The Florida Office of Insurance Regulation’s Division of Workers’ Compensation is having a busy January.
Starting today, Jan. 5, the Division of Workers’ Compensation will hold meetings on key medical reimbursement issues. The division also has posted proposed changes to medical billing rules and to rules regarding physician dispensing of medicine.
At today’s meeting, at 4 p.m. Eastern time, the state’s Three-Member Panel will convene to consider adopting its 2023 Biennial Report and to review a report on medical reimbursement disputes and violations. The panel is made up of the state’s chief financial officer or his appointee and two members appointed by the governor, one representing employer interests and one employee interests. Until recently, the CFO’s designee has been the state’s insurance commissioner. But Commissioner David Altmaier resigned from office last week.
By law, the panel must report every odd year to the Legislature on changes needed to the state’s workers’ comp system. This year, a draft of the report recommends doing away with legislative ratification of fee schedules. The report shows that reimbursement changes for hospitals, doctors and ambulatory surgical centers have not been ratified by lawmakers since at least 2016, leaving payment levels out of date and out of line with other states, in many examples.
“To promote the self-execution of the workers’ compensation system, the Legislature should exempt the reimbursement manuals from legislative ratification,” the draft of the 2023 Biennial Report reads.
The panel will also consider urging the Legislature to update the statue regarding treatment guidelines for injured workers. Florida law refers to an outdated, 2003 set of guidelines and does not mention the Official Disability Guidelines and the American College of Occupational and Environmental Medicine guidelines that are widely used across the country.
“Updating this portion of the statute to include specific treatment guidelines will add clarification and remove excess administrative burden on both the payor and provider communities,” the draft report notes. “It may also reduce litigation (petitions for benefits) requesting authorization for medical procedures, services, and medicine.”
The panel also will review a report on medical reimbursement disputes and violations. The report notes that workers’ compensation insurers had referred 12 health care providers, including six doctors, one hospital and five chiropractors for alleged violations. Most were for failure to substantiate medical necessity, but at least half of the complaints were dismissed for lack of supporting documentation.
The division found that in reviewing petitions from physicians, the doctors had been underpaid in 75% of the cases outlined in the complaints. That was a 6% drop from the previous year.
Of 3.4 million medical bills in fiscal 2021-2022, DWC received 7,241 reimbursement disputes. Some 4,700 cases were closed, with almost 1,900 resolutions.
The Three-Member Panel meeting will be held virtually and can be accessed through the GoToMeeting app. The link is here. Stakeholders may also listen via phone. The number is +1 (571) 317-3116 and the access code is 989-161-421.
Surgical Center Reimbursement Rules
The DWC will hold a hearing on Thursday, Jan. 12 to discuss proposed rule changes for ambulatory surgical centers, something that has been an issue for insurers in years past. The virtual meeting will begin at 1 p.m. Eastern time. It is available online at https://meet.goto.com/963789349, or via phone at (646) 749-3129. The phone access code is 963-789-349.
The DWC has also posted much-discussed rule changes on physician dispensing of medication and insurers’ notification and payment processing requirements, and will host a workshop Jan. 13.
Rules on physician dispensing have been a point of contention for years in Florida. With the latest proposal, the DWC is essentially starting over, after insurance companies challenged a 2020 bulletin from the state Department of Financial Services. The bulletin appeared to authorize dispensing, without the department going through the normal rulemaking process.
Workers’ comp insurers have said that physician dispensing is not unlike self-dealing when doctors own the pharmacy providing the meds, and it allows higher charges and few safeguards on drug conflicts or overuse by patients.
The online workshop will begin at 10 a.m. and can be accessed here.
Shocking the Conscience
The division also proposed a rule change that will add correctional officers to the types of first responders who may be eligible for paid time off and treatment for post-traumatic stress after witnessing any number of gruesome injuries that “shock the conscience,” as required by state law.
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