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					THE FLORIDA WORKERS’
COMPENSATION SYSTEM

        TUTORIAL
           for
 EXPERT MEDICAL ADVISORS
 This tutorial will provide the reader with
  highlights from each of the pertinent
 medical sections of the Florida Statutes.

 The Department of Financial Services’ - Division
 of Workers’ Compensation’s internet site offers
a complete copy of Chapter 440, F.S. on the home
      web page: http://www.fldfs.com/wc.

    (Click on “Ch. 440 FL Statutes” located in the
   topics listed on the left side of the home page.)
       Through this program…


 THE EXPERT MEDICAL ADVISOR WILL BE ABLE
  TO UNDERSTAND HIS/HER RESPONSIBILITIES
FOR PROVIDING EXPERT OPINION TO FACILITATE
  THE RESOLUTION OF MEDICAL CARE ISSUES
 AND DISPUTES PENDING BEFORE THE DIVISION
    OR A JUDGE OF COMPENSATION CLAIMS
      The Florida Workers’
   Compensation System Goals
          provide for the following:


 A Self Executing System

 Quick Efficient Delivery of
  Medical Benefits

 Medically Necessary Treatment

 Facilitation of Return to Work
        WHAT ARE WORKERS’
      COMPENSATION BENEFITS?

• MEDICAL -
 MEDICALLY NECESSARY
    MEDICAL CARE

• INDEMNITY -
 WAGE REPLACEMENT BENEFITS

• REEMPLOYMENT -
 VOCATIONAL REHABILITATION
 BENEFITS TO FACILITATE EARLY
 RETURN TO SUITABLE GAINFUL
 EMPLOYMENT
WHAT IS THE ROLE OF THE PHYSICIAN
WHO RENDERS CARE AND SERVICES
   TO INJURED WORKERS IN THE
FLORIDA WORKERS’ COMPENSATION
             SYSTEM?
      THE ROLE OF THE PHYSICIAN

TO ESTABLISH AN ACCURATE DIAGNOSIS
    The Clinical Evaluation must be based on
    History/Physical/Diagnostics, Diagnosis & Treatment,
    Studies and Consultations
TO PRESCRIBE “MEDICALLY NECESSARY” TREATMENT
    Definition - s.440.13(1)(m), F.S.
   The Proposed Treatment Plan MUST BE submitted on
    Form DFS-F5-DWC-25 (DWC-25)
TO COMMUNICATE THE PATIENT’S FUNCTIONAL STATUS
   Identify Medical Restrictions/Limitations relating to work & full
     time or transitional duty
   Prescribe Restrictions/Limitations and submit to the insurer
     on DWC-25
              STANDARDS OF CARE
                       s.440.13(16), F.S.

The health care provider’s care and treatment shall
   be based on the following standards of care.

 Treatment is inherently scientifically logical
 Treatment focuses on clinical dysfunction
 High intensity, short duration treatment approach
 Treatment plan, therapies, medication, functional
    limitations/restrictions periodic review
 Additionally, the treatment plan is reviewed upon
    receiving information from other health care
    providers [no less than] every 30 days
              STANDARDS OF CARE
                         (continued)
                      s.440.13(16), F.S.


 Treatment MATCHES physiologic and clinical problem
 Treatment SHALL match type, intensity, duration of
   service necessary for identified problem

 Restrictions / Limitations are based on objective
   RELEVANT medical findings

 Restrictions / Limitations are reviewed continuously
   and at EACH and EVERY visit

 Return to work (RTW) is an integral part of the
   treatment plan
      THE ROLE OF THE PHYSICIAN
                         (continued)

WHEN PROVIDING SPECIFIC LIMITATIONS / RESTRICTIONS

The health care provider shall identify:

       Specific Parameters (i.e. load, frequency, duration,
          position)
         Measured inabilities
         Detriments to recovery
         Imminent danger to self or others
         Alternative methods of function

      THE HEALTH CARE PROVIDER IS TO IDENTIFY
       THE EMPLOYEE’S PHYSICAL LIMITATIONS, AND
       ADDRESS RETURN TO WORK STATUS
        STANDARDS OF CARE
                    (continued)
                 s.440.13(16), F.S.

The Standards of Care shall be followed in providing
medical care under Chapter 440:

 (a) Abnormal anatomical findings alone, in the
     absence of objective relevant medical
     findings, shall not be an indicator of injury or
     illness, a justification for the provision of
     remedial medical care or the assignment of
     restrictions, or the foundation for limitations.
        STANDARDS OF CARE
                  (continued)
               s.440.13(16), F.S.

(b) At all times during evaluation and treatment,
    the provider shall act on the premise that
    returning to work is an integral part of the
    treatment plan.
   The assignment of restrictions and limitations
   shall be reviewed with each patient exam and
   upon receipt of new information…

        The health care provider shall
         report changes in restrictions and
         limitations on the Form DWC-25.
          STANDARDS OF CARE
                     (continued)
                  s.440.13(16), F.S.

(c) Reasonable, necessary medical care of injured
    employees shall in all situations:
   1. Utilize a high intensity, short duration
      treatment approach
   2. Include reassessment of treatment plans,
      regimes, therapies, prescriptions, and functional
      limitations or restrictions prescribed by the
      provider every 30 days
   3. Be focused on treatment of the individual
      employees specific clinical dysfunction or status
         STANDARDS OF CARE
                     (continued)
                  s.440.13(16), F.S.

All treatment shall be inherently scientifically logical,
and the evaluation or treatment procedure must match
the documented physiologic and clinical problem.
Treatment shall match the type, intensity, and duration
of service required by the problem identified.

        The carrier may disallow
           reimbursement for a procedure
           when the treatment procedure does
           not match the problem identified.
       THE ROLE OF THE PHYSICIAN
                          (continued)
TO ESTABLISH THE DATE OF MAXIMUM MEDICAL MPROVEMENT
     MMI is reached when no further recovery is anticipated
     or when maximum improvement is a reasonable medical
     probability [s.440.02(10), F.S.]

TO DOCUMENT THE PERMANENT IMPAIRMENT RATING (PIR)
         The physician shall:
          calculate PIR at the time of MMI
          identify anatomical/functional abnormalities or losses
           resulting from work-related injury or illness
          identify the injured workers’ permanent
           restrictions/limitations
 PERMANENT IMPAIRMENT RATING
                  s.440.15(3)(b), F.S.




Pursuant to the Florida Statutes, only physicians
licensed under Florida Statute Chapters, as appropriate
(considering the nature of the injury), are authorized to
render an opinion regarding the permanent impairment
rating of an injured employee:

     458 Medical             469 Osteopathic
     460 Chiropractors 461 Podiatrists
     463 Optometrists        466 Dentists
     TEMPORARY TOTAL DISABILITY
                    s.440.15(2)(a), F.S.

When does the healthcare provider assign MMI & PIR?

     “…once the employee reaches the maximum number
     of weeks allowed, or the employee reaches the date
     of maximum medical improvement, whichever occurs
     earlier, temporary disability benefits shall cease and
     the injured worker’s permanent impairment shall be
     determined.”

    Once the physician determines the employee
      has achieved maximum medical improvement,
      the physician SHALL calculate the permanent
      impairment rating.
PERMANENT IMPAIRMENT RATING
              s.440.15(3)(d), F.S.


 After the employee has been certified by a
 doctor as having reached maximum medical
 improvement… the certifying doctor shall
 evaluate the condition of the employee and
 assign an impairment rating, using the
 impairment schedule on the following slide.

 Maximum medical improvement and
   impairment rating shall be reported by the
   physician to the carrier on the Form DWC-25.
 PERMANENT IMPAIRMENT RATING/
 MAXIMUM MEDICAL IMPROVEMENT
                   s.440.15(3)(d)1., F.S.


“The certifying doctor shall issue a written report to the
employee and the carrier certifying that maximum medical
improvement has been reached…and providing any other
information required by the department by rule.”
(report MMI/PIR on Form DWC-25, specifying permanent
restrictions / limitations pursuant to 69L-7.602, F.A.C.)


 “The carrier shall establish an overall
 maximum medical improvement date
 and permanent impairment rating,
 based on all such reports.”
 PERMANENT IMPAIRMENT RATING
                 s.440.15(3)(d), F.S.

 If the certification and evaluation are performed by a
 doctor other than the employee’s treating doctor, the
 certification and evaluation must be submitted to the
 treating doctor, the employee, and the carrier within
 10 days after the evaluation. The treating doctor
 must indicate to the carrier agreement or
 disagreement with the other doctor’s certification and
 evaluation.

 The certifying doctor who is not the employee’s
   treating doctor must submit a completed Form
   DWC-25 to the treating doctor, the employee and
   the carrier within 10 days after the evaluation.
      SUBSEQUENT INJURY;
        APPORTIONMENT
              s.440.15(5)(b), F.S.



The degree of permanent impairment or disability
attributable to the accident or injury shall be
compensated in accordance with this section,
apportioning out the preexisting permanent
condition based on the anatomical impairment
rating attributable to the preexisting condition.
 RATING PERMANENT IMPAIRMENT
                   s.440.15(3)(b), F.S.

The health care provider shall use the following resources
to calculate a permanent impairment rating (based on the
date of injury or accident – DOI):
                           •   AMA, 3RD EDITION
                               for DOI: prior to 07/01/90

                           • MINNESOTA GUIDE
                              for DOI: 07/01/90 to 06/20/93

                           • 1993 Florida Impairment
                             Rating Guide (FIRG)
                              for DOI: 06/21/93 to 01/07/97

                           • 1996 FL Uniform P.I.R.
                             Schedule
                              for DOI: 01/08/97 and thereafter
          Florida Statutes



Chapter 440, Florida Statutes, identifies the
employer, health care provider and insurer/
carrier duties and responsibilities related to
the provision of care for Florida injured
workers. The health care provider should
review the following excerpts to be familiar
with the Florida Statutes pertaining to
medical services.
              Florida Statutes


•   440.02    Definitions.
•   440.09    Coverage.
•   440.093   Mental and nervous injuries.
•   440.102   Drug-free workplace program
              requirements.
• 440.105     Prohibited activities; reports;
              penalties; limitations. (Fraud)
• 440.13      Medical services and supplies;
              penalty for violations; limitations
            Florida Statutes

• 440.134   Workers’ compensation managed
            care arrangement
• 440.15(3) Permanent impairment benefits/
            rating
• 440.15(5) Subsequent injury; apportionment
• 440.151   Occupational diseases
• 440.20    Time for payment of compensation
            and medical bills; penalties for late
            payment
• 440.491   Reemployment of injured workers;
            rehabilitation
       Florida Statutes s.440.02
                   Definitions

(10) “Date of maximum medical improvement”
     means the date after which further recovery
     from, or lasting improvement to, an injury or
     disease can no longer reasonably be
     anticipated, based upon reasonable medical
     probability.

(15)(a) Employee – means any person who receives
     remuneration from an employer for the
     performance of any work or service while
     engaged in any employment …and includes, but
     is not limited to, aliens and minors.
           Florida Statutes s.440.09
                        Coverage
The following factors impact whether an injury or illness
is compensable under Florida’s workers’ compensation.
(1) Major Contributing Cause – means the cause which is
    more than 50% responsible for the injury as compared to
    all other causes combined for which treatment or benefits
    are sought.

(1) Pain or other subjective complaints alone, in the
    absence of objective relevant medical findings, are not
    compensable.

(1) Objective relevant medical findings are those objective
    findings that correlate to the subjective complaints of the
    injured employee and are confirmed by physical
    examination findings or diagnostic testing.
        Florida Statutes s.440.09
                Coverage     (continued)

(1)(a) Subsequent Injury – No compensation or
     benefits for any subsequent injury the employee
     suffers as a result of an original work injury unless
     the original injury is the major contributing cause of
     the subsequent injury.

(1)(b) If a work injury combines with a preexisting
     disease or condition to cause or prolong disability
     or need for treatment, the employer must pay
     compensation or benefits only to the extent that the
     work injury remains more than 50% responsible for
     the injury as compared to all other causes
     combined.

    MAJOR CONTRIBUTING CAUSE must be
     demonstrated by medical evidence only.
         Florida Statutes s.440.09
                 Coverage      (continued)


(3)   Compensation is not payable if the injury was
      occasioned primarily by the intoxication of the
      employee; by the influence of any drugs not
      prescribed by a physician; or by the willful intention
      of the employee to injure or kill himself, herself, or
      another.

(7)(c) If the injured worker refuses to submit to a
       drug test, it shall be presumed in the absence of
       clear and convincing evidence to the contrary that
       the injury was occasioned primarily by the influence
       of drug.
      Review of Coverage
          s.440.09(1)(a)(b), F.S.


   The treatment must be based on objective
    RELEVANT medical findings

   The work-related injury must be the MAJOR
    CONTRIBUTING CAUSE

   The diagnosis must be determined by
    MEDICAL EVIDENCE only

   Pain and/or a subjective complaint without
    objective RELEVANT medical findings is
    NOT COMPENSABLE
        Florida Statutes s.440.093
           Mental and nervous injuries
(1) A mental or nervous injury due to stress, fright, or
    excitement only is not an injury by accident arising
    out of the employment. A physical injury resulting
    from mental or nervous injuries unaccompanied by
    physical trauma requiring medical treatment shall
    not be compensable under this chapter.

(2) Mental and nervous injuries occurring as a
    manifestation of an injury compensable under this
    chapter shall be demonstrated by clear and
    convincing medical evidence…The compensable
    physical injury must be and remain the major
    contributing cause…Compensation is not payable
    for the mental, psychological or emotional injury
    arising out of depression…
       Florida Statutes s.440.093
      Mental and nervous injuries (cont.)



(3) Subject to the payment of permanent benefits
    under s.440.15, in no event shall temporary
    benefits for a compensable mental or nervous
    injury be paid for more than 6 months after the
    date of maximum medical improvement for the
    injured employee’s physical injury or injuries…
       Florida Statutes s.440.102
 Drug-free workplace program requirements


(1)(c) “Drug” means alcohol, including a distilled
       spirit, wine, a malt beverage or an intoxicating
       liquor; an amphetamine; a cannabinoid;
       cocaine; phencyclidine (PCP); a hallucinogen;
       methaqualone; an opiate; a barbiturate ; a
       benzodiazepine; a synthetic narcotic; a
       designer drug; or a metabolite of any of the
       substances listed. An employer may test an
       individual for any or all of such drugs.
      Florida Statutes s.440.102
Drug-free workplace program requirements

(5)(e)2. A specimen for a drug test may be taken or
         collected by …a physician, a physician
         assistant, a registered professional nurse, a
         licensed practical nurse, or a nurse practitioner
         or a certified paramedic who is present at the
         scene of an accident for the purpose of
         rendering emergency medical service or
         treatment.

(5)(m) An employer shall pay the cost of all drug
       tests, initial and confirmation, which the
       employer requires of employees. An
       employee or job applicant shall pay the costs of
       any additional drug tests not required by the
       employer.
      Florida Statutes s.440.102
Drug-free workplace program requirements


 (5)(p) All authorized remedial treatment, care and
    attendance provided by a health care provider to
    an injured employee before medical and
    indemnity benefits are denied under this section
    must be paid for by the carrier or self-insured.
    However, the carrier or self-insurer must have given
    reasonable notice to all affected health care
    providers that payment for treatment, care and
    attendance provided to the employee after a future
    date certain will be denied.
       Florida Statutes s.440.105
         Prohibited activities; reports;
             penalties; limitations

(1)(a) …any professional practitioner licensed or
    regulated by the Department of Health…or any
    employee thereof, having knowledge or who
    believes that a fraudulent act or any other act or
    practice which, upon conviction, constitutes a
    felony or misdemeanor under this chapter is being
    or has been committed shall send to the Division
    of insurance Fraud, Bureau of Workers’
    Compensation Fraud, a report or information
    pertinent to such knowledge or belief and such
    additional information relative thereto as the
    bureau may require.
       Florida Statutes s.440.105
         Prohibited activities; reports;
             penalties; limitations


(4)(c) It shall be unlawful for any physician licensed
    under chapter 458, osteopathic physician licensed
    under chapter 469L, chiropractic physician
    licensed under chapter 460, podiatric physician
    licensed under chapter 461, optometric physician
    licensed under chapter 463, or any practitioner
    licensed under the laws of this state to knowingly
    and willfully assist, conspire with, or urge any
    person to fraudulently violate any of the provisions
    of this chapter.
    Florida Statutes s.440.105(7)
                Fraud Statement

Fraud Statement - An injured employee or any other
party making a claim under this chapter shall provide
his or her personal signature attesting that he or she
has reviewed, understands, and acknowledges the
following statement:
   “Any person who, knowingly and with
   intent to injure, defraud, or deceive any
   employer or employee, insurance
   company, or self-insured program, files a
   statement of claim containing any false or
   misleading information commits insurance
   fraud, punishable as provided in s.
   817.234.”
       Florida Administrative Code
                 Rule 69L-3.0047, F.A.C.
                  Fraud Statement

  (2) A party who makes claims for services provided
      to the claims-handling entity on a recurring basis
      may make one personally signed attestation to
      the claims-handling entity as required by Section
      440.105(7), F.S., which will satisfy the
      requirement for all claims submitted to the
      claims-handling entity for the calendar year in
      which the attestation is submitted.

 Health Care Providers must submit a signed fraud
   statement once per calendar year to each insurer /
   carrier from which they are requesting reimbursement.
       Florida Statutes 440.105(7)

                Fraud Statement
  If the injured employee or other party refuses to sign
  the document attesting that he or she has reviewed,
  understands, and acknowledges the statement,
  benefits, or payments under this chapter shall be
  suspended until such signature is obtained.


 The insurer may disallow payment for a medical
  bill if the health care provider fails to have a
  signed Fraud Statement on file with the insurer.
     Florida Statutes 440.13
            Medical Services


 Each subsection of the following Florida
Statutes is presented in detail to familiarize
 the health care provider with the Florida
Statutes pertinent to treatment rendered to
  injured workers in the Florida Workers’
           Compensation system.
      Florida Statutes 440.13
             Medical Services


DEFINITIONS
• 440.13(1)(d): Health care provider certification
• 440.13(1)(h): Health care provider who renders
                care pursuant to a prescription or
                under the supervision of a
                physician
• 440.13(1)(l): Medical necessity
• 440.13(1)(q): Physician
       Florida Statutes 440.13
              Medical Services


• 440.13(2)(d): Carrier right to transfer care
• 440.13(3)(a): Provider certification; Authorization
                 prior to provision of care

• 440.13(3)(b): Emergency care; authorization
• 440.13(3)(c): Provider referrals
• 440.13(3)(g): Employee liability for payment
     Florida Statutes 440.13
           Medical Services


• 440.13(3)(d) & (i): Carrier authorization
• 440.13(4)(a): Form DFS-F5-DWC-25

• 440.13(4)(b) Provision of medical records
• 440.13(4)(c): Physician-patient privilege
• 440.13(5)(a): Independent medical
                 examinations (IME)
      Florida Statutes 440.13
               Medical Services

• 440.13(5)(d): IME No-show provisions
• 440.13(7)(a): Reimbursement disputes
• 440.13(8)(b) Overutilization; statute or rule
                  violations; health care provider
                  penalties/sanctions

• 440.13(9):      Expert Medical Advisors

• 440.13(10):     Witness (deposition) fees
       Florida Statutes 440.13
                Medical Services

• 440.13(12):    Reimbursement allowances

• 440.13(13):    Removal of physicians from the list
                 of certified health care providers

• 440.14(14)(c): Co-payment after assignment of
                 MMI

• 440.13(15):    Practice Parameters

• 440.13(16):    Standards of Care - reasonable
                 necessary medical care
          Florida Statutes 440.13(1)
                       Definitions

(c) “Carrier” means, for purposes of this section, insurance
    carrier, self-insurance fund or individually self-insured
    employer, or assessable mutual insurer.
(d) “Certified health care provider” means a health care
    provider who has been certified by the Division or who
    has entered an agreement with a licensed managed care
    organization to provide treatment to injured workers
    under this section. Certification of such health care
    provider must include documentation that the health care
    provider has read and is familiar with the portions of the
    statute, impairment guides, practice parameters,
    protocols of treatment, and rules which govern the
    provision of remedial treatment, care, and attendance.
         Florida Statutes 440.13(1)
                       Definitions

(h) “Health care provider” means a physician or any
    recognized practitioner who provides skilled services
    pursuant to a prescription or under the supervision or
    direction of a physician and who has been certified by
    the Division as a health care provider…
(l) “Medically necessary” or “medical necessity” means
    any medical service or medical supply which is used to
    identify or treat an illness or injury, is appropriate to the
    patient’s diagnosis and status of recovery, and is
    consistent with the location of service, the level of care
    provided, and applicable practice parameters…The
    service must not be of an experimental, investigative,
    or research nature.
         Florida Statutes 440.13(1)
                      Definitions
(o) “Pattern or practice of overutilization” means repetition
    of instances of overutilization within a specific medical
    case or multiple cases by a single health care provider.
(q) “Physician” or “doctor” means a physician licensed
    under chapter 458, an osteopathic physician licensed
    under chapter 469L, a chiropractic physician licensed
    under chapter 460, a podiatric physician licensed
    under chapter 461, an optometrist licensed under
    chapter 463, or a dentist licensed under chapter 466,
    each of whom must be certified by the Division…
(r) “Reimbursement dispute” means any disagreement
    between a health care provider or health care facility
    and carrier concerning payment for medical treatment.
CARRIER TRANSFER OF CARE
              s.440.13(2)(d), F.S.




The carrier has the right to transfer the care of
an injured employee from the attending health
care provider if an independent medical
examination determines that the employee is
not making appropriate progress in recuperation.
     CERTIFICATION & INSURER
         AUTHORIZATION
             Non-Emergency Care
                s. 440.13(3)(a), F.S.


Conditions of eligibility for reimbursement
The health care provider must have:

           Certification from the Division and
           Insurer/Carrier authorization prior to
            provision of services

       Notice of Injury: Filing the DWC-1 is the
            responsibility of the Employer.
CERTIFIED HEALTH CARE PROVIDER



 “Certified Health Care Provider” means a health
 care provider who has been certified by the
 Division or who has entered an agreement with a
 licensed managed care organization to provide
 treatment to injured workers under Chapter 440,
 pursuant to s.440.13(1)(d), Florida Statutes.”
 CERTIFIED HEALTH CARE PROVIDER

          How does a physician become a
         “Certified Health Care Provider”?


 The physician must meet the qualifications specified
  in Rule 69L-29, F.A.C.
 The physician must submit an accurately completed
  application for Health Care Provider Certification to
  the Division
The application may be printed from the following link:
  http://www.fldfs.com/wc/pdf/DFS-3160-0020.pdf
       CERTIFICATION & INSURER
           AUTHORIZATION
                EMERGENCY CARE
                   s.440.13(3)(b), F.S.

For emergency care & services:

 Pre-authorization & use of a
   certified HCP is not required

 The HCP must notify the carrier by
   close of 3rd business day

 The treatable condition must arise
   from work-related accident
                 +
    Emergency is defined. . .




 In s. 395.002(9), F.S.

 As an acute, severe (includes pain),
   causes impairment, death, or dysfunction


 And covers screening, exam, evaluation,
   care, treatment, or surgery to relieve /
   alleviate symptoms
EXPERIMENTAL, INVESTIGATIVE OR
     RESEARCH IN NATURE

 How does a health care provider gain approval
 for treatment that may be deemed experimental,
 investigative or research in nature?

Effective October 1, 2003, the insurer / carrier has
statutory authority to determine if a treatment procedure is
experimental, investigative or research in nature.

Effective October 1, 2003, all requests for determination of
coverage for treatment procedures that may be
experimental, investigative or research in nature shall be
submitted by the health care provider to the carrier.
     PROVIDER REFERRALS
               s.440.13(3)(c),F.S.



  “A health care provider may not refer the
   employee to another health care provider,
   diagnostic facility, therapy center, or other
   facility without prior authorization from the
   carrier, except when emergency care is
   rendered. “

 Referrals must be made to another certified
   health care provider, unless the referral is
   for emergency treatment.
          EMPLOYEE LIABILITY
            FOR PAYMENT

  Can the injured employee be billed for services
provided in relation to a compensable work injury?


  “The employee is not liable for payment of
   medical treatment or services provided pursuant
   to this section except as otherwise provided in
   this section. “ s.440.13(3)(g), F.S.
  )

  “…providers have recourse against the employer
  or carrier for payment for services rendered in
  accordance with this chapter.” s.440.13(14)(a), F.S.
    PAYMENT OF MEDICAL FEES
                s.440.13(14)(a), F.S.

“ Except for emergency care treatment, fees for
medical services are payable only to a health care
provider certified and authorized to render remedial
treatment, care or attendance under this chapter…
A health care provider may not collect or receive a
fee from an injured employee within this state,
except as otherwise provided by this chapter…
Such providers have recourse against the employer
or carrier for payment for services rendered in
accordance with this chapter.”
PAYMENT OF MEDICAL FEES
          Patient Copayment
           s.440.13(14)(c), F.S.

When may the healthcare provider collect
 payment from the injured employee?

“ Notwithstanding any other provision of this
chapter, following overall maximum medical
improvement from an injury compensable under
this chapter, the employee is obligated to pay a
copayment of $10 per visit for medical services.
The copayment shall not apply to emergency
care provided to the employee.”
          SUBSEQUENT INJURY;
            APPORTIONMENT
                  s.440.15(5)(b), F.S.


“If a compensable injury, disability, or need for medical
care, or any portion thereof, is a result of aggravation or
acceleration of a preexisting condition, or is the result of
merger with a preexisting condition, only the disabilities
and medical treatment associated with such compensable
injury shall be payable under this chapter…”


 The carrier may reduce reimbursement for medical
   services by the percentage of impairment or
   disability attributed to the preexisting condition.
   OCCUPATIONAL DISEASES
              s.440.151(1)(a), F.S.


…in no case shall an employer be liable for
compensation under the provisions of this section
unless such disease has resulted from the nature
of the employment in which the employee was
engaged under such employer…and the nature of
the employment was the major contributing cause
of the disease. Major contributing cause must be
shown by medical evidence only, as demonstrated
by physical examination findings and diagnostic
testing.
     OCCUPATIONAL DISEASES
                 s.440.151(2), F.S.

Whenever used in this section the term “occupational
disease” shall be construed to mean only a disease
which is due to causes and conditions which are
characteristic of and peculiar to a particular trade,
occupation, process , or employment than for the
general public. “Occupational disease” means only a
disease for which there are epidemiological studies
showing that exposure to the specific substance
involved, at the levels to which the employee was
exposed, may cause the precise disease sustained
by the employee.
     PAYMENT OF MEDICAL BILLS
                       s.440..20, F.S.

How long does an insurer/carrier have to pay a bill?

“(2)(b) The carrier must pay, disallow, or deny all medical,
    dental, pharmacy, and hospital bills submitted to the
    carrier in accordance with department rule no later
    than 45 calendar days after the carrier’s receipt of the
    bill.

“(4) If the carrier is uncertain of its obligation to provide all
    benefits or compensation, the carrier shall immediately
    and in good faith commence investigation of the
    employee’s entitlement to benefits under this chapter
    and shall admit or deny compensability within 120 after
    the initial provision of compensation or benefits…
             INSURER / CARRIER
               AUTHORIZATION
                   s.440.13(3)(d), F.S.

How long does an insurer/carrier have to authorize or
disallow a physician’s written request for treatment?

    “A carrier must respond to a written request for
     authorization from an authorized health care
     provider by close of the third business day after
     receipt of the request.”

      Prior authorization is NOT REQUIRED for
                EMERGENCY SERVICES.
      INSURER / CARRIER
        AUTHORIZATION
                 (continued)
             s.440.13(3)(i), F.S.

“A carrier must respond to a written request for
specialist consultations, surgical operations,
physiotherapeutic or occupational therapy
procedures, X-ray examinations or special
diagnostic or laboratory tests that cost more
than $1000 within 10 days after receipt of the
request.”

 Completion and submission of the
  DFS-F5-DWC-25 is considered a written
  request for authorization of treatment.
            FORM DWC-25
            Rule 69L-7.602, F.A.C.


     DFS-F5-DWC-25 -- Florida Workers’
       Compensation Uniform Medical
      Treatment/Status Reporting Form
         (adopted for use July 4, 2004)




A copy of the DWC-25 can be obtained from the
    Division website at the following link:
   http://www.fldfs.com/wc/pdf/DWC-25.pdf
             FORM DWC-25
              s.440.13(4)(a), F.S.



“Any health care provider providing necessary
remedial treatment, care, or attendance to any
injured worker shall submit treatment reports to
the carrier in a format prescribed by the
department.”


               The format prescribed by the
              department is the Form DFS-F5-
                    DWC-25 (DWC-25).
                FORM DWC-25
                  s.440.13(4)(a), F.S.

 “A claim for medical or surgical treatment is not
 valid or enforceable …unless, by the close of
 the third business day following the first
 treatment, the physician providing treatment
 furnishes to the employer or carrier…”
                a Form DWC-25




An insurer/carrier may disallow payment for services
if the health care provider does not submit a Form
DWC-25, pursuant to Rule 69L-7.602, F.A.C.
               FORM DWC-25
               Rule 69L-7.602, F.A.C.




 Insurers and providers shall utilize ONLY the
   Form DWC-25 for physician reporting of the
   injured employee’s medical treatment / status.

 Any other reporting form MAY NOT be used in
   lieu of or supplemental to the Form DWC-25

   Therefore, the physician is not required to
   complete any other insurer/carrier forms.
               FORM DWC-25
              Rule 69L-7.602, F.A.C.

  The Form DWC-25:

 Must be signed by the authorized physician
 Does not replace physician notes, medical
   records or required billing forms

 Information must be consistent with medical
   notes, medical records, diagnostic testing, etc.

 Becomes a part of the patient’s medical record
   maintained by the physician

 Must be submitted to the employer upon request
FORMS SUBMITTED TO CARRIER
            Rule 69L-7.602, F.A.C.


 Health Care Providers who render direct
 billable services shall submit to the carrier a
 medical bill for reimbursement of services
 using the Form DFS-F5-DWC-9 (CMS 1500)
 regardless of employment arrangement.


 A copy of the DFS-F5-DWC-9 can be obtained
            from the CMS website:
     http://www.cms.hhs.gov/cmsforms/
PROVISION OF MEDICAL RECORDS
                s.440.13(4)(b), F.S.

Medical records must be produced upon request.

 “Upon the request of the department, each medical
 report or bill obtained or received by the employer,
 the carrier, or the injured employee…, including any
 report of an examination, diagnosis , or disability
 evaluation, must be produced by the health care
 provider to the department pursuant to rules
 adopted by the department.”

 Health care providers who willfully refuse to
   provide medical records or discuss the medical
   condition of the injured employee are subject to
   the penalties set forth in s.440.13(8)(b), F.S.
PROVISION OF MEDICAL RECORDS
               s.440.13(4)(b), F.S.


  “The health care provider shall also furnish
  to the injured employee or his or her
  attorney and the employer or carrier or its
  attorney, on demand, a copy of his or her
  office chart, records, and reports, and may
  charge the injured employee no more than
  50 cents per page for copying the records
  and the actual direct cost to the health care
  provider or health care facility for x rays,
  microfilm, or any other nonpaper records..”
 PHYSICIAN-PATIENT PRIVILEGE
               s.440.13(4)(c), F.S.

 A “release of information” is not required for the
 health care provider to release medical records,
unless otherwise specified in the Florida Statutes.

“An employee who reports an injury or illness
alleged to be work-related waives any physician-
patient privilege with respect to any condition or
complaint reasonably related to the condition for
which the employee claims compensation.”

“Release of medical information by the health care
provider or other physician does not require the
authorization of the injured employee.”
  INDEPENDENT MEDICAL
   EXAMINATIONS (IME)
           s.440.13(5)(a), F.S.


The physician performing the IME shall complete:
 A physical examination of the injured employee
 A review of medical records
 Determination of functional limitations and
   restrictions
 Calculation of Permanent Impairment Rating if at
   Maximum Medical Improvement
 Report to Carrier and Employee (a Form DWC-25
   and written medical report)
          INDEPENDENT MEDICAL
           EXAMINATIONS (IME)
                  s.440.13(5)(a), F.S.




“In any dispute concerning overutilization, medical
benefits, compensability, or disability under this
chapter, the carrier or the employee may select an
independent medical examiner.”

 Although a physician may be certified as an EMA,
  when an IME is requested the EMA is functioning
  as health care provider, not as an EMA.
   INDEPENDENT MEDICAL
    EXAMINATIONS (IME)
             s.440.13(5)(a), F.S.



“If the parties agree, the examiner may be a
health care provider treating or providing other
care to the employee.”

“The independent medical examiner may not
provide follow-up care if such recommendation
for care is found to be medically necessary.”
     INDEPENDENT MEDICAL
      EXAMINATIONS (IME)
             s.440.13(5)(a), F.S.


“The employer and employee shall be entitled to
only one independent medical examination per
accident and not one independent medical
examination per medical specialty.”

“The party requesting and selecting the
independent medical examination shall be
responsible for all expenses associated with
said examination…”
   IME NO-SHOW PROVISIONS
         FOR PAYMENT
               s.440.13(5)(d), F.S.

“If the employee fails to appear for the independent
medical examination scheduled by the employer or
carrier …the employee is barred from recovering
compensation for any period during which he or
she has refused to submit to such examination.”

“Further, the employee shall reimburse the
employer or carrier 50 percent of the physician’s
cancellation or no-show fee…”
  REIMBURSEMENT DISPUTES
               s.440.13(7), F.S.


What is a health care provider to do if he/she is
    improperly reimbursed for services?
A health care provider may file a petition for
reimbursement dispute resolution with the
Division, pursuant to s.440.13(7), F.S. and
Rule 69LA-31, F.A.C.
The form for filing a Petition for Resolution of
Reimbursement Dispute may be printed from
the following link:
http://www.fldfs.com/wc/pdf/DFS-3160-0023.pdf
    REIMBURSEMENT DISPUTES
                   s.440.13(7), F.S.


“Any health care provider…who elects to contest the
disallowance or adjustment of payment by a carrier
under subsection (6) must, within 30 days after
receipt of notice of disallowance or adjustment of
payment, petition the Division to resolve the dispute.”

“The petition must be accompanied by all documents
and records that support the allegations contained in
the petition. Failure of a petitioner to submit such
documentation to the Division results in dismissal of
the petition. “
  CARRIER UTILIZATION REVIEW
                  s.440.13(6), F.S.


All insurer/carrier’s are responsible to perform
utilization review.

“Carriers shall review all bills, invoices, and other
claims for payment submitted by health care
providers in order to identify overutilization and
billing errors…”

“If a carrier finds that overutilization of medical
services or a billing error has occurred…it must
disallow or adjust payment for such services…”
      OVERUTILIZATION,
 STATUTE OR RULE VIOLATIONS,
  HCP PENALTIES / SANCTIONS
                s.440.13(8)(b), F.S.


                             “
“If the Division determines that a health care
provider has engaged in a pattern or practice of
overutilization or a violation of this chapter or
rules adopted by the Division, including a pattern
or practice of providing treatment in excess of the
practice parameters or protocols of treatment, it
may impose one or more…penalties.”
   DIVISION OF WORKERS’
COMPENSATION JURISDICTION
              s.440.13(11)(c), F.S.




“The Division has exclusive jurisdiction to
decide any matters concerning reimbursement,
to resolve any overutilization dispute under
subsection (7), and to decide any question
concerning overutilization under subsection (8)
which question or dispute arises after January
1, 1994.”
POTENTIAL PROVIDER PENALTIES
                 s.440.13(8)(b), F.S.


1. An order barring the provider from payment under
   this chapter.
2. Deauthorization of care under review.
3. Denial of payment for care rendered in the future.
4. Decertification of a health care provider as an
   expert medical advisor …
5. A fine assessed by the Division not to exceed
   $5000 per instance of overutilization or violation.
6. Notification of and review by the appropriate
   licensing authority.
    WITNESS (Deposition) FEES
                s.440.13(10), F.S.

What reimbursement is made to the health care
        provider acting as a witness?

 “Any health care provider who gives a deposition
 shall be allowed a witness fee. The amount
 charged by the witness may not exceed $200 per
 hour. An expert witness who has never provided
 direct professional services to a party but has
 merely reviewed medical records and provided
 an expert opinion or has provided only direct
 professional services that were unrelated to the
 workers’ compensation case may not be allowed
 a witness fee in excess of $200 per day. “
            PROVIDER AUDITS
                s.440.13(11)(a), F.S.

 What happens to the health care provider who
  fails to comply with the laws and rules that
   apply to Florida workers’ compensation?

“The Division of Workers’ Compensation may
investigate health care providers to determine
whether providers are complying with this chapter
and with rules adopted by the Division…If the
Division finds that a health care provider has
improperly billed, overutilized, or failed to comply
with Division rules or the requirements of this
chapter…may impose penalties as set forth in
subsection (8) or other sections of this chapter.
 REIMBURSEMENT FOR MEDICAL
         SERVICES
                s.440.13(12)(a), F.S.

How is the reimbursement schedule determined?

“The panel (Three Member Panel) shall determine
statewide schedules of maximum reimbursement
allowances for medically necessary treatment, care,
and attendance provided by physicians …and durable
medical equipment.”

“An individual physician, hospital…shall be reimbursed
either the agreed-upon contract price or the maximum
reimbursement allowance in the appropriate
schedule.”
 REIMBURSEMENT FOR MEDICAL
         SERVICES
                s.440.13(12)(b), F.S.

“4. Maximum reimbursement for a physician licensed
under chapter 458 or 469L shall be increased to 110
percent of the reimbursement allowed by Medicare,
using appropriate codes and modifiers or the medical
reimbursement level adopted by the three-member panel
as of January 1, 2003, whichever is greater.”

“5. Maximum reimbursement for surgical procedures
shall be increased to 140 percent of the reimbursement
allowed by Medicare or the medical reimbursement level
adopted by the three member panel as of January 1,
2003, whichever is greater.”
            REIMBURSEMENT
               Rule 69L-7.020, F.A.C.

   Where can a health care provider locate the
maximum reimbursement allowances for services?

   “The Florida Workers’ Compensation Health
   Care Provider Reimbursement Manual, 2005
   Edition…contains reimbursement policies ,
   guidelines, codes and maximum reimbursement
   allowances for services and supplies provided by
   health care providers.”
       The appropriate Health Care Provider
        Reimbursement Manual is determined
        by the manual in effect on the date the
        service is provided.
        REIMBURSEMENT
           Rule 69L-7.020, F.A.C.

Reimbursement manuals may be viewed on or
     printed from the Division website:
             www.fldfs.com/wc




     Location of Reimbursement
     Manuals, Forms and Rules

        www.fldfs.com/WC/
   EXPERT MEDICAL ADVISOR
           (EMA)

 How does a physician become a Florida
  workers’ compensation Expert Medical
  Advisor?

 What are the Expert Medical Advisor’s
  duties and responsibilities within the Florida
  Workers’ Compensation system?

 Who can select the Expert Medical Advisor?
     EXPERT MEDICAL ADVISORS
                    s.440.13(9), F.S.

         How does a physician become an
            Expert Medical Advisor?

 The physician must meet the qualifications specified
  in Rule 69LA-30.003, F.A.C.
 The physician must submit a completed application
  for Expert Medical Advisor Certification to the
  Division.
The application may be printed from the following link:
  http://www.fldfs.com/wc/pdf/DFS-3160-0021.pdf
        EXPERT MEDICAL ADVISOR
            CERTIFICATION
                  Rule 69LA-30, F.A.C.

Expert Medical Advisor certification requires that the
physician 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 440.091 and knowledge of the Florida
Administrative Code Rules 69L-7.602 and 69L-7.020
              or complete this tutorial.
    EXPERT MEDICAL ADVISORS
               Rule 69LA-30.003, F.A.C.


To be certified as an Expert Medical Advisor, a
physician shall meet the following qualifications:

 Must have been certified as a health care provider
   by the Division for not less than 12 months prior to
   the date of application; and

 Must hold valid licensure, issued by the Florida
   Department of Health, with “clear and active” status;
   and

 Must hold specialty-board certification or specialty-
   board eligibility; and
    EXPERT MEDICAL ADVISORS
               Qualifications (continued)
 Must demonstrate experience in the assignment of
   permanent impairment ratings greater than zero
   (0%); and

 Must demonstrate experience in performing
   independent medical examinations; and

 Must have completed twenty hours of continuing
   medical education, specifically related to the
   practitioner’s field of specialty, within two years
   prior to the date of application; and

 Must possess knowledge of the Florida Statutes
   and Florida Administrative Code related to workers’
   compensation.
    EXPERT MEDICAL ADVISORS
              Rule 69LA-30.004, F.A.C.



Throughout the certification period, the Expert
    Medical Advisor shall notify the Division:

 If specialty-board certification has expired
 If Florida Department of Health license status is
    changed from “clear and active”

 Of any change in address or contact information
   EXPERT MEDICAL ADVISORS
              Rule 69LA-30.007, F.A.C.

              CONFLICT OF INTEREST

  “Upon receiving notice of selection by the Division
  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.”


 An Expert Medical Advisor shall decline selection
  as an EMA if a conflict of interest exists.
 EXPERT MEDICAL ADVISORS
               s.440.13(9), F.S.


• An EMA may ONLY be contracted by the
  Division or Judges of Compensation
  Claims

• EMAs are contracted to settle disputes
  related to:
      - Reimbursement allowances
      - Differing health care provider opinions
      - Medical necessity of services rendered
   EXPERT MEDICAL ADVISORS
                   s.440.13(9), F.S.


“The Division shall certify expert medical advisors
in each specialty to assist the Division and the
judges of compensation claims…”

“As a prerequisite for certification or recertification,
the Division shall require, at a minimum, that the
expert medical advisor have specialized workers’
compensation training or experience under the
workers’ compensation system of this state and
board certification or board eligibility.”
EXPERT MEDICAL ADVISORS
                s.440.13(9), F.S.


“The Division shall contract with one or more
entities that employ, contract with, or otherwise
secure expert medical advisors to provide peer
review or expert medical consultation, opinions,
and testimony to the Division or to a judge of
compensation claims in connection with
resolving disputes relating to reimbursement,
differing opinions of health care providers, and
health care and physician services rendered
under this chapter, including utilization issues.”
EXPERT MEDICAL ADVISORS
                s.440.13(9), F.S.


“Expert medical advisors contracting with the
Division shall, as a term of such contract, agree
to provide consultation or services in
accordance with the timetables set forth in this
chapter and to abide by rules adopted by the
Division…pertaining to procedures for review of
services rendered by health care providers and
preparation of reports and testimony or
recommendations for submission to the
Division or the judge of compensation claims.”
 EXPERT MEDICAL ADVISORS
                 s.440.13(9), F.S.


“If there is a disagreement in the opinions of the
health care providers…The opinion of the expert
medical advisor is presumed to be correct unless
there is clear and convincing evidence to the
contrary as determined by the judge of
compensation claims.”

“The expert medical advisor appointed to conduct
the evaluation shall have free and complete
access to the medical records of the employee.”
    EXPERT MEDICAL ADVISORS
                 s.440.13(9)(d), F.S.


  “The expert medical advisor must complete his or
  her evaluation and issue his or her report to the
  Division or to the judge of compensation claims
  within 15 days after receipt of all medical records.
  The expert medical advisor must furnish a copy of
  the report to the carrier and to the employee.”

 The expert medical advisor shall submit an
  accurately completed Form DWC-25 to the insurer/
  carrier by close of the following business day
  when a patient physical examination is performed.
   EXPERT MEDICAL ADVISORS
                 s.440.13(9)(f), F.S.


“The party ordering the services of an expert medical
advisor to resolve a dispute must compensate the
advisor for his or her time in accordance with a
schedule adopted by the Division.”

“If the employee prevails in a dispute …based on the
expert medical advisor’s findings, the employer or
carrier shall pay for the costs…”

“The Division may assess a penalty not to exceed
$500 against any carrier that fails to timely compensate
an advisor in accordance with this section.”
 EXPERT MEDICAL ADVISORS
               s.440.13(9)(f), F.S.

  Who reimburses for the services of an
        Expert Medical Advisor?
 The party ordering the services of an expert
 medical advisor to resolve a dispute must
 compensate the advisor for his or her time .
  If the employee prevails in a dispute …based
  on the expert medical advisor’s findings, the
  employer or carrier shall pay for the costs…

 An Expert Medical Advisor shall submit
  his/her bill on an invoice approved by the
  Judge of Compensation Claims or the
  Division.
   EXPERT MEDICAL ADVISORS
            Rule 69LA-30.008(5), F.A.C.



 REIMBURSEMENT SCHEDULE FOR SERVICES
           CONTRACTED BY:


Judges of Compensation Claims - $300.00
   per hour for no more than 8 hours per case
Division of Workers’ Compensation- $200.00
   per hour for no more than 8 hours per case
    REMOVAL OF PHYSICIANS FROM
      Division LIST OF CERTIFIED
      HEALTH CARE PROVIDERS
                     s.440.13(13), F.S.

     The Division may remove a provider from the
   Division’s list of certified health care providers or
                 Expert Medical Advisors.

“The Division shall remove from the list of physicians…
authorized to provide remedial treatment, care and
attendance under this chapter the name of any
physician…found after reasonable investigation to have:
  (a) Engaged in professional or other misconduct or
  incompetency in connection with medical services
  rendered under this chapter;
  REMOVAL OF PHYSICIANS FROM
      Division LIST (continued)
                   s.440.13(13), F.S.

(b) Exceeded the limits of his…professional
    competence… or to have made materially false
    statements regarding his…qualifications in
    his…application;
(c) Failed to transmit copies of medical reports to the
    employer or carrier, or failed to submit full and
    truthful medical reports of all his…findings to the
    employer or carrier as required…;
(d) Solicited, or employed another to solicit for himself
    …professional treatment, examination, or care of an
    injured employee in connection with any claim…;
 REMOVAL OF PHYSICIANS FROM
     Division LIST (continued)
                   s.440.13(13), F.S.


(e) Refused to appear before, or to answer upon
    request of, the Division…any legal question, or to
    produce any relevant book or paper concerning
    his…conduct under any authorization granted to
    him…under this chapter;
(f) Self-referred in violation of this chapter or other
     laws of this state; or
(g) Engaged in a pattern or practice of overutilization
    or a violation of this chapter or rules adopted by
    the Division…
      Florida Statutes 440.134
    WC Managed Care Arrangements

The following list provides the statutes related
   to Workers’ Compensation Managed Care
Arrangements, including a brief description for
               each subsection.


• 440.134(1)(g): Definition of WCMCA
• 440.134(1)(i): Definition of medical care
                  coordinator
• 440.134(1)(j): Definition of provider network
• 440.134(1)(k): Definition of primary care provider
       Florida Statutes 440.134
     WC Managed Care Arrangements
                  (continued)



• 440.134(4):   AHCA authorization as WCMCA
• 440.134(6):   Plan of Operation elements -
                WCMCA
• 440.134(7):   Provision of Records to insurer/
                carrier - WCMCA
• 440.134(8):   Training and education of HCP
                and Administrative Staff
 Florida Statutes 440.134
WC Managed Care Arrangements
              (continued)



Complete information regarding Workers’
Compensation Managed Care
Arrangements may be viewed at the
Division’s home webpage (listed under
CH. 440, FL Statutes) at the following link:
            www.fldfs.com/wc
    Florida Administrative Code
Rules pertaining to Medical Services

                  Chapter 69L

•    Rule 69L-3.0047 = Fraud Statement
•    Rule 69L-7.602 = Billing, Filing and Reporting
                      of Medical Services
•    Rule 69L-7.020 = Health Care Provider
                      Reimbursement Manual
    Florida Administrative Code
   Rules pertaining to Medical Services

                    Chapter 69L

• Rule 69LA-29 - Health Care Provider Certification
• Rule 69LA-30 - Expert Medical Advisor Certification
• Rule 69LA-31 - Reimbursement Disputes
   Florida Administrative Code



Florida Administrative Code rules may be viewed
at or printed from the following Internet address:


         http://fac.dos.state.fl.us/
     ? QUESTIONS ?
   Contact the Specialist On-Call
         (850) 413-1613




Workers’ Compensation Medical Services Unit
CONGRATULATIONS!




 YOU HAVE SUCCESSFULLY
 COMPLETED THE EXPERT
MEDICAL ADVISOR TUTORIAL
This concludes the Florida Workers’
Compensation Tutorial for Expert
Medical Advisors. Completion of this
tutorial fulfills the Expert Medical
Advisor certification criteria requiring
the physician to attest to familiarity with
the rules and statutes relating to the
provision of benefits and services in the
Florida Workers’ Compensation system.

				
DOCUMENT INFO
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