Florida Workers' Compensation's focus is to ensure that carriers' claims-handling practices promote the self-executing features of the system and result in the prompt and accurate delivery of benefits to injured workers at an affordable cost to employers.
Florida Workers' Compensation interprets the statutory language in s. 440.134(1)(i), Florida Statutes, which defines a "medical care coordinator" as a key construct in the carrier's plan of operation for the successful operation of an approved workers' compensation managed care arrangement. Accordingly, Florida Workers' Compensation will refer instances to the attention of the Agency for Healthcare Administration when medical care is delayed or not provided because medical care is not managed by a physician medical care coordinator as the ultimate, responsible party. Florida Workers' Compensation is well able to distinguish the role of the adjuster in determining whether a claim is compensable and will hold the carrier responsible for properly executing its right to question liability for benefits under s. 440.20(4), Florida Statutes. Likewise, when a carrier fails to comply with the law in investigating liability and improperly delegates to an adjuster (or even another licensed health care provider) the management of medical care, Florida Workers' Compensation will advise carriers of practices that it determines as unacceptable claims-handling. Corrective action may range from consultations to improve internal processes if requested by the carrier or may require more punitive action based on documentation that a carrier is not complying with legitimate rules or specific law.
Only with all parties within the system working together, can this be accomplished. The key is open communication among employees, employers, carriers, and health care providers. The responsibilities and rights of the injured worker should be explained and reinforced through constant communication between the employer and the employee, with the adjuster being available to answer questions during this uncertain time in the injured worker's life; and with Florida Workers' Compensation serving as an informational resource. All parties should take every opportunity to emphasize to the injured worker the importance of following the doctor's advice and keeping medical appointments since failure to do so may interfere with the recovery and return to work and also may jeopardize the payment of future lost wages.
Judges cannot discount a doctor's testimony if he was paid above the fee schedule when the injured worker was furnished medically necessary treatment and care through a managed care arrangement contractual agreement. As a point of clarification, an insurer does not have to use the Health Care Provider Fee for Service Reimbursement Manual as a benchmark when negotiating a contract with a health care provider in a managed care arrangement. When the terms of payment with a provider within a workers' compensation managed care arrangement are established by an insurer, the contract levels of reimbursement may be provider specific or based on any national treatment standards and guidelines for authorization and reimbursement of medically necessary services. However, the contractual terms must be mutually accepted by both parties.
Your employer, upon becoming aware of your injury, should provide medically necessary treatment by a health care provider for such period as the nature of the injury or the process of recovery may require. This includes medicines, medical supplies, durable medical equipment, orthotics, prostheses, and other medically necessary apparatus. Medical care must be authorized by the employer/carrier and provided by a physician from a list of those authorized to render medical care.
The law requires that the employer/carrier provide the appropriate medical care. However, if an injured worker objects to the medical treatment furnished by the employer, it shall be the duty of the employer/carrier to select another physician to treat the injured worker. Medical care must be authorized by the employer/carrier and provided by a physician from a list of those authorized to render medical care.
"Physician" includes chiropractors and osteopaths authorized by the employer/carrier. Chiropractic care is limited to 24 visits or 12 weeks, whichever comes first.
A: If an injured worker objects to the medical treatment furnished by the employer/carrier, another physician can be selected by the employer/carrier to treat the injured worker. The injured worker or carrier may also select a one time Independent Medical Examination (IME), per accident.
A: The health care provider must provide the injured worker or his attorney, on demand, a copy of the medical records and reports. A health care provider who willfully refuses to provide medical records shall be subject to one or more of the penalties set forth in s.440.13(8).
The health care provider must provide the injured worker a copy of his office chart, records, and reports, and may charge the injured worker an amount authorized by the division for the copies.
In order to receive mileage or prescription drug reimbursement, a request must be sent to the carrier. Mileage reimbursement requests must contain a list of the dates the injured worker went to doctors, physical therapists, or hospitals for tests or treatments. The names of the medical providers and the total round trip mileage will also be required on the request. For drug reimbursement the injured worker needs to submit a completed DWC-10 form (Statement of Drugs and Medical Supplies) before reimbursement will be approved.
Medical benefits should be provided by the employer to the injured worker for such period as the nature of the injury or the process of recovery may require so long as the 12 month/24 month statute of limitations has not run.
For dates of accident 10/01/1989 and forward, rehabilitation is strictly voluntary on the part of the carrier and the injured worker. However, when an injured worker has suffered an injury and it appears that the injury will preclude the injured worker from earning wages equal to wages earned prior to the injury, the injured worker is entitled to screening for appropriate training and education. The injured worker may request a screening to determine his entitlement to reemployment services. Reemployment services may include vocational counseling, job seeking skills, on-the-job training and formal retraining. Contact the Department of Education, Division of Vocational Rehabilitation, Bureau of Rehabilitation and Reemployment Services at one of the district offices for more details.
If your health insurance is being discontinued you may be eligible to convert coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA). You can contact the US Department of Labor, Pension Welfare Benefits Administration at (202)219-8776 for additional information. In instances where health insurance is terminated, the amount of any employers' contribution would go into a readjusted average weekly wage and in some instances might increase the indemnity benefit available to the injured worker.
Workers' Compensation Managed Care Arrangements may be authorized by the Agency for Health Care Administration to use more than one plan of operation or managed care provider network. This can be accomplished either by requesting approval for more than one plan of operation as part of the initial application process or by requesting approval of one or more alternative plans of operation in addition to the original previously authorized plan of operation. However, effective 10/1/2001, employers are no longer required to provide medically necessary treatment solely through a managed care arrangement. Further clarification may be obtained from the Agency for Health Care Administration at (850)922-6481.
Workers' Compensation Managed Care Arrangements may market more than one alternative plan of operation using different provider networks in the same county provided that the Workers' Compensation Managed Care Arrangement has obtained authorization of those alternative plans from the Agency for Health Care Administration and that these alternative plans have an approved provider network in the counties where they are marketed. Further clarification may be obtained from the Agency for Health Care Administration at (850)922-6481.
The payment of an additional fee is not required for amendments, additions, or changes to a previously authorized Workers' Compensation Managed Care Arrangement plan of operation unless such changes are being requested as part of the biannual renewal of the Workers' Compensation Managed Care Arrangement authorization. Further clarification may be obtained from the Agency for Health Care Administration at (850)922-6481.
A third party administrator or managed care organization cannot be authorized as a Workers' Compensation Managed Care Arrangement unless it meets the definition of insurer according to 440.134(1)(e), Florida Statutes. Third party administrator's and managed care organization's do not typically qualify under that definition.
The subject of a three party agreement arose to address a potential problem with those situations in which an insurer contracted with a third party administrator or managed care organization for Workers' Compensation Managed Care services and the third party administrator or managed care organization then subcontracted with a provider network. It was the Agency for Health Care Administration's concern that the third party administrator or managed care organization could switch provider networks without adequately informing the contracted insurers of the change, thereby disrupting medical care for injured workers. It is in the best interest of all parties involved in a Workers' Compensation Managed Care Arrangement to clearly understand what each of their respective responsibilities are in the managed care arrangement partnering effort. The three party agreement is only one method of insuring that all parties are knowledgeable about the other parties involved in the operation of the Workers' Compensation Managed Care Arrangement. Therefore, the Agency for Health Care Administration is requesting that in a Workers' Compensation Managed Care Arrangement in which there are subcontracted relationships, similar to those described above, the insurer consider the utilization of a three-party agreement, or include in the contracts, language which clearly defines the roles, responsibilities, and reporting mechanisms for notification of affected parties when there is a change of the provider network. Further clarification may be obtained from the Agency for Health Care Administration at (850)922-6481.
A self-insured employer may utilize its own appropriately qualified employees to provide case management services. The Agency for Health Care Administration does not prohibit any particular arrangement of in-house or contracted services as long as it ensures the provision of accessible, timely, high quality, medical services and promotes return to work for injured workers. Further clarification may be obtained from the Agency for Health Care Administration at (850)922-6481.
A Workers' Compensation Managed Care Arrangement may customize an existing, previously authorized provider network by adding or deleting certain providers provided that the customized network still meets the minimum travel time and provider content requirements of the Agency for Health Care Administration. Changes made to the content of a previously authorized provider network within a specific service area must be identified in the application if the service area is being customized for a particular insurer and a copy of the customized network must be filed with the Agency for Health Care Administration. Applicants must explicitly identify the modified service area in the application or amendment request as "customized". Further clarification may be obtained from the Agency for Health Care Administration at (850)922-6481.
A Workers' Compensation Managed Care Arrangement may use an existing provider network, construct its own network by contracting with and credentialing providers, or customize an existing network to meet its needs as long as the provider network meets the Agency for Health Care Administration's minimum travel time and provider content requirements. Further clarification may be obtained from the Agency for Health Care Administration at (850)922-6481.
A consortium of public entities can file a single Workers' Compensation Managed Care Arrangement application with a $1,000 application filing fee provided that the entities in the consortium have an interlocal or similar type of agreement, or language in their by-laws which meets certain requirements contained in subsection 163.001(5), Florida Statutes. Minimum content requirements for these agreements are:
Further clarification may be obtained from the Agency for Health Care Administration at (850)922-6481.
The Agency for Health Care Administration has determined that, in addition to chiropractors, podiatrists, optometrists, and dentists, a Workers' Compensation Managed Care Arrangement may also designate the following type of physicians licensed under chapter 458 or chapter 459, Florida Statutes, as primary care physicians:
Pursuant to a July 1997 policy change, the Agency for Health Care Administration has determined that specialty physicians licensed under chapter 458, Florida Statutes, may also be designated as PCP's and MCC's for specific types of injuries. Further clarification may be obtained from the Agency for Health Care Administration at (850)922-6481.
A medical care coordinator must be a primary care physician. Section 440.134, Florida Statutes, states:
"Medical care coordinator means a primary care provider within a provider network who is responsible for managing the medical care of an injured worker....A medical care coordinator shall be a physician licensed under chapter 458 or an osteopath licensed under chapter 459."
Those physician types licensed under chapter 458 or chapter 459,
Florida Statutes, which are allowed by the Agency for Health Care
Administration to be primary care providers may also be designated as a
medical care coordinator.
Further clarification may be obtained from the Agency for Health Care
Administration at (850)922-6481.
The Agency for Health Care Administration requires a separate review and approval of large deductible Workers' Compensation Managed Care Arrangement insurer products only when the plan of operation for the coordination and provision of medical services to injured workers differs before and after the deductible requirement has been met. If the self-insurance deductible only affects which entity pays for services, then Agency for Health Care Administration review and approval is not required. Further clarification may be obtained from the Agency for Health Care Administration at (850)922-6481.
A Workers' Compensation Managed Care Arrangement may use ARNP's to provide primary care services provided that the ARNP is in compliance with the requirements of the nurse practice act. This requires that the ARNP operate under treatment protocols which have been previously approved by a physician licensed under chapter 458 or chapter 459, Florida Statutes. Further clarification may be obtained from the Agency for Health Care Administration at (850)922-6481.
The Florida Workers’ Compensation Institute (FWCI) handles sales of the FIRG. You may purchase a copy by contacting them at (850) 425-8156.
You may fax your request to purchase this manual to the Department of Financial Services, Division of Administration, Bureau of Finance and Support, Processing Section at (850) 488-3429. The cost for this manual is 50 cents per page. Upon receipt of payment, the fee schedule will be mailed to you. If you should have additional questions regarding the purchase of this manual, please call the Processing Section at (850) 413-2622. Access to this manual is also available through the Division of Workers' Compensation website "Publications" link at http://www.myfloridacfo.com/wc/publications.html.
Please contact the Office of Medical Services at (850) 413-1613 for instructions on submitting a request related to non-payment of medical bills.
Please contact the Office of Medical Services at (850) 413-1613 for instructions on submitting a Petition for Resolution of Reimbursement Dispute (DFS Form 3160-0023).
