Division of Workers’ Compensation Wednesday, August 14, 2019
Regulatory and Legislative Update Andrew Sabolic Assistant Director andrew.sabolic@myfloridacfo.com 850-413-1628
2019 Legislative Update HB 1399 – WC Reform, sponsored by Rep. Byrd • Provides additional criteria to meet the definition of “specificity” for purposes of filing a PFB. Must also provide “evidence of good faith to resolve the dispute”. • Explicitly requires the carrier to authorize or deny a request for medical authorization in 3 or 10 days after receipt, unless a material deficiency exists. • Revises outpatient facility reimbursements: 160% of Medicare for scheduled surgeries and 200% of Medicare for non-scheduled surgeries. Adds a stop-loss provision to the schedule of per diem rates for inpatient services. • Increases the combined maximum TTD and TPD durations to 260 weeks. Allows for additional 26 weeks of TTD if the IW has not reached MMI. Conforms to the Westphal Supreme Court decision. • Requires carriers to report defense attorney costs to the OJCC. • Allows carrier’s to deviate from OIR approved workers’ compensation rates, up to 5%, without prior approval from OIR. • Requires the Department to develop additional claims performance measures specifically related to the quality, timeliness, and cost-effectiveness of the delivery of care to injured workers. The Department must also create a rating system for all by November 30, 2019 and publish the carrier performance results on its website beginning in fiscal year 2019/2020. • Died in the House.
2019 Legislative Update 440.61 Insurance company performance measures and rating system (1) The department shall develop performance measures and a rating system to document and rate the performance of insurance companies licensed to write workers' compensation insurance. (2) The rating system must: (a) Include the capability of listing results by rating, searching by company or industry group, and facilitating the comparison of companies. (b) Be designed to assist employers in choosing a workers' compensation insurance company by making the insurance company's performances related to the quality, timeliness, and cost effectiveness of the delivery of care to injured workers transparent. (c) Be completed by November 30, 2019. (3) Beginning with the 2019-2020 fiscal year and for each fiscal year thereafter, the department shall make the results of the insurance companies' performances publicly available on the department's website.
Insurer Regulatory Report (IRR) • Developed in Spring of 2017 • Audit History • Engages and informs • Centralized Performance regulated entities about their System Data overall claims-handling • Claims and Medical EDI Data performance • Reimbursement Manual MRAs • Provides comparative data vs. Contracted Rate Medical and industry trends Bill Payment Data • Assists regulated entities in • Opioid Medication Data identifying key processes, • Injured Worker Feedback Data policies, or practices that are instrumental in maintaining • Assessment Data or improving performance • In the future: levels • PFB Data • Denial Data • Claim Cost Data
2019 Legislative Update SB 1636 – Workers’ Compensation Reform, sponsored by Sen. Perry • Provides additional criteria to meet the definition of “specificity” for purposes of filing a PFB. Must also provide “evidence of good faith to resolve the dispute”. • Increases the combined maximum TTD and TPD durations to 260 weeks. Allows for additional 26 weeks of TTD if the IW has not reached MMI. Conforms to the Westphal Supreme Court decision. • Codifies the First District Court of Appeals opinion in the Miles case allowing an injured worker to contract with and directly pay an attorney. Requires the reporting of attorney fees and costs paid by the claimant directly to their attorney. • Extends the timeframe from 30 to 45 days from the date a PFB is filed with the JCC for the attachment of E/C paid attorney fees. • Allows the JCC, at its discretion, to award E/C paid attorney fees not to exceed $150 per hour should the percentage of benefits secured fee schedule is in adequate. • Resolves the PEO “gap coverage” issue • Died in Senate.
2019 Legislative Update HB 983 – Ratification of Department Rules relating to expanded workers’ compensation benefits for First Responders, sponsored by Rep. Casello and Sen. Book • 69L-3.009 Injuries that Qualify as Grievous Bodily Harm of a Nature that Shocks the Conscience. Pursuant to section 112.1815, F.S., for purposes of determining the compensability of employment-related posttraumatic stress disorder for first responders, the following injuries qualify as grievous bodily harm of a nature that shocks the conscience: (continues on next page)
2019 Legislative Update (1) Decapitation (6) Impalement (full or partial), (7) Severance (full or partial), (2) Degloving, and (3) Enucleation (8) Third degree burn on 9% or more of the body. (4) Evisceration (5) Exposure of one or more internal organs Adopted in December of 2018 with (a) Brain, a ratification and effective date of: (b) Heart, June 25, 2019 (c) Intestines, (d) Kidneys, (e) Liver, or (f) Lungs
Medical Cost Distribution
Three-Member Panel Draft Policy Recommendations Outpatient Reimbursement: As recommended in previous Biennial Reports, the Legislature should reduce reimbursements for outpatient services to rebalance system costs. The Legislature should replace the charge-based reimbursement system for outpatient services in hospitals and ambulatory surgical centers with a percentage of Medicare or other alternative framework that adequately reimburses facilities and provides cost containment and reimbursement predictability.
Per Diem Stop-Loss
Three-Member Panel Draft Policy Recommendations Inpatient Reimbursement: The Legislature should establish specific per diem amounts and a stop-loss threshold to appropriately reimburse hospitals for catastrophic and complex injuries. The new amounts and threshold should create long-term cost-containment and reimbursement predictability.
Three-Member Panel Draft Policy Recommendations Physician Reimbursement: The Legislature should increase the percentage of Medicare rates paid to physicians. The increase in physician reimbursements can be off-set by the justifiable decrease in reimbursements to hospitals and ambulatory surgical centers, as discussed in the previous sections.
Three-Member Panel Draft Policy Recommendations Repackaged Drug Reimbursements: Numerous states have sought to curtail the physician- dispensing of drugs to workers’ compensation patients, with some states banning the practice. To avoid a repeat of the escalation of costs for physician- dispended drugs, which Florida experienced prior to 2013, the Legislature should require physicians to receive prior approval from insurance carriers to specifically dispense prescription drugs directly to workers’ compensation patients.
Three-Member Panel Draft Policy Recommendations Legislative Ratification of the Reimbursement Manuals: To promote the self- execution of the workers’ compensation system, the Legislature should either exempt the reimbursement manuals from legislative ratification or establish a maximum cost impact percentage threshold for each reimbursement manual for which ratification is not required.
Attorney Fees Medical Authorization
Three-Member Panel Draft Policy Recommendations Medical Authorization: The Legislature should amend section 440.13(3)(d), F.S., to clarify the term “respond” as that term does not definitively obligate carriers to render a decision on a request for authorization in a consistent manner. The Legislature should also consider modifying a carrier’s 3-day and 10- day “response” deadline to expedite requested medical treatment based on a physician’s use of evidence-based treatment guidelines.
Three-Member Panel Draft Policy Recommendations Treatment Guidelines: At a minimum, the Legislature should repeal subsection 440.13(14), F.S. and all the references to practice parameters and protocols contained in section 440.13, F.S. If the Legislature still supports in the merits of evidence- based treatment guidelines, subsection 440.13(15), F.S., Standards of Care should be amended to include the use evidence-based treatment guidelines in providing medical care to injured workers, and all references to practice parameters and protocols should be eliminated.
Opportunities for Industry Improvement Charlene Miller Lisel Laslie Bureau Chief Bureau Chief Monitoring & Audit Employee Assistance & Ombudsman Office
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