RULE CHAPTER 69L-34 FLORIDA ADMINISTRATIVE CODE (F.A.C.) CARRIER REPORT OF HEALTH CARE PROVIDER VIOLATIONS WEB TRAINING

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1 RULE CHAPTER 69L-34 FLORIDA ADMINISTRATIVE CODE (F.A.C.) CARRIER REPORT OF HEALTH CARE PROVIDER VIOLATIONS WEB TRAINING Office of Medical Services Bureau of Monitoring and Audit Division of Workers Compensation Department of Financial Services

2 Rule Chapter 69L-34, F.A.C. Carrier Report of Health Care Provider Violation (HCP Violation Rule) Web Training Objectives To discuss the scope of the HCP Violation Rule and the process by which industry partners may report HCP violations of Chapter 440, Florida Statutes (F.S.), to the Division To establish the Division may use paid medical claims data and HCP violation reports to initiate a Division investigation, pursuant to s (11), F.S. 22

3 Rule Chapter 69L-34, F.A.C. - HCP Violation Rule Purpose & Effect To clarify that carriers satisfy the mandatory overutilization reporting requirements in s (8), F.S., when in compliance with reporting requirements of Rule 69L-7.602(5)and (6), F.A.C., Florida Workers Compensation Medical Services Billing, Filing and Reporting Rule (Billing Rule) 33

4 HCP Violation Rule - Purpose & Effect continued To introduce an elective/discretionary process to report HCP violations of Chapter 440, F.S., and applicable administrative rules To incorporate Health Care Provider Violation Referral Form, DFS-F6-DWC-2000 (Referral Form), effective September 6, 2011, for reporting health care provider violations 44

5 Rule 69L Definitions Health Care Provider (Provider) Physician or recognized practitioner as defined in s (1)(h), F.S., who is certified by the Division to receive reimbursement under Chapter 440, F.S., for services rendered to injured employees Providers who, pursuant to s (3)(f), F.S., consent to the jurisdiction of the Division by accepting payment under Chapter 440, F.S. 55

6 Rule Definitions continued Instance of Overutilization A specific inappropriate service or level of service provided to an injured employee NOTE: Overutilization is related to treatment rendered; therefore, a recommendation for treatment that would constitute overutilization is not a violation. 6

7 Rule Definitions continued Supportive Documentation All documents and records that reasonably support an allegation of a violation of this Rule Chapter Verifiable Delivery Process The ability to document a common carrier s pick-up and delivery date or a US Postal Service postmark date 7

8 Rule Definitions continued HCP Violation A health care provider s non-compliance with Chapter 440, F.S. and Division rules such as: Failing to refund an overpayment of reimbursement pursuant to s (11)(a), F.S. Failing to submit medical records and reports pursuant to s (4)(a) and (c), F.S., or 69L-7.602(4), F.A.C. 8

9 HCP Violation cont d. Rule Definitions continued Collecting or receiving payment from an injured employee in violation of s (14)(a), F.S. Failing to follow Standards of Care, pursuant to s (16), F.S., including overutilization of services Failing to properly bill medical services, pursuant to the Billing Rule 9

10 Rule Definitions continued Improper Billing and Billing Errors Non-compliance with the Billing Rule and applicable reimbursement manual(s); Improper form completion Filing of incorrect medical claim form Use of invalid or incorrect billing codes, modifiers, REV codes, etc 10

11 Rule 69L Mandatory Carrier Reporting of Overutilization of Services Carrier satisfies requirement to report all instances of overutilization of treatment rendered or recommended pursuant to s (8), F.S., when carrier complies with the: Explanation of Bill Review (EOBR) requirements in the Billing Rule or Notice of Denial requirements in Rule 69L-3.012, F.A.C. 11

12 Mandatory Carrier Reporting continued Rule 69L-7.602(5)(o), F.A.C., requires Carriers to file medical data elements to include EOBR codes documenting the carrier s bill review process for: Disallowing and adjusting reimbursement for overutilization of services Explaining the reimbursement of each billed line item adjudicated 1212

13 Mandatory Carrier Reporting continued Rule 69L-3.012, F.A.C., requires Carriers to issue a DFS-F2-DWC-12, Notice of Denial form to the Provider and injured employee to deny authorization of recommended treatment that otherwise constitutes overutilization of services NOTICE OF DENIAL DFS-F2-DWC-12 FORM 13

14 Rule 69L Elective Referral of Alleged HCP Violation Filing a Referral to report a HCP violation is DISCRETIONARY and SHALL: Be on a Health Care Provider Violation Referral Form, DFS-F6-DWC 2000 Form ( Referral form) Be accompanied by supportive documents (e.g. DWC- 25 forms, peer review reports, medical bills, collection letters, etc ) Identify one (1) violation per referral form 14

15 Elective Referral of Alleged HCP Violation continued Be filed with the DWC Office of Medical Services in Tallahassee, FL NOTE: The elective reporting of an overutilization violation neither satisfies nor negates the carrier s obligation for reporting instances of overutilization pursuant to s (8), F.S. 1515

16 Rule 69L Timeliness of a Referral Properly completed Referrals and supportive documentation related to a Provider s billing practice SHALL be filed within 180 days after: Issuance of an EOBR identifying the reported violation, such as: A Billing error Overutilization of services The Failure to submit medical records reports required for the adjudication of a medical bill 16

17 Timeliness of a Referral continued Referrals related to a Provider billing an injured employee or failing to provide requested medical records and reports shall be filed within 180 days of: The date of written notice to Provider identifying violation The carrier s received date of a copy of a bill collection notice to injured employee for payment of covered treatment 17

18 Rule 69L Referral Investigation The Division MAY initiate an investigation of an alleged Provider violation based on: An audit of paid medical claim data filed with the Division and/or Receipt of a completed Referral form and all supportive documentation 1818

19 Referral Investigation continued The Division MAY request additional documentation from Carrier and Provider to support its investigation A Provider or Carrier must submit, to the Division, within 45 days of receipt of a written request: The requested documentation or A written explanation why the documentation is not available 19

20 Referral Investigation continued The Carrier s or Provider s failure to submit documentation within 45 days of receipt of request SHALL result in: Issuance of Division finding(s) based on documentation filed with referral or received subsequent to document request deadline or Termination of Division s investigation 20

21 Referral Investigation continued A finding of a provider violation SHALL result in one or more of the following administrative sanctions pursuant to s (8),(11) and (13), F.S.: Removal from the DWC provider database Barring future payment under Chapter 440 Administrative fine not to exceed $5,000 per instance of overutilization Referral to licensing authority for further review 21

22 Rule 69L Invalid Referrals Complaints related to the following issues are not subject to agency action under this rule and shall be dismissed: Reimbursement dispute issues pending a Determination, pursuant to s (7), F.S.; or Medical benefit dispute issues pending a Judge of Compensation Claims order 22

23 HCP Violation Rule Summary Rule effective September 6, 2011 Carrier satisfies mandatory reporting of Instances of Overutilization requirements of s (8), F.S., by: Filing medical claims data as required in Billing Rule or Denying authorization of a recommended medical benefit, pursuant to Rule 69L-3.012, F.A.C. 23

24 HCP Violation Rule Summary continued Filing an HCP Referral: Is OPTIONAL Is not A SUBSTITUTE for mandatory reporting requirements of statute and rule Must be filed within 180 days of notification of violation Must be filed on a Health Care Provider Violation Referral Form, DFS-F6-DWC

25 HCP Violation Rule Summary continued Alleged violation must be related to rendered services that are: Not properly billed Not properly reported Not appropriate for compensable condition Reimbursed in error due to HCP billing error or overutilization of services 25

26 HCP Violation Rule Summary continued The following types of referrals will be dismissed in accordance with the Rule: Reimbursement dispute issues addressed in petitions filed with Division Medical benefit issues addressed in Petition for Benefits filed with JCC s office Untimely filed referrals will also be dismissed 26

27 Questions and Policy Clarification Inquiries regarding the HCP Violation Rule may be directed to: The HCP Violation Rule and Referral Form are available on the Division s website at: 27

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