of the curative documentation upon the Petitioner will shall constitute failure to submit requested documentation to the Department.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7) 440.13(7)(b), 440.13(11) FS. History–New 11-28-06, Formerly 59A-31.004, Amended    .

 

Substantial rewording of Rule 69L-31.005 follows. See Florida Administrative Code for present text.

 

69L-31.005 Written Determinations Petition Requirements.

(1) The Department will render a written determination on whether the Carrier properly adjusted or disallowed payment by relying upon the applicable reimbursement schedules, practice parameters, protocols of treatment, and standards and policies set forth in chapter 440, F.S. (and the rules promulgated therefrom), along with the Petition Form, and Response Form, and all supporting documentation submitted to the Department by the Petitioner and the Carrier to support their respective positions. The Department will use an Expert Medical Advisor, in accordance with section 440.13(9)(b), F.S., to resolve Reimbursement Disputes associated with the disallowance or adjustment of payment based upon: 1) overutilization; or 2) Medical Necessity of the services in the Notice of Disallowance or Adjustment when both the Petitioner (pursuant to paragraph 69L-31.003(3)(e), F.A.C.) and Carrier (pursuant to paragraph 69L-31.004(3)(b), F.A.C.) have provided documentation to support their respective decisions on the Medical Necessity of the services.

(2) In its written determination, the Department will only address the specific line item(s) in the Notice of Disallowance or Adjustment that the Petitioner contends were improperly disallowed or adjusted.

(3) If the Carrier has failed to meet the requirement set forth in paragraph 69L-31.004(3)(a), F.A.C., the Department, in its written determination, will only address the specific line item(s) in the Notice of Disallowance or Adjustment that the Petitioner contends were improperly denied.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7), 440.13(9), 440.13(11) FS. History–New 11-28-06, Formerly 59A-31.005, Amended    .

 

69L-31.006 Consolidation of Petitions.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(e) FS. History–New 11-28-06, Formerly 59A-31.006, Repealed.

 

69L-31.007 Service of Petition on Carrier and All Affected Parties.

(1) The Ppetitioner must shall effectuate service on upon the Ccarrier and on all affected parties by serving a copy of the Ppetition Form, and all supporting documentation submitted to the Department documents and records in support of the petition, by United States Postal Services (USPS) certified mail on the specific entity identified on the Notice of Disallowance or Adjustment Explanation of Bill Review as the entity the Ccarrier designates to receive service of the Petition Form and all supporting documentation on behalf of the Ccarrier and all affected parties. If the Explanation of Bill Review does not specifically identify the name and mailing address of the entity the carrier designates to receive service on behalf of the carrier and all affected parties, as required by paragraph 69L-7.602(5)(q), F.A.C., the petitioner may effectuate service of the petition upon the carrier and all affected parties by serving a copy of the petition and copies of all documents and records in support of the petition by United States Postal Service (USPS) certified mail upon the entity who issued the Explanation of Bill Review at the address from which the Explanation of Bill Review was issued.

(2) A Petition for Resolution of Reimbursement Dispute must be served upon the carrier and all affected parties by United States Postal Service (USPS) certified mail. Service upon the carrier shall include one copy set of all documents and records submitted to the Department in support of the petition.

(3) Service by certified mail means service by United States Postal Service (USPS) certified mail. Service by United States Postal Service (USPS) delivery other than USPS certified mail or service by common carrier does not constitute service by USPS certified mail, as required by section 440.13(7)(a), F.S., statute, even if the Carrier’s carrier delivery and receipt of the documents is petition are confirmed. 

(2) (4) If a Ccarrier has not been properly served in accordance with this rule subsection, the Ppetitioner will be notified by the Department of the deficiency in service. The Ppetitioner will shall have ten (10) calendar days from receipt of the notice of deficiency in service to provide the Department with proof the deficiency in service identified in the notice of deficiency has been cured by proper service. If the Department does not receive proof of proper service within ten (10) calendar days after Ppetitioner’s receipt of the notice of deficiency, the petition will be dismissed with prejudice. For purposes of this rule, “proof of proper service” means that a copy of the Ppetition Form, and all supporting documentation submitted to the Department, one copy set of all documents and records in support of the petition have been sent by United States Postal Service (USPS) certified mail to the proper entity at the proper address as set forth in this rule, and a certified mail receipt number is provided to the Department to confirm mailing.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7) 440.13(7)(a), 440.13(11) FS. History–New 11-28-06, Formerly 59A-31.007, Amended    .

 

Substantial rewording of Rule 69L-31.008 follows. See Florida Administrative Code for present text.

69L-31.008 Computation of Time.

(1)(a) The forty-five (45) day time period within which a Petition Form must be submitted to the Department begins upon receipt of the Notice of Disallowance or Adjustment by the Health Care Provider or by an entity designated by the Health Care Provider to receive such notice on behalf of the Health Care Provider. 

(b) The Health Care Provider must document receipt of the Notice of Disallowance or Adjustment by either: 1) using a date stamp that clearly reflects the date of receipt of the Notice of Disallowance or Adjustment by the Health Care Provider; or 2) using a verifiable login process. A date-stamped Notice of Disallowance or Adjustment will be accepted as proof of the date of receipt. A copy of the applicable portion of the login roster showing the date of login of the Notice of Disallowance or Adjustment will be accepted as proof of the date of receipt through a verifiable login process.

(c) If receipt cannot be established through a date stamp or verifiable login process, the Petitioner may provide a copy of the envelope in which the Notice of Disallowance or Adjustment was sent that clearly and legibly shows the postmark date, in which case receipt will be deemed to be five (5) calendar days after the postmark date.

(d) If the Petitioner does not establish the date of its receipt of the Notice of Disallowance or Adjustment by any of the methods set forth in this subsection through documentation accompanying the Petition Form, the Health Care Provider’s receipt of the Notice of Disallowance or Adjustment will be deemed to be five (5) calendar days after the issue date on the Notice of Disallowance or Adjustment. An affidavit attesting to the date of receipt will not be accepted as proof of the date of receipt.

(2) Petitioning the Department to resolve a Reimbursement Dispute is effectuated upon submission of the Petition Form and supporting documentation to the Department. The timeliness of a Petition Form will be calculated based on the date of submission of the Petition Form to the Department in accordance with subsection (4), below.

(3) The thirty (30) day time period within which a Response Form must be submitted to the Department begins upon the date the Carrier receives the Petition Form, which will be established by the USPS certified mail receipt date. If the Department issues a notice of deficiency to the Petitioner, then the thirty (30) day time period within which a Response Form must be submitted to the Department begins upon the date the Carrier receives the curative documentation, which will be established by the USPS certified mail receipt date. Timely submission by the Carrier to the Department of the Response Form and supporting documentation will be determined based on the date of submission of the Response Form and supporting documentation to the Department in accordance with subsection (4), below.

(4) Submission of a Petition Form or Response Form to the Department must be by USPS mail, by common carrier, or by hand delivery. If submission is by USPS mail, the date of submission to the Department will be the postmark date placed on the envelope by USPS. If submission is by common carrier, the date of submission to the Department will be the common carrier pick-up date. If submission is by hand delivery, the date of submission will be the date the Petition Form or Response Form is hand delivered to the receptionist at the hand delivery address listed on the forms (which can only be accomplished Monday through Friday, between 8:00 a.m. and 5:00 p.m., Eastern Time, excluding state of Florida holidays).

(5) Time periods established for petitioning the Department to resolve a Reimbursement Dispute or responding to a Petition Form are not tolled by any of the following actions: requesting an on-site audit; conducting an on-site audit; referral of the Health Care Provider for peer review consultation; or an independent medical examination of the injured employee.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7) 440.13(7)(a) and (b), 440.13(11) FS. History–New 11-28-06, Formerly 59A-31.008, Amended    .

 

69L-31.009 Carrier Response Requirements.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(b) FS. History–New 11-28-06, Formerly 59A-31.009, Repealed    .

 

69L-31.010 Effect of Non-Response by Carrier. 

Rulemaking Authority 440.13(7), 440.591 FS. Law Implemented 440.13(7)(b) FS. History–New 11-28-06, Formerly 59A-31.010, Repealed    .

 

69L-31.011 Complete Record.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(c) FS. History–New 11-28-06, Formerly 59A-31.011, Repealed    .

 

69L-31.012 Joint Stipulation of the Parties.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7) FS. History–New 11-28-06, Formerly 59A-31.012, Repealed    .

 

69L-31.013 Petition Withdrawal.

(1) Prior to the issuance of a determination, the Ppetitioner may voluntarily withdraw its Petition Form for Resolution of Reimbursement Dispute.

(2) The withdrawal must of a petition shall be in writing and must clearly indicate:

(a) The case number assigned by the Department; or

(b) The name of the Petitioner health care provider or facility requesting withdrawal,; (b) tThe name of the Ccarrier against which whom the Reimbursement Dispute petition has been initiated,;(c) tThe date(s) of service identified on the Petition Form, covered by the petition; and (d) tThe identity of the injured employee to whom medical services were delivered.

(3) Upon the Department’s The result of receipt by the Department of a written request for withdrawal of a Petition Form, the Department will close its file on the matter without further action petition shall be dismissal of the determination case by the Department.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7) 440.13(7)(a) and, (c), 440.13(11) FS. History–New 11-28-06, Formerly 59A-31.013, Amended    .

 

69L-31.014 Overutilization Issues Raised in Reimbursement Dispute Resolution.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(b) and (c), FS. History–New 11-28-06, Formerly 59A-31.014, Repealed    .

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Andrew Sabolic

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: CFO Jimmy Patronis

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: November 21, 2019

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: November 21, 2019