Bill Text: FL S1662 | 2013 | Regular Session | Introduced
Bill Title: Workers' Compensation
Spectrum: Partisan Bill (Republican 1-0)
Status: (Failed) 2013-05-03 - Died in Banking and Insurance, companion bill(s) passed, see CS/SB 662 (Ch. 2013-131) [S1662 Detail]
Download: Florida-2013-S1662-Introduced.html
Florida Senate - 2013 SB 1662
By Senator Grimsley
21-00273-13 20131662__
1 A bill to be entitled
2 An act relating to workers’ compensation; amending s.
3 440.13, F.S.; prohibiting an employer or carrier from
4 refusing to authorize a health care provider to treat
5 an injured employee solely because the health care
6 provider is also the dispensing practitioner;
7 authorizing a health care provider to dispense and
8 fill prescriptions for medicines if the health care
9 provider who is also the dispensing practitioner
10 receives authorization from an employer or a carrier
11 to treat an employee; prohibiting the Department of
12 Financial Services, an employer, or carrier from
13 requiring the injured employee to use a specified
14 pharmacy, pharmacist, or dispensing practitioner;
15 deleting provisions to conform to changes made by the
16 act; providing the reimbursement amount for
17 prescription medications; specifying circumstances
18 under which a provider is required to give a credit to
19 the insurance carrier or self-insured employer for
20 each prescription that costs more than a specified
21 amount; providing for the deposit of the credit;
22 requiring the department to recalculate the amount of
23 the provider rebate; prohibiting a physician or the
24 physician’s assignee from holding an ownership
25 interest in a licensed pharmaceutical repackaging
26 entity or to set or cause to be set a repackaged
27 pharmaceutical average wholesale price; providing an
28 effective date.
29
30 Be It Enacted by the Legislature of the State of Florida:
31
32 Section 1. Subsections (3) and (12) of section 440.13,
33 Florida Statutes, are amended, present subsection (17) is
34 amended and redesignated as subsection (18), and a new
35 subsection (17) is added to that section, to read:
36 440.13 Medical services and supplies; penalty for
37 violations; limitations.—
38 (3) PROVIDER ELIGIBILITY; AUTHORIZATION.—
39 (a) As a condition for to eligibility for payment under
40 this chapter, a health care provider who renders services must
41 be a certified health care provider and must receive
42 authorization from the carrier before providing treatment. This
43 paragraph does not apply to emergency care. An employer or a
44 carrier may not refuse to authorize a health care provider to
45 treat an injured employee solely because the health care
46 provider is also the dispensing practitioner, as defined in s.
47 465.0276. The department shall adopt rules to administer
48 implement the certification of health care providers.
49 (b) A health care provider who renders emergency care shall
50 must notify the carrier by the close of the third business day
51 after it has rendered such care. If the emergency care results
52 in admission of the employee to a health care facility, the
53 health care provider shall must notify the carrier by telephone
54 within 24 hours after initial treatment. Emergency care is not
55 compensable under this chapter unless the injury requiring
56 emergency care arose as a result of a work-related accident.
57 Pursuant to chapter 395, all licensed physicians and health care
58 providers in this state shall be required to make their services
59 available for emergency treatment of any employee eligible for
60 workers’ compensation benefits. To refuse to make such treatment
61 available is cause for revocation of a license.
62 (c) A health care provider may not refer the employee to
63 another health care provider, diagnostic facility, therapy
64 center, or other facility without prior authorization from the
65 carrier, except when emergency care is rendered. Any referral
66 must be to a health care provider that has been certified by the
67 department, unless the referral is for emergency treatment, and
68 the referral must be made in accordance with practice parameters
69 and protocols of treatment as provided for in this chapter.
70 (d) A carrier shall must respond, by telephone or in
71 writing, to a request for authorization from an authorized
72 health care provider by the close of the third business day
73 after receipt of the request. A carrier who fails to respond to
74 a written request for authorization for referral for medical
75 treatment by the close of the third business day after receipt
76 of the request consents to the medical necessity for such
77 treatment. All such requests must be made to the carrier. Notice
78 to the carrier does not include notice to the employer.
79 (e) Carriers shall adopt procedures for receiving,
80 reviewing, documenting, and responding to requests for
81 authorization. Such procedures must shall be for a health care
82 provider certified under this section.
83 (f) By accepting payment under this chapter for treatment
84 rendered to an injured employee, a health care provider consents
85 to the jurisdiction of the department as provided set forth in
86 subsection (11) and to the submission of all records and other
87 information concerning such treatment to the department in
88 connection with a reimbursement dispute, audit, or review as
89 provided by this section. The health care provider must further
90 agree to comply with any decision of the department rendered
91 under this section.
92 (g) The employee is not liable for payment for medical
93 treatment or services provided pursuant to this section except
94 as otherwise provided in this section.
95 (h) The provisions of s. 456.053 are applicable to
96 referrals among health care providers, as defined in subsection
97 (1), treating injured workers.
98 (i) Notwithstanding paragraph (d), a claim for specialist
99 consultations, surgical operations, physiotherapeutic or
100 occupational therapy procedures, X-ray examinations, or special
101 diagnostic laboratory tests that cost more than $1,000 and other
102 specialty services that the department identifies by rule is not
103 valid and reimbursable unless the services have been expressly
104 authorized by the carrier, or unless the carrier has failed to
105 respond within 10 days to a written request for authorization,
106 or unless emergency care is required. The insurer shall
107 authorize such consultation or procedure unless the health care
108 provider or facility is not authorized or certified, unless such
109 treatment is not in accordance with practice parameters and
110 protocols of treatment established in this chapter, or unless a
111 judge of compensation claims has determined that the
112 consultation or procedure is not medically necessary, not in
113 accordance with the practice parameters and protocols of
114 treatment established in this chapter, or otherwise not
115 compensable under this chapter. Authorization of a treatment
116 plan does not constitute express authorization for purposes of
117 this section, except to the extent the carrier provides
118 otherwise in its authorization procedures. This paragraph does
119 not limit the carrier’s obligation to identify and disallow
120 overutilization or billing errors.
121 (j) Notwithstanding anything in this chapter to the
122 contrary, a sick or injured employee is shall be entitled, at
123 all times, to free, full, and absolute choice in the selection
124 of the pharmacy or pharmacist dispensing and filling
125 prescriptions for medicines required under this chapter. It is
126 expressly forbidden for the department, an employer, or a
127 carrier, or any agent or representative of the department, an
128 employer, or a carrier, to select the pharmacy or pharmacist
129 which the sick or injured employee must use; condition coverage
130 or payment on the basis of the pharmacy or pharmacist utilized;
131 or to otherwise interfere in the selection by the sick or
132 injured employee of a pharmacy or pharmacist.
133 (k) If a health care provider who is also the dispensing
134 practitioner, as defined in s. 465.0276, receives authorization
135 from an employer or a carrier to treat an employee pursuant to
136 paragraph (a), the health care provider may dispense and fill
137 prescriptions for medicines under this chapter. For purposes of
138 dispensing and filling prescriptions for medicines, the
139 department, employer, or carrier, or an agent or representative
140 of the department, employer, or carrier, may not select the
141 pharmacy, pharmacist, or dispensing practitioner that the
142 employee must use.
143 (12) CREATION OF THREE-MEMBER PANEL; GUIDES OF MAXIMUM
144 REIMBURSEMENT ALLOWANCES.—
145 (a) A three-member panel is created, consisting of the
146 Chief Financial Officer, or the Chief Financial Officer’s
147 designee, and two members to be appointed by the Governor,
148 subject to confirmation by the Senate, one member who, on
149 account of present or previous vocation, employment, or
150 affiliation, is shall be classified as a representative of
151 employers, the other member who, on account of previous
152 vocation, employment, or affiliation, is shall be classified as
153 a representative of employees. The panel shall determine
154 statewide schedules of maximum reimbursement allowances for
155 medically necessary treatment, care, and attendance provided by
156 physicians, hospitals, ambulatory surgical centers, work
157 hardening programs, pain programs, and durable medical
158 equipment. The maximum reimbursement allowances for inpatient
159 hospital care is shall be based on a schedule of per diem rates,
160 to be approved by the three-member panel no later than March 1,
161 1994, to be used in conjunction with a precertification manual
162 as determined by the department, including maximum hours in
163 which an outpatient may remain in observation status, which may
164 shall not exceed 23 hours. All compensable charges for hospital
165 outpatient care are shall be reimbursed at 75 percent of usual
166 and customary charges, except as otherwise provided by this
167 subsection. Annually, The three-member panel shall annually
168 adopt schedules of maximum reimbursement allowances for
169 physicians, hospital inpatient care, hospital outpatient care,
170 ambulatory surgical centers, work-hardening programs, and pain
171 programs. An individual physician, hospital, ambulatory surgical
172 center, pain program, or work-hardening program is shall be
173 reimbursed either the agreed-upon contract price or the maximum
174 reimbursement allowance in the appropriate schedule.
175 (b) It is the intent of the Legislature to increase the
176 schedule of maximum reimbursement allowances for selected
177 physicians effective January 1, 2004, and to pay for the
178 increases through reductions in payments to hospitals. Revisions
179 developed pursuant to this subsection are limited to the
180 following:
181 1. Payments for outpatient physical, occupational, and
182 speech therapy provided by hospitals are shall be reduced to the
183 schedule of maximum reimbursement allowances for these services
184 which applies to nonhospital providers.
185 2. Payments for scheduled outpatient nonemergency
186 radiological and clinical laboratory services that are not
187 provided in conjunction with a surgical procedure are shall be
188 reduced to the schedule of maximum reimbursement allowances for
189 these services which applies to nonhospital providers.
190 3. Outpatient reimbursement for scheduled surgeries are
191 shall be reduced from 75 percent of charges to 60 percent of
192 charges.
193 4. Maximum reimbursement for a physician licensed under
194 chapter 458 or chapter 459 is shall be increased to 110 percent
195 of the reimbursement allowed by Medicare, using appropriate
196 codes and modifiers or the medical reimbursement level adopted
197 by the three-member panel as of January 1, 2003, whichever is
198 greater.
199 5. Maximum reimbursement for surgical procedures is shall
200 be increased to 140 percent of the reimbursement allowed by
201 Medicare or the medical reimbursement level adopted by the
202 three-member panel as of January 1, 2003, whichever is greater.
203 (c) As to reimbursement for a prescription medication, the
204 reimbursement amount for a prescription shall be the average
205 wholesale price plus $4.18 for the dispensing fee, except where
206 the carrier has contracted for a lower amount. Fees for
207 pharmaceuticals and pharmaceutical services shall be
208 reimbursable at the applicable fee schedule amount. Where the
209 employer or carrier has contracted for such services and the
210 employee elects to obtain them through a provider not a party to
211 the contract, the carrier shall reimburse at the schedule,
212 negotiated, or contract price, whichever is lower. No such
213 contract shall rely on a provider that is not reasonably
214 accessible to the employee.
215 (c)(d) Reimbursement for all fees and other charges for
216 such treatment, care, and attendance, including treatment, care,
217 and attendance provided by any hospital or other health care
218 provider, ambulatory surgical center, work-hardening program, or
219 pain program, may must not exceed the amounts provided by the
220 uniform schedule of maximum reimbursement allowances as
221 determined by the panel or as otherwise provided in this
222 section. This subsection also applies to independent medical
223 examinations performed by health care providers under this
224 chapter. In determining the uniform schedule, the panel shall
225 first approve the data which it finds representative of
226 prevailing charges in the state for similar treatment, care, and
227 attendance of injured persons. Each health care provider, health
228 care facility, ambulatory surgical center, work-hardening
229 program, or pain program receiving workers’ compensation
230 payments shall maintain records verifying their usual charges.
231 In establishing the uniform schedule of maximum reimbursement
232 allowances, the panel must consider:
233 1. The levels of reimbursement for similar treatment, care,
234 and attendance made by other health care programs or third-party
235 providers;
236 2. The impact upon cost to employers for providing a level
237 of reimbursement for treatment, care, and attendance which will
238 ensure the availability of treatment, care, and attendance
239 required by injured workers;
240 3. The financial impact of the reimbursement allowances
241 upon health care providers and health care facilities, including
242 trauma centers as defined in s. 395.4001, and its effect upon
243 their ability to make available to injured workers such
244 medically necessary remedial treatment, care, and attendance.
245 The uniform schedule of maximum reimbursement allowances must be
246 reasonable, must promote health care cost containment and
247 efficiency with respect to the workers’ compensation health care
248 delivery system, and must be sufficient to ensure availability
249 of such medically necessary remedial treatment, care, and
250 attendance to injured workers; and
251 4. The most recent average maximum allowable rate of
252 increase for hospitals determined by the Health Care Board under
253 chapter 408.
254 (d)(e) In addition to establishing the uniform schedule of
255 maximum reimbursement allowances, the panel shall:
256 1. Take testimony, receive records, and collect data to
257 evaluate the adequacy of the workers’ compensation fee schedule,
258 nationally recognized fee schedules and alternative methods of
259 reimbursement to certified health care providers and health care
260 facilities for inpatient and outpatient treatment and care.
261 2. Survey certified health care providers and health care
262 facilities to determine the availability and accessibility of
263 workers’ compensation health care delivery systems for injured
264 workers.
265 3. Survey carriers to determine the estimated impact on
266 carrier costs and workers’ compensation premium rates by
267 implementing changes to the carrier reimbursement schedule or
268 implementing alternative reimbursement methods.
269 4. Submit recommendations on or before January 1, 2003, and
270 biennially thereafter, to the President of the Senate and the
271 Speaker of the House of Representatives on methods to improve
272 the workers’ compensation health care delivery system.
273
274 The department, as requested, shall provide data to the panel,
275 including, but not limited to, utilization trends in the
276 workers’ compensation health care delivery system. The
277 department shall provide the panel with an annual report
278 regarding the resolution of medical reimbursement disputes and
279 any actions pursuant to subsection (8). The department shall
280 provide administrative support and service to the panel to the
281 extent requested by the panel.
282 (17) REIMBURSEMENT FOR PRESCRIPTION MEDICATION.—The
283 reimbursement amount for prescription medication is the average
284 wholesale price plus $4.18 for the dispensing fee, unless the
285 carrier and the provider seeking reimbursement have directly
286 contracted with each other for a lower reimbursement amount.
287 (a) If a prescription has been repackaged or relabeled, the
288 provider shall give a $15 credit to the insurance carrier or
289 self-insured employer for each prescription that costs more than
290 $25. The credit must be reflected in the Explanation of Bill
291 Review provided by the carrier or employer. The credit does not
292 apply if the carrier and the provider seeking reimbursement have
293 directly contracted with each other for a lower reimbursement
294 amount. Any credit to a self-insured employer must be directly
295 deposited to the self-insurance fund of the entity. Beginning
296 July 1, 2015, and every 2 years thereafter, the Department of
297 Financial Services shall recalculate the amount of the provider
298 rebate based on actual claim data submitted to the department
299 for the previous 2 years.
300 (b) A physician or the physician’s assignee may not hold an
301 ownership interest in a licensed pharmaceutical repackaging
302 entity and may not set or cause to be set a repackaged
303 pharmaceutical average wholesale price.
304 (18)(17) PENALTIES.—A person who fails Failure to comply
305 with this section violates the provisions shall be considered a
306 violation of this chapter and is subject to penalties as
307 provided for in s. 440.525.
308 Section 2. This act shall take effect July 1, 2013.
