To promulgate a rule consistent with the Agency’s authority to establish the procedural requirements for the Expert Medical Advisor (EMA) program authorized in Section 440.13(9), Florida Statutes.

AGENCY FOR HEALTH CARE ADMINISTRATION
Health Facility and Agency Licensing

RULE NO: RULE TITLE
59A-30.002: Definitions
59A-30.003: Procedure for Certification
59A-30.004: Selection Criteria for Expert Medical Advisors
59A-30.005: Assignment of Expert Medical Advisors
59A-30.006: Temporary Expert Medical Advisors
59A-30.007: Expert Medical Advisor Responsibilities
59A-30.008: Carrier Responsibilities
59A-30.009: Recertification of Expert Medical Advisors
59A-30.010: Decertification
PURPOSE AND EFFECT: To promulgate a rule consistent with the Agency’s authority to establish the procedural requirements for the Expert Medical Advisor (EMA) program authorized in Section 440.13(9), Florida Statutes.
SUMMARY: The proposed rules substantially reword Chapter Rule 59A-30, Florida Administrative Code, to clarify the requirements for being certified and successfully participating as an Agency approved Expert Medical Advisor.
SUMMARY 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(9) FS.
LAW IMPLEMENTED: 440.13(9) FS.
A HEARING WILL BE HELD AT THE TIME, DATE AND PLACE SHOWN BELOW:
TIME AND DATE: Friday, July 28, 2006, 9:00 a.m. – 11:30 a.m.
PLACE: Conference Room 104-J, Hartman Building, 2012 Capital Circle, S.E., Tallahassee, Florida
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Welby Cox-Meyers, Registered Nursing Consultant

THE FULL TEXT OF THE PROPOSED RULE IS:

59A-30.002   Definitions.

For purposes of this rule the following definitions apply:

(1) “Board certification” or “board certified” means the physician has been awarded board certification or diplomate status by the American Board of Medical Specialties, American Board of Internal Medicine, American Board of Physician Specialties, American Osteopathic Association, American Board of General Dentistry, American Board of Podiatric Orthopedics and Primary Podiatric Medicine, American Board of Podiatric Surgery, American Chiropractic Rehabilitation Board, American Chiropractic Neurology Board, American Board of Chiropractic Internists, American Chiropractic Board of Nutrition, American Chiropractic Board of Occupational Health, American Board of Chiropractic Orthopedists, American Board of Chiropractic Radiology, or American Chiropractic Board of Sports Physicians. “AHCA” means the Agency for Health Care Administration.

(2)  “Board eligible” or “board eligibility” means the physician has been recognized by the applicable national-specialty board as eligible to take the board certification examination. “Application” means form AHCA Form 3160-0021 required by these rules in order to request to become an expert medical advisor. The AHCA Form 3160-0021 application form is incorporated into this rule chapter by reference in subsection 59A-30.003(1), F.A.C.

(3) Board certification” means the physician has passed the required examination(s) to become certified by his/her licensing board pursuant to Rules 61F2-11.012 and 61F2-11.013, F.A.C.; Rules 61F8-10.001 and 61F8-10.0015, F.A.C.; or a Board approved by the American Board of Medical Specialties (ABMS) or the American Podiatric Medical Association (APMA); or the American Osteopathic Association (AOA).

(4)    “Board eligible” means the physician has completed all requirements necessary to take a Board certification examination pursuant to subsection (3) above.

(5)    “Carrier” is defined in Section 440.13(1)(c), Florida Statutes.

(6)    “Conflict of interest” means that an expert medical advisor has examined or has prior knowledge of the injured employee to be evaluated or has a financial or ownership interest in the outcome of the case.

(7) “Decertification” means Agency revocation of certification to be an expert medical advisor to the Agency or to a judge of compensation claims.

(8)    “Disciplinary action” means administrative sanctions imposed upon a physician by either the Agency or the Department of Health.

(9)    “Agency” is defined in Section 440.02(12), Florida Statutes.

(10) “Expert medical advisor” means a physician who has been certified by the Agency as an expert medical advisor and who has contracted with the Agency to provide peer review or medical consultation to the Agency or to a judge of compensation claims.

(11)  “Physician” is defined in Section 440.13(1)(r), Florida Statutes.

Specific Authority 440.13(9), 440.591 FS. Law Implemented 440.13(9) FS. History–New 1-23-95, Formerly 38F-54.002, Amended_________.

 

59A-30.003 Qualifications Procedure for Expert Medical Advisor Certification

(1) To be certified as an Eexpert Mmedical Aadvisor, a physician shall meet the following qualifications:

(1) Must have been certified as a health care provider by the Agency pursuant to Chapter 59A-29, F.A.C., for a period of not less than twelve months prior to the date of the Expert Medical Advisor application

(a) Meet the eligibility requirements as set out in Rule 59A-30.004, F.A.C.; and

(b) Submit a signed, typed and completed application form AHCA Form 3160-0021 to the following address: Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop-26, Tallahassee, Florida 32308-5403. Illegible or unsigned applications shall be returned. The application form AHCA Form 3160-0021 is hereby incorporated by reference into Chapter 59A-30, F.A.C. The version of the form required by this rule shall bear the date January 20, 1995. A copy of the application form AHCA Form 3160-0021 may be obtained from the Agency at the address set forth in this paragraph.

(c) Submit a current curriculum vitae, together with the application form AHCA Form 3160-0021, which shall include:

1.  Type of practice (administration, medical teaching, medical research, group practice, consulting, retired, other);

2.  Type of specialty including year of certification, recertification/subcertification as appropriate and name of certifying board;

3.  Year of birth;

4.  Date of medical degree and name of university conferring the degree;

5.  Hospital affiliations;

6.  Professional memberships;

7.  Teaching positions;

8.  Military record;

9.  Name of articles and journals in which published.

(d) Submit photocopy of current specialty board certificate or submit proof of specialty board eligibility.

(e) Submit a copy of verification of Agency approved workers’ compensation course completion.

(2) Must hold valid licensure, issued by the Florida Department of Health, with “clear and active” status; and  Within 30 days following verification of eligibility, the Agency shall notify the applicant of his/her status as an expert medical advisor.

(3) Must hold specialty-board certification or specialty-board eligibility applicable to the specialty for which the applicant seeks certification. If the applicable national-specialty board does not recognize “board eligible” or “board eligibility” status, the applicant must hold board certification for the specialty; and

(4) Must demonstrate experience in the assignment of permanent impairment ratings greater than zero (0%) to Florida’s injured employees, pursuant to Rule 69L-7.604, F.A.C., within the two-year period immediately preceding the date of application; and

(5) Must demonstrate experience in performing independent medical examinations pursuant to Sections 440.13(2) or 440.13(5), Florida Statutes, within the two-year period immediately preceding the date of application; and

(6)  Must have completed twenty hours of continuing medical education, specifically related to the practitioner’s field of specialty, within the two-year period immediately preceding the date of application. Completion of courses required for licensure by the Florida Department of Health addressing Domestic Violence, HIV-AIDS and Prevention of Medical Errors will not be applied to the medical continuing education requirements for Expert Medical Advisor certification; and

(7) Must possess knowledge of the Florida Statutes related to workers’ compensation, specifically Sections 440.02, 440.09, 440.093, 440.102, 440.105, 440.13, 440.134, 440.15(3), 440.15(5), 440.151, 440.20 and 440.491, F.S.; and possess knowledge of the Florida Administrative Code Rules 69L-7.602 and 69L-7.020, F.A.C., related to workers’ compensation.

Specific Authority 440.13(9), 440.591 FS. Law Implemented 440.13(9) FS. History–New 1-23-95, Amended 6-8-95, Formerly 38F-54.003, Amended _________.

 

59A-30.004 Application Selection Criteria for Certification Expert Medical Advisors.

(1) A physician shall apply for Expert Medical Advisor certification by submitting a signed, legible and accurately completed Expert Medical Advisor Certification Application, AHCA Form 3160-0021, to the following address: AHCA Workers’ Compensation Medical Services Unit, c/o Department of Financial Services, Division of Workers’ Compensation, 200 E. Gaines Street, Tallahassee, FL, 32399-4232. The Expert Medical Advisor Certification Application, AHCA Form 3160-0021, revised May 2006, is incorporated by reference into Chapter 59A-30, F.A.C., and may be obtained from the AHCA Workers’ Compensation Medical Services Unit; c/o Department of Financial Services, Division of Workers’ Compensation’s website: www.fldfs.com/wc/forms.html#7. The minimum criteria for a physician to be certified as an expert medical advisor is as follows:

(a) Be certified as a health care provider by the Agency pursuant to Chapter 59A-29, F.A.C.; and

(b) Possess board certification or board eligibility in specialty or area of practice. The physician shall be in good standing with a certifying board listed in this rule. The list of ABMS, AOA and APMA boards referred to in this rule is hereby incorporated by reference. The version of the list required by this rule shall bear the date October 15, 1994. A copy of the list may be obtained from the Agaency for Health Care Administration, 2727 Mahan Drive, Mail Stop-26, Tallahassee, Florida 32308-5403; and

(c) Treated no fewer than 24 work-related injuries per calendar year in the one year period before the date of the application.  The treatment provided shall have been approved by the carrier; and

(d) Attended at least one Agency sponsored or Agency approved workshop during the two year period before the date of application including training on impairment rating using the Florida Impairment Rating Guide; and

(e) Performed no fewer than 12 independent medical examinations in workers’ compensation cases in the two years before the date of application; and

(f) Performed medical record reviews in workers’ compensation cases in the two years before the date of application; and

(g) Assigned no fewer than twelve permanent impairment ratings with a rating greater than 0% to an injured employee pursuant to Rule 4L-7.604, F.A.C.; and

(h) Satisfies one of the following:

1. Been in practice a minimum of 20 hours per week in the five years before the date of application and has practiced in his/her specialty in the three years before the date of application; or

2. Is on the faculty of an institution of higher learning in his/her discipline; or

3. Participated on an Agency advisory committee, task force committee, or peer review committee or has performed consultant services for the Agency within the three years before the date of application.

(2) As part of the Expert Medical Advisor certification application, the physician shall agree to provide consultation or services in accordance with the timetables set forth in Chapter 440, Florida Statutes and abide by rules adopted by the Agency, including, but not limited to, rules pertaining to procedures for review of the services rendered by health care providers and preparation of reports and testimony or recommendations for submission to the Agency or judge of compensation claims A physician who has been suspended or decertified by the Agency pursuant to Chapter 59A-29, F.A.C., is not eligible to be selected as an expert medical advisor during the period of suspension or decertification.

(3) The application shall be accompanied by the following documentation to establish that the qualifications for Expert Medical Advisor certification set forth in Rule 59A-30.003, F.A.C., have been met:

(a) To document specialty-board certification or specialty-board eligibility, the applicant must submit a copy of a current certificate of national specialty-board certification or written proof of specialty-board eligibility and documentation that indicates any expiration date for specialty-board certification or specialty-board eligibility applicable to the specialty for which the applicant seeks certification.

(b) To demonstrate experience in the assignment of permanent impairment ratings to Florida’s   injured employees, pursuant to Rule 69L-7.604, F.A.C., the applicant must submit five completed DFS-F5-DWC-25 forms (with all patient identification redacted) indicating assignment of the date of maximum medical improvement and calculation of the permanent impairment rating greater than zero (0%) for injured employee evaluations completed within the two-year period immediately preceding the date of application; and

(c) To demonstrate experience in performing independent medical examinations pursuant to Sections 440.13(2) or 440.13(5), Florida Statutes, the applicant must submit copies of five independent medical examination reports (with all patient identification redacted) written for workers’ compensation injured employees within the two-year period immediately preceding the date of application; and

(d) To demonstrate completion of twenty hours of continuing medical education, specifically related to the practitioner’s field of specialty, the applicant must submit copies of certificates of completion for twenty hours of continuing medical education, related to the specialty field of practice, completed within the two-year period immediately preceding the date of application. Certificates for courses required for licensure by the Florida Department of Health addressing Domestic Violence, HIV-AIDS and Prevention of Medical Errors will not be applied to the medical education requirements for Expert Medical Advisor certification; and Attended at least one Agency sponsored or Agency approved workshop during the two year period before the date of application including training on impairment rating using the Florida Impairment Rating Guide.

(4) To demonstrate knowledge of Florida Workers’ Compensation, the physician must attest to knowledge of the Florida Statutes related to workers’ compensation, specifically Sections 440.02, 440.09, 440.093, 440.102, 440.105, 440.13, 440.134, 440.15(3), 440.15(5), 440.151, 440.20 and 440.491; and knowledge of the Florida Administrative Code Rules 69L-7.602 and 69L-7.020. If an Expert Medical Advisor applicant is not otherwise familiar with the statutes and rules identified above, he/she may attest to familiarity with those rules and statutes upon completion of the Workers’ Compensation Health Care Provider Educational Tutorial available on the Department of Financial Services, Division of Workers’ Compensation’s website: www.fldfs.com/wc.

(5) The Agency will review the Expert Medical Advisor certification application, pursuant to the requirements of Section 120.60, Florida Statutes, and notify the applicant of any deficiencies in the application submitted. If the Agency does not receive, within 30-calendar days of the applicant’s receipt of notice of deficiencies, information curing all deficiencies identified by the Agency, the Expert Medical Advisor Certification Application will be denied.

(6) Throughout the certification period, the Expert Medical Advisor shall notify the Agency:

(a) If specialty-board certification has expired.

(b) If Florida Department of Health license status is changed from “clear and active”.

(c) Of any change in address or contact information.

(7) Expert Medical Advisor certification shall be for a period of two years. If at any time during the certification period, the physician no longer meets all qualifications for Expert Medical Advisor certification, the Expert Medical Advisor certification shall be revoked.

Specific Authority 440.13(9), 440.591 FS. Law Implemented 440.13(9) FS. History–New 1-23-95, Formerly 38F-54.004, Amended_________.

 

59A-30.005 Selection Assignment of Expert Medical Advisors.

(1) All individuals contracted to provide services through certification as an Expert Medical Advisor will be placed on an Agency list of certified Expert Medical Advisors eligible for selection as an Expert Medical Advisor by the Agency or a judge of compensation claims. The expert medical advisor shall be utilized by the Agency and the judges of compensation claims pursuant to Sections 440.13(9)(b)(c), Florida Statutes.

(2) When Eexpert Mmedical Aadvisor services are needed requested by a judge of compensation claims or the Agency, the Agency shall:

(a) Select an Expert Medical Advisor from the Agency’s list of certified Expert Medical Advisors; and within 10 days, assign an expert medical advisor through a rotation system based on the specific physician expertise requested.

(b) Make the necessary arrangements for the Expert Medical Advisor to provide the Expert Medical Advisor services

(3) When Expert Medical Advisor services are needed in a proceeding before a judge of compensation claims, the judge of compensation claims shall:  The Agency shall contact the expert medical advisor; define the assignment; notify the carrier prior to the service being rendered; and notify the requesting party of the name of the Expert Medical Advisor selected.

(a) Select an Expert Medical Advisor from the Agency’s list of certified Expert Medical Advisors; and

(b) Make the necessary arrangements for the Expert Medical Advisor to provide the Expert Medical Advisor services.

(4) Upon receiving notice of selection by the Agency or judge of compensation claims as an Expert Medical Advisor the physician shall disclose any conflict of interest related to the case for which the physician was selected and shall decline selection as an Expert Medical Advisor.

(5) A physician who has been decertified pursuant to Chapter 59A-29, F.A.C., and/or has ever been decertified pursuant to Rule 59A-30.010, F.A.C., shall not be certified as an Expert Medical Advisor.

Specific Authority 440.13(9), 440.591 FS. Law Implemented 440.13(9) FS. History–New 1-23-95, Formerly 38F-54.005, Amended_________.

 

59A-30.006 Temporary Expert Medical Advisors.

(1) When the Agency or a judge of compensation claims needs requests the services or opinion of an Eexpert Mmedical Aadvisor services and the particular area of expertise requested there is no not represented among the available Eexpert Mmedical Aadvisors, on the Agency’s list of certified Expert Medical Advisors who meets the needs of the judge of compensation claims and is available to provide the Expert Medical Advisor services needed, the judge of compensation claims may propose a specific physician for temporary Expert Medical Advisor certification by the Agency. shall select a qualified individual upon the recommendation of a state or national medical professional organization.

(2) The selectee shall send to the Agency will certify the specific physician proposed by the judge of compensation claims as a temporary Expert Medical Advisor if one of the following is met: a copy of his/her license and board certification or verify his/her board eligibility before being assigned the status of temporary expert medical advisor.

(a) All parties in a proceeding before the judge of compensation claims stipulate to the  qualifications of the medical-specialty-board certified physician to provide Expert Medical Advisor services in the judge of compensation claims proceeding; or

(b) The physician has a valid and active license to practice medicine, has medical specialty-board certification and the judge of compensation claims has established that the physician has training or experience applicable to the specific medical issue before the judge of compensation claims.

(3) Certification as a temporary Expert Medical Advisor shall be limited to the specific case for which the judge of compensation claims proposed the physician for temporary Expert Medical Advisor certification  Approval to serve services are requested.

(4) A physician who has been suspended or decertified pursuant to Chapter 59A-29, F.A.C. and/or has ever been decertified pursuant to Rule 59A-30.010, F.A.C., shall not be certified approved as a temporary Expert Medical Advisor.

(5)  Upon receiving notice of selection by the judge of compensation claims as a temporary Expert Medical Advisor, the physician shall disclose any conflict of interest related to the case for which the physician was selected and shall decline selection as a temporary Expert Medical Advisor.

Specific Authority 440.13(9), 440.591 FS. Law Implemented 440.13(9) FS. History–New 1-23-95, Formerly 38F-54.006, Amended _________.

 

59A-30.007 Expert Medical Advisor Responsibilities.

(1) An physician expert medical advisor shall disclose any conflict of interest upon receiving notice of selection as an Expert Medical Advisor and shall not accept selection if a conflict of interest exists an assignment when he or she has the specific the case in question. For the purposes of this rule, “conflict of interest” means that an Expert Medical Advisor has matters of business or private interest or potential gain that may influence decisions or opinions related to the medical care provided, the physician examined or has prior knowledge of the injured employee, that are in existence while fulfilling responsibilities to be evaluated or has a financial or ownership interest in the outcome of the case.

(2) When the judge of compensation claims selects an Expert Medical Advisor, the Expert Medical Advisor shall complete and submit a written report to the judge of compensation claims within 15-calendar days following Within 45 days after the receipt of all medical records and or examination of the injured employee the expert medical advisor shall complete an evaluation of the injured employee and issue a report of the results of his/her evaluation to the Agency and/or, if requested, to a judge of compensation claims. The medical records, which may be submitted to an Expert Medical Advisor shall be within the discretion of the judge of compensation claims.

(3) When the Agency selects an Expert Medical Advisor, the Expert Medical Advisor shall complete and submit a written report to the Agency within 15-calendar days following receipt of all medical records. Reimbursement for expert medical advisor services shall not exceed $200 per hour or a maximum reimbursement of $1600 per case, not including reasonable expenses associated with travel, when applicable.

(4) The Eexpert Mmedical Aadvisor shall furnish a copy of the written report to the insurer carrier and to the injured employee pursuant to Section 440.13(9)(d), Florida Statutes.

Specific Authority 440.13(9), 440.591 FS. Law Implemented 440.13(9) FS. History–New 1-23-95, Formerly 38F-54.007, Amended_________.

 

59A-30.008 Billing and Reimbursement for Expert Medical Advisor Services Carrier Responsibilities.

(1) Within 30-calendar days following completion of the written report, the physician must submit billing for Expert Medical Advisor services on the Agency approved or judge of compensation claims approved invoice, as applicable, documenting total number of hours and total dollar charges.

(2) In a judge of compensation claims proceeding, if additional diagnostic testing is required for the Expert Medical Advisor to render a medical opinion, charges for diagnostic testing shall:

(a) Require prior authorization from the judge of compensation claims; and

(b) Be billed in accordance with Rule 69L-7.602, F.A.C.; and

(c) Be reimbursed in accordance with the appropriate Florida Workers’ Compensation reimbursement manual in effect on the date services were completed.

(3) Within 45-calendar days from receipt of both the Expert Medical Advisor’s copy of the written report and invoice, reimbursement shall be rendered to the Expert Medical Advisor The carrier shall reimburse an expert medical advisor within 45 days of receipt of the expert medical advisor’s evaluation pursuant to Section 440.13(9)(f), Florida Statutes.

(4) Hourly reimbursement for Expert Medical Advisor services shall include reimbursement for all services rendered except specialty-diagnostic testing.

(5) Reimbursement for Expert Medical Advisor services, pursuant to an Expert Medical Advisor Contract, shall be as follows:

(a) For an Expert Medical Advisor selected by the Agency pursuant to subsection 59A-30.005(2), F.A.C., reimbursement shall not exceed $200.00 per hour for no more than eight hours per case, not including reasonable expenses associated with travel, when applicable, which will be reimbursed in accordance with Section 112.081, Florida Statutes.

(b)   For an Expert Medical Advisor selected by a Judge of Compensation Claims pursuant to subsection 59A-30.005(3), F.A.C., reimbursement shall not exceed $300.00 per hour for no more than eight hours per case, not including reasonable expenses associated with travel, when applicable, which will be reimbursed in accordance with Section 112.081, Florida Statutes.

Specific Authority 440.13(9), 440.591 FS. Law Implemented 440.13(9) FS. History–New 1-23-95,  Formerly 38F-54.008, Amended________.

 

59A-30.009 Recertification of Expert Medical Advisors.

Specific Authority 440.13(9), 440.591 FS. Law Implemented 440.13(9) FS. History–New 1-23-95, Formerly 38F-54.009, Repealed________.

 

59A-30.010 Expert Medical Advisor Decertification.

(1) An Eexpert Mmedical Aadvisor shall be decertified for any one of the following:

(a) The physician is removed from the Agency’s list of physicians authorized to provide services to workers’ compensation injured employees.

(b) The physician fails to report a conflict of interest and decline selection in a case assignment as required in Rule 59A-30.004, F.A.C. Decertification pursuant to Section 440.13(13), Florida Statutes, and Chapter 59A-29, F.A.C.; or

(2) If an Expert Medical Advisor is decertified by the Agency, the physician shall not be eligible for certification as an Expert Medical Advisor in the future. Failure to report prior involvement or conflict of interest in a case assignment; or

(3) Failure to meet the terms of the expert medical advisor contract with the Agency.

Specific Authority 440.13(9), 440.591 FS. Law Implemented 440.13(9) FS. History–New 1-23-95, Formerly 38F-54.010, Amended________.

NAME OF PERSON ORIGINATING PROPOSED RULE: Welby Cox-Myers
NAME OF SUPERVISOR OR PERSON WHO APPROVED THE PROPOSED RULE: Tom Warring, Bureau Chief, Managed Health Care
DATE PROPOSED RULE APPROVED BY AGENCY HEAD: June 27, 2006
DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAW: April 7, 2006