Division of Workers Compensation Wednesday, August 24, 2016 - PowerPoint PPT Presentation

Carrier Reports of HCP Provider Violations Rule 69L-34, F.A.C.

Medical Services Section Bureau of Monitoring and Audit Contact Information (850) 413-1613 Theresa Pugh, Program Administrator Medical Services Theresa.Pugh@myfloridacfo.com Lavounia Bozman, Sr. Management Analyst I Lavounia.Bozman@myfloridacfo.com

Customer Assistance 850-413-1613 workers.compmedservice@myfloridacfo.com

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Carrier Compliance and Industry Performance Pam Macon Bureau Chief Compliance

Today’s Topics • Bureau of Monitoring and Audit Data • Explanation of Bill Reviews • Medical Services Statistics • Q & A

Bureau of Monitoring & Audit The Bureau of Monitoring and Audit (M&A) is responsible for ensuring that the practices of insurers, claim administrators and providers meet the requirements of Chapter 440, Florida Statutes and the Florida Administrative Code.

Bureau of Monitoring & Audit The responsibilities are handled through four programmatic areas: – Audit Section – Penalty Section – Permanent Total Disability Section – Medical Services Section

Audit Section Pursuant to Sections 440.185, 440.20, and 440.525, Florida Statutes and the rules of the Florida Administrative Code, the Audit Section examines claims- handling practices of: – Insurers – Self-insurers – Self-insurance funds – Other claims-handling entities

AUDIT SECTION During FY 2015-2016, the Audit Section:  50 on-site insurer audits  5,809 insurer claim files  Identified 749 files with underpayments  additional injured worker payments of $337,728 for indemnity benefits, penalties, and interest

AUDIT SECTION FY 2014/2015 FY 2015/2016 Category Totals Category Totals Number of Audits 56 Number of Audits 50 Total Files Reviewed 5,303 Total Files Reviewed 5,809 Files Reviewed for 3,597 Files Reviewed for Indemnity 4,274 Indemnity Payments Payments Underpaid Files 491 Underpaid Files 749 Total amount of UP + P&I $310,845 Total amount of UP + P&I $337,728 Identified Identified Total Pattern & Practice $392,500 Total Pattern & Practice $202,500 Penalties Assessed Penalties Assessed

Untimely Indemnity Payment and FRoI Penalties by Fiscal Year $120,000 $100,000 $102,300 $80,000 $83,300 $78,900 $70,850 $60,000 $64,200 $60,300 $40,000 $27,500 $25,800 $20,000 $0 FY12-13 (61 Audits) FY 13-14 (52 Audits) FY 14-15 (56 Audits) FY 15-16 (50 Audits) Total Amount of Penalties Issued for Untimely Indemnity Payments Total Amount of Penalties Issued for Untimely First Reports of Injury or Illness

Total Non-Willful Pattern & Practice Penalties by Fiscal Year 180 $450,000 160 $400,000 $392,500 140 $350,000 120 $300,000 100 $250,000 80 $200,000 $202,500 60 $150,000 $160,000 40 $100,000 $102,500 20 $50,000 41 64 81 157 0 $0 FY12-13 (61 Audits) FY13-14 (52 Audits) FY14-15 (56 Audits) FY 15-16 (50 Audits)

PENALTY SECTION The Penalty Section is responsible for evaluating and assessing insurer performance of timely payments of initial indemnity benefits and medical bills, and the untimely reporting of First Reports of Injury or Illness and medical bills.

CPS – First Reports Reviewed # of First Reports Fiscal Year Reviewed FY 11-12 53,211 FY 12-13 51,690 FY 13-14 52,344 FY 14-15 53,929 FY 15-16 54,731

CPS Performance Statistics Timely Initial Benefit Timely Filing of First Fiscal Year Payments Reports FY 11-12 95% 95% FY 12-13 95% 95% FY 13-14 95% 95% FY 14-15 95% 93% FY 15-16 93% 95%

CPS Performance Statistics Timely Medical Bill Timely Medical Fiscal Year Payments Bill Filing FY 11-12 99% 99% FY 12-13 98% 96% FY 13-14 99% 98% FY 14-15 99% 99% FY 15-16 98% 98%

PERMANENT TOTAL DISABILITY SECTION Division pays permanent total supplemental benefits on accidents prior to July 1, 1984 to eligible injured workers FY 2015-2016 supplemental benefits for 987 claims totaling $14,624,125 were calculated, approved, and processed

EXPLANATIONS OF BILL REVIEW (EOBRs) What is an EOBR? An Explanation of Bill Review is the notice of payment or notice of adjustment, disallowance or denial sent by a carrier, service company/third party administrator or any entity acting on behalf of a carrier to a health care provider containing code(s) and code descriptor(s), in conformance with subsection 69L-7.740(13), Florida Administrative Code.

EXPLANATIONS OF BILL REVIEW (EOBRs) What is the purpose of the EOBR? The purpose is to communicate to the provider, the carrier’s decision to pay, disallow or adjust reimbursement. The carrier is required to explain the reimbursement for each billed line item by using the EOBR codes (listed in Rule within subsection 69L- 7.740(13)(b) , F.A.C.) that best describe the carrier’s reimbursement decision.

EXPLANATIONS OF BILL REVIEW • Explanations of Bill Review (EOBRs) must contain the following elements per rule 69L-7.740, F.A.C.: – Insurer’s name; – Insurer’s mailing address; – Division-issued insurer ID number – EOBR Codes from the Billing Rule – Compliant descriptors – Name of the dispute copy designee – Name of the dispute copy designee’s mailing address – Disallowance language

MEDICAL SERVICES SECTION • Responsibilities: – Establishing rules and policy – Implementing the Three- Member Panel’s uniform schedules for Maximum Reimbursement Allowances (MRAs) – Resolving medical reimbursement disputes between providers and payers – Certifying Expert Medical Advisors

MEDICAL SERVICES SECTION • A Petition for Reimbursement Dispute must be filed within 45 days from receipt of the carrier’s notice of disallowance or adjustment of payment. • The carrier must submit, within 30 days of receipt of the petition, its response and all documentation to the department to substantiate its disallowance or adjustment.

MEDICAL SERVICES SECTION • Beginning Fiscal Year 15-16, there were 13,064 pending Petitions for Resolution of Reimbursement Disputes (Petitions) • During Fiscal Year 15-16, the Medical Services Section: – Received 5,533 Petitions – Processed 18,133 Petitions

MEDICAL SERVICES SECTION • The Medical Services Section issues Dismissals or Determinations for all Petitions received • In Fiscal Year 2015-2016, the Section issued: – 9,570 Determinations – 8,546 Dismissals

Medical Services Data Petitions Submitted by Provider Type FY 12-13 FY 13-14 FY 14-15 FY 15-16 Practitioner 7,805 8,412 7,323 3,601 ASC 737 665 331 400 Hospital 350 266 453 341 Inpatient Hospital 1,303 1,069 1,550 1,184 Outpatient Total 10,209 10,483 9,659 5,533

Medical Services Data Petitions Determination Outcomes by Provider Type FY 12-13 FY 13-14 FY 14-15 FY 15-16 Practitioner 2,573 2.992 4,326 8,221 ASC 584 512 213 240 Hospital Inpatient 217 183 226 215 Hospital Outpatient 966 767 996 894 Total 4,340 5,454 5,761 9,570

Medical Services Data Petitions Dismissal Outcomes by Provider Type FY 12-13 FY 13-14 FY 14-15 FY 15-16 Practitioner 2,605 4,432 2,374 7,636 ASC 216 173 104 175 Hospital Inpatient 140 96 181 174 Hospital 448 270 432 548 Outpatient Other 0 0 2 13 Total 3,409 4,971 3,093 8,546

Charlene Miller, Bureau Chief (850) 413-1738 • Charlene.Miller@myfloridacfo.com Derrick Richardson, Audit and PT Manager (850) 413-1671 • Derrick.Richardson@myfloridacfo.com

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When a Notice of Action or Change is Required Charlene Miller & Lawanna Morrow Bureau of Monitoring and Audit

Electronic Notice of Action or Change, Including Change in Claims Administration 69L-56.304 & 69L-56.3045 Florida Administrative Code

Notices of Action or Change Top 10 Sequencing Errors/Rejections • Report RTW Info • Report MMI Info • Report a Change From TTD to TPD • Report Adjustment to AWW/CR • Report Annual Increase of PTD Supplemental Benefits • Report Suspension of Benefits • Report a Settlement • Report Reinstatement of Benefits • Report a Change From TPD to TTD • Report an Acquired Claim

EDI Resources http://www.myfloridacfo.com/division/WC/EDI/default.htm

EDI Resources http://www.myfloridacfo.com/division/WC/EDI/default.htm

Cla laim ims s EDI I questions estions should ould be sent nt via ia email ail to to cla laims.edi ims.edi@myflo @myfloridacfo.com ridacfo.com 71

Auditing Notice of Action or Change Compliance • Compliance percentages are documented in Audit Reports, and Pattern and Practice Penalties are assessed for compliance percentages below 90% per 440.525(4) , Florida Statutes and Rule 69L-24.007 , Florida Administrative Code.

Notices of Action or Change Compliance by Fiscal Year 6,500 80.00% 75.00% 6,000 922 70.00% 912 5,500 65.00% 904 892 734 5,000 60.00% 786 4,500 55.00% 521 982 719 50.00% 4,000 45.00% 3,500 1053 40.00% 3,000 35.00% 2,500 30.00% 4,647 4,318 4,121 25.00% 2,000 3,735 20.00% 1,500 2,727 15.00% 1,000 10.00% 500 5.00% 0 0.00% FY 11-12 FY 12-13 FY 13-14 FY 14-15 FY 15-16 Timely Not Sent Sent Late Compliance

FY 15/16 Reason Notice of Change was # of Late Notices of Necessary Forms Action or Report RTW Info 232 Change Report MMI Info 127 Filed Late Report a Settlement 69 Report Suspension of Benefits 64 Report Reinstatement of Benefits 58 Report Adjustment to AWW/CR 53 Report a Change From TTD to TPD 53 Report Annual Increase of PTD Supps 33 Report a Change From TPD to TTD 18

Reason Notice of Change was # of Not Filed FY 15/16 Necessary Forms Report RTW Info Notices of 268 Report MMI Info Action or 236 Change Report a Change From TTD to TPD 121 Not Filed Report a Settlement 112 Report Suspension of Benefits 72 Report Annual Increase of PTD Supps 69 Report a Change From TPD to TTD 63 Report Adjustment to AWW/CR 52 Report Reinstatement of Benefits 35 Report the Recoupment of Paid 12 Benefits

Contacts: Charlene.Miller@myfloridacfo.com Bureau Chief, Bureau of Monitoring & Audit (850) 413-1738 Derrick.Richardson@myfloridacfo.com Operations Management Consultant Manager (850) 413-1671 Lawanna.Morrow@myfloridacfo.com Workers’ Compensation Administrator -Tallahassee (850) 413-1791 Kamilah.Knighton@myfloridacfo.com Workers’ Compensation Administrator -Orlando (407) 835-4492

Division of Workers’ Compensation Medical & Claims EDI Update August 2016 Michelle Carter Bureau of Data Quality and Collection

Florida Medical EDI

Discussion Topics  Revision F Phase-In Schedule  Revision F Testing  Helpful Resources

Revision F Phase-In Schedule

Revision F Phase-in Schedule All phase-in schedule dates are based on the effective date of the Workers’ Compensation Medical Reimbursement and Utilization Rule – which took effect on February 18, 2016.

Revision F Phase-in Schedule Group 1 (Submitter ID 001 – 199) Testing began on July 18, 2016 (150 days after the effective date of rule) and must be completed by August 31, 2016 (195 days of the effective date of the rule).

Revision F Phase-in Schedule Group 2 (Submitter ID 200 – 899) Testing begins on September 1, 2016 (195 days after the effective date of rule) and must be complete within 240 days of the effective date of the rule (October 15, 2016).

Revision F Phase-in Schedule Group 3 (Submitter ID 900 and above) Testing begins on October 16, 2016 (240 days after the effective date of rule) and must be complete within 285 days of the effective date of the rule (November 29, 2016).

Revision F Testing

Revision F Testing  Electronic files containing five (5) test bills (for each form type tested) must be transmitted to the Division by current batch submitters.  Electronic files containing fifteen (15) test bills (for each form type tested) must be transmitted to the Division by new batch submitters.

Revision F Testing  The ‘Test/Production Indicator’ in the file name and ‘Transmission Header Record’ must be set to ‘T’.

Revision F Testing  Current web submitters must submit five (5) test bills (for each form type tested) to the Division.  New web submitters must submit fifteen (15) test bills (for each form type tested) to the Division.

Revision F Testing  There are several test scenarios that must be completed. Pre- filled “dummy” bills and information pertaining to the scenarios have/will be sent to all submitters prior to the test start date.  If any changes are made to the information listed on any of the “dummy” bills provided, a copy must be sent to the Division via fax or email.

Revision F Testing  Revision F testing is not considered complete until all bills have been accepted by the Medical Data Management System, passed visual comparison to paper bills and all test scenarios have been successfully completed.  Submitters will be notified via email upon completion of testing.

Please direct any questions related to Medical EDI submissions to: MedicalDataManagementTeam@myfloridacfo.com Fax number for test bills: (850) 413-1986

Helpful Resources

Helpful Resources There have been changes recently made to the Division’s website. http://www.myfloridacfo.com/Division/WC/

Helpful Resources

Helpful Resources

Helpful Resources

Florida Claims EDI

Discussion Topics  Triage & Training Team  TA-FL Errors (Non-Fatal)  Helpful Resources

Triage & Training Team The Division has expanded its efforts to assist Trading Partners with successfully submitting claims transactions by creating the Triage & Training Team.

Triage & Training Team In an effort to help minimize rejections and improve the quality of data submitted to the Division, the Triage & Training Team provides training on various Claims EDI related issues by partnering with individual claim administrators.