Workers’ Compensation Rule Development Workshop Report: Health Care Provider Compliance Reporting

On Wednesday, December 2, 2009, the Florida Department of Financial Services, Division of Workers’ Compensation (“Division”) held a Rule Development Workshop on proposed Rules comprised by Chapter 69L-34, F.A.C. entitled “Carrier Report of Health Care Provider Violations.”  To view the meeting notice, click here.

Division Attorney Paul Thigpin; Eric Lloyd from the Division’s Office of Medical Services and Division Assistant Director Andrew Sabolic presided at the Workshop.

The following proposed Rules were reviewed:

• 69L-34.001: Definitions
• 69L-34.002: Mandatory Carrier Reporting
• 69L-34.003: Referral of Alleged Health Care Provider Violation
• 69L-34.004: Timeliness of Referral
• 69L-34.005: Referral Investigation
• 69L-34.006: Invalid Referrals

According to the Division officials, the proposed Rules, which require carriers to report overutilization pursuant to section 440.13(8), F.S., satisfy the statutory requirement. 

Rule 69L-34.003 codifies discretionary reporting for specific health care provider violations, including overutilization, by using the “Health Care Provider Violation Referral Form”(“Form”), a copy of which is attached for review.

Significant discussion took place among the Division officials and interested parties present at the Workshop regarding the compliance reporting provisions.  Some opined that the optional nature of 69L-34.003 was unclear.  The Division officials stated that they would explore revisions to the proposed Rule in order to clarify that the Form is discretionary and that the reporting of overutilization satisfies the statutory requirement.

The definition of “violation” also was discussed.  Currently, the proposed Rule defines a violation as:  ” . . . a provider’s non-compliance with Chapter 440 and Division rules, which shall include: failing to submit medical records and reports; failing to refund an overpayment of reimbursement, collecting or receiving payment from an injured employee; or failing to follow standards of care.”

Some interested parties argued that additional, specific statutory provisions should be included (section 440.09, F.S. relating to coverage and section 440.151, F.S. relating to occupational diseases).  There was some discrepancy as to whether the Division has the jurisdiction to include the additional provisions.  Division officials noted that they would consider the suggestions that were given. 

Other issues raised at the Workshop included:

• The lack of a definition of practice parameters
• Inclusion of the term “material” in the definition of “improper billing and billing error” in order to avoid punitive measures for minor errors
• The requirement for filing the Form within 180 days after a carrier’s Explanation of Bill Review
• Allowing a provider to respond to a violation alleged on the Form.

The Division officials indicated they will consider the testimony presented at the Workshop and accordingly attempt to further clarify the proposed Rule.

The record will remain open for an additional 14 days through December 16, 2009 for further written comments.

Should you have any questions or comments, please contact Colodny Fass.

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