The proposed rulemaking amends rules governing the process for the resolution of reimbursement disputes between workers’ compensation carriers and health care providers, creates a rule, and repeals five rules. The major changes proposed include: ...

 

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 proposed rulemaking amends rules governing the process for the resolution of reimbursement disputes between workers’ compensation carriers and health care providers, creates a rule, and repeals five rules. The major changes proposed include: adding a rule for defined terms; simplifying requirements for submission of reimbursement disputes; repealing rules related to consolidation of petitions, joint stipulations, and non-response by a carrier; and adopting revised forms.

SUMMARY: The proposed rulemaking adds definitions; simplifies requirements for submission of reimbursement disputes; repeals rules related to consolidation of petitions, joint stipulations, and non-response by a carrier; and adopts revised forms.

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)(e), 440.591 FS.

LAW IMPLEMENTED: 440.13(7), 440.13(11)(a) and (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: Tuesday, November 27, 2018, 11:00 a.m. ET

PLACE: Hartman Building, Room 102, 2012 Capital Circle SE, Tallahassee, FL 32301

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).

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Theresa Pugh, Program Administrator – Medical Services Section, Bureau of Monitoring and Auditing, Division of Workers’ Compensation, Department of Financial Services, telephone: [phone], email:

[e-mail].

 

THE FULL TEXT OF THE PROPOSED RULE IS:

 

69L-31.002 Definitions.

In addition to the definitions in section 440.13(1), F.S., for the purposes of Rule Chapter 69L-31, F.A.C., the following definitions apply:

(1) “Notice of Disallowance or Adjustment” means an Explanation of Bill Review (EOBR), as defined in paragraph 69L-7.710(1)(y), F.A.C., or any document that:

(a) Identifies the amount of disallowance or adjustment of payment that corresponds with the medical bill submitted by the Health Care Provider;

(b) Identifies the name and address of the Carrier and the entity issuing the document;

(c) Contains a statement indicating that the document is issued for purposes of noticing the Health Care Provider of the disallowance or adjustment of payment for purposes of section 440.13(7), F.S.; and

(d) Identifies specific EOBR codes related to the adjudication of each line item billed.

(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/2018, (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, regardless of whether the petition is submitted in hard copy or electronically. 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 contested 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 contested 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; and

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

(4) The Petition Form will be dismissed if all documentation required by paragraphs (3)(a)-(d), above, was not submitted with the Petition Form.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(a), 440.13(11)(c) 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/2018, (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. Any submission by a carrier 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 shall result in a notice of deficiency by the Department. A carrier shall have ten (10) calendar days from receipt of the notice of deficiency to cure the deficiency identified in the Department’s notice of deficiency. Failure to timely cure the deficiency shall constitute failure to submit requested documentation to the Department.

(3) The Carrier must serve the Response Form, accompanied by all supporting documentation, on the Department in accordance with the timeframe set forth in section 440.13(7)(b), 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 served on 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.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(b), 440.13(11)(c) 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 (including all supporting documentation) submitted to the Department by the Petitioner and the Carrier to support their respective positions.

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

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7), 440.13(11)(c) 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 Notice of Disallowance or Adjustment Explanation of Bill Review does not specify specifically identify the name and mailing address for of the entity the Ccarrier designates to receive service on behalf of the Ccarrier and all affected parties (for EOBRs, this is required by subsection 69L-7.740(14), F.A.C.), as required by paragraph 69L-7.602(5)(q), F.A.C., the Ppetitioner may effectuate service of the Ppetition Form on upon the Ccarrier and all affected parties by serving a copy of the Ppetition Form, and all supporting documentation submitted to the Department, and copies of all documents and records in support of the petition by United States Postal Service (USPS) certified mail on upon the entity that who issued the Notice of Disallowance or Adjustment Explanation of Bill Review at the address from which the Notice of Disallowance or Adjustment 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.

(4) If a carrier has not been properly served in accordance with this subsection, the petitioner will be notified by the Department of the deficiency in service. The petitioner 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) days after petitioner’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 petition and 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)(a), 440.13(11)(c) 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 served on 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 from 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 from 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 service of the Petition Form and supporting documentation on the Department. The timeliness of a Petition Form will be calculated based on the date of service of the Petition Form on the Department in accordance with subsection (4), below.

(3) The thirty (30) day time period within which a Response Form must be served on the Department begins upon the date the Carrier receives the Petition Form, 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 service of the Response Form and supporting documentation on the Department in accordance with subsection (4), below.

(4) Service of a Petition Form or Response Form on the Department must be by USPS mail, by common carrier, by hand delivery, or by electronic submission via the Division of Workers’ Compensation Medical Services Web Portal. If service is by USPS mail, the date of service on the Department will be the postmark date placed on the envelope by USPS. If service is by common carrier, the date of service on the Department will be the common carrier pick-up date. If service on the Department is by hand delivery, the date of service 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). If service is by electronic submission via the Division of Workers’ Compensation Medical Services Web Portal, the date of service will be the date the Department receives the electronic submission.

(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)(a) and (b), 440.13(11)(c) 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)(a) and, (c), 440.13(11)(c) FS. History–New 11-28-06, Formerly 59A-31.013, Amended    .

 

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

If the Ccarrier, in its Carrier Response to Petition for Resolution of Reimbursement Dispute, asserts in its Response Form and submits documentation substantiating that a basis for disallowing the Health Care Provider’s petitioner’s claim for reimbursement payment is overutilization by the Health Care Provider and submits documentation substantiating the assertion, and the Department, in its discretion, determines that the Rreimbursement Ddispute cannot be resolved without addressing the overutilization issue, the Department will issue a determination finding pursuant to section 440.13(7), F.S., that the Rreimbursement Ddispute cannot be resolved under section 440.13(7), F.S., and is being converted to a proceeding under either section sections 440.13(8) or 440.13(11), F.S., or both.

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

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Theresa Pugh

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

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: November 2,2018

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: May 14, 2018