Division of Workers Compensation Wednesday, August 24, 2016 - - PowerPoint PPT Presentation

Division of Workers’ Compensation

Wednesday, August 24, 2016

Regulatory and Legislative Update

Andrew Sabolic Assistant Director

2016 Legislative Update

Highlights of House Bill 613 –effective 10/1/16:

• 25 percent penalty credit for certain employers;
• Establishing a deadline for employers to file certain

documentation to receive a penalty reduction;

• Reducing the imputed payroll multiplier from 2 times

to 1.5 times the statewide average weekly wage;

• Relieving employers of the obligation to notify the

DFS by telephone or telegraph within 24 hours of any work related death

3

2016 Legislative Update

Highlights of House Bill 613 –effective 10/1/16:

• Removing insurers and employers from the medical

reimbursement dispute provision since they meet their adjustment, disallowance and provider violation reporting duties through other provisions of law;

• Eliminating fees collected by the DFS related to new insurer

registrations and Special Disability Trust Fund notices of claim and proofs of claim;

• Revising the method for certifying an expert medical examiner;
• Eliminating the Preferred Worker Program

4

2016 Legislative Update

SB 1402 – 2015 Health Care Provider Reimbursement Manual

• Legislative ratification of the manual
• New maximum reimbursement allowances

are based upon 2014 Medicare rates

• 1.8% increase in costs
• Became effective on July 1, 2016

5

What to expect during the 2017 Legislative Session?

• Legislation to ONLY address the unconstitutionality
• f the attorney fee cap and the duration temporary

total disability benefit OR

• Comprehensive legislation to address other system

cost drivers and administrative efficiencies OR

• Do nothing and wait until the 2018 session

6

Activities and Initiatives

• 2017 Three-Member Panel Biennial Report
• Insurer Regulatory Report
• WCATF & SDTF Assessment Rates
• Check Cashing Store Database Results
• Mini-MAP
• Investigator’s Observations for

Underwriting (IOU)

7

Determine your performance among your peers

Audit Data

EAO Data

Financial Accountability Data

Data Quality & Collection

Activities and Initiatives

• 2017 Three-Member Panel Biennial Report
• Insurer Regulatory Report
• WCATF & SDTF Assessment Rates
• Check Cashing Store Database Results
• Mini-MAP
• Investigator’s Observations for

Underwriting (IOU)

14 14

Emerging Issues

• Compound drugs
• Timeliness of medical authorization
• Proper application of contracts for health

care provider payments

• Analysis of “outlier” health care provider

bills

15 15

Qu Ques estions tions

Policy in the Workers’ Compensation Medical Arena

Theresa Pugh Program Administrator Medical Services Section

Discussion Topics

• 69L-7 Rule Series: Workers’ Compensation Medical

Reimbursement and Utilization Review (AKA the Billing Rule)

• 69L-8 Rule Series: Selected Materials Incorporated by Reference
• 69L-7.100: Reimbursement Manual for Ambulatory Surgical

Centers

• 69L-7.020: Healthcare Provider Reimbursement Manual
• 69L-7.501: Reimbursement Manual for Hospitals
• 69L-30: Expert Medical Advisors
• 69L-31: Utilization and Reimbursement Dispute Rule
• 69L-34: Carrier Report of Health Care Provider Violations

Workers’ Compensation Medical Reimbursement and Utilization Review, 69L-7 Rule Series

• Adopted and went into effect on February 18, 2016
• Substantial rewrite and reorganization of existing Rule

69L-7.710, F.A.C. (aka the Billing Rule)

• Five separate rules
• 69L-7.710: Definitions
• 69L-7.720: Forms Incorporated by Reference
• 69L-7.730: Health Care Medical Billing and Reporting

Responsibilities

• 69L-7.740: Insurer Authorization and Medical Bill Review

Responsibilities

• 69L-7.750: Insurer Electronic Medical Report Filing to the Division

Rewrite of 69L-7.710, F.A.C. (aka the Billing Rule)

• Effective February 18, 2016

69L-7.710: Definitions 69L-7.720: Forms Incorporated by Reference 69L-7.730: Health Care Medical Billing and Reporting Responsibilities 69L-7.740: Insurer Authorization and Medical Bill Review Responsibilities 69L-7.750: Insurer Electronic Medical Report Filing to the Division

69L-7

7.710 7.720 7.730 7.740 7.750

Workers’ Compensation Medical Reimbursement and Utilization Review, 69L-7 Rule Series

• Summary of changes:
• Incorporates Revision F
• Allows for the use of revised national billing forms
• Establishes the use of ICD-10 Coding
• Contains billing instructions for dispensing

repackaged medication

• Updates EOBR codes
• Updates definitions

• Adopted and went into effect on February 18, 2016
• Reorganizes incorporated reference materials used in

conjunction with DWC medical reimbursement manuals and throughout the medical billing rule

Selected Materials Incorporated by Reference, 69L-8 Rule Series

Selected Materials Incorporated by Reference, 69L-8 Rule Series

• Rule Chapter 69L-8 contains the following:
• 69L-8.071: Materials for use with the Florida Workers’

Compensation Health Care Provider Reimbursement Manual

• 69L-8.072: Materials for use with the Florida Workers’

Compensation Reimbursement Manual for Ambulatory Surgical Centers

• 69L-8.073: Materials for use with the Florida Workers’

Compensation Hospital Reimbursement Manual

• 69L-8.074: Materials for use throughout Rule Chapter 69L-7,

F.A.C.

Reimbursement Manual for Ambulatory Surgical Centers, 2015 Edition, Rule 69L-7.100, F.A.C.

• Effective 1/1/2016
• Adopted September 28, 2015 & based on date of service
• Increased the Number of MRAs to 90
• Clarified surgical implant policy
• Prohibited multiple surgery reduction
• Reduced reimbursement from 70% of the billed

charge to 60% of the billed charge if the procedure is not listed in the fee schedule and a contract does not apply

• Workshop held July 28, 2016
• Will require legislative ratification
• Incorporates updated schedule of MRAs
• Includes 81 MRAs
• General reimbursement remains:

The MRA, or 60% of billed charge if procedure not listed in schedule, or An agreed upon contract price

Reimbursement Manual for Ambulatory Surgical Centers, 2016 Edition , Rule 69L-7.100, F.A.C.

Healthcare Provider Reimbursement Manual, 2015 Edition, Rule 69L-7.020, F.A.C.

• Adopted July 2015
• Ratified during 2016 legislative session
• Effective July 1, 2016
• (based on date of service)
• Incorporated 2014 Medicare Relative Value

Units (RVUs)

Healthcare Provider Reimbursement Manual, 2016 Edition, Rule 69L-7.020, F.A.C.

• Workshop held July 28, 2016
• Updates MRAs to incorporate 2016 Medicare

Relative Value Units (RVUs)

• Will not require ratification

Hospital Reimbursement Manual, 2014 Edition, Rule 69L-7.501, F.A.C.

• Effective January 1, 2015
• (based on date of service or date of discharge

for admissions)

• Increased Stop-Loss Reimbursement

threshold

• Increased per-diem rates
• Established Outpatient Base Rates
• Established Geographic Modifiers

Hospital Reimbursement Manual, 2016 Edition, Rule 69L-7.501, F.A.C.

• Workshop held July 28, 2016
• Increases Stop-Loss Reimbursement threshold

to $65,587.00

• Increases per-diem rates
• Inpatient trauma:

– Surgical - $4,216.00 Non-Surgical - $2,534.00

• Inpatient acute care:

– Surgical - $4,215.00 Non-Surgical - $2,501.00

• Updates Outpatient Base Rates
• Updates Geographic Modifiers

Expert Medical Advisors, Rule 69L-30, F.A.C.

• Effective March 1, 2016
• Introduced the online certification and educational

tutorial

• Simplified the qualifications for becoming a certified

Expert Medical Advisor

• Increased reimbursement fees for EMA services
• Established reimbursement fees for ancillary EMA

services

• Anticipate updating to reflect statutory change –

effective 10/1/2016

Expert Medical Advisors

• About 140 Expert Medical Advisors
• We need EMAs in the following specialties
• Internal Medicine
• Neurology and Psychiatry
• Pain Management
• Anesthesiology
• Eligible for use by DWC or JCC to resolve disputed

appropriateness of medical care and treatment issues

• Florida DWC EMA Website:

https://msuwebportal.fldfs.com/

Expert Medical Advisors Web Portal

Utilization and Reimbursement Dispute Rule, Rule 69L-31, F.A.C.

• First workshop held January 12, 2016
• Second workshop held June 10, 2016
• Summary of changes:
• Relaxes requirements for notices of disallowance or

adjustment of payment require to file a petition

• Notice of Deficiencies will remain
• Reflects the statutory change to 45 days for filing

reimbursement dispute petitions and 30 days for filing carrier response to petitions

• Clarifies contract review in determination process

Carrier Report of Health Care Provider (HCP) Violations, Rule Chapter 69L-34, F.A.C.

• General Violation types:
• Improper Billing of Services
• Improper Reporting of Services
• Improper Form Completion
• Standard of Care Violation, including overutilization
• Referral Submission Types
• Manual- Form DFS-F6-DWC-2000 Health Care Provider

Violation Referral

• Health Care Provider Violations Website:

https://apps8.fldfs.com/hcprov/default.aspx

Carrier Reports of HCP Violations Performance Rule 69L-34, F.A.C.

Carrier Reports of HCP Provider Violations Rule 69L-34, F.A.C.

Medical Services Section Bureau of Monitoring and Audit Contact Information (850) 413-1613

Theresa Pugh, Program Administrator Medical Services Theresa.Pugh@myfloridacfo.com Lavounia Bozman, Sr. Management Analyst I Lavounia.Bozman@myfloridacfo.com

Customer Assistance 850-413-1613

workers.compmedservice@myfloridacfo.com

Qu Ques estions tions

Carrier Compliance and Industry Performance

Pam Macon Bureau Chief Compliance

Today’s Topics

• Bureau of Monitoring and Audit Data
• Explanation of Bill Reviews
• Medical Services Statistics
• Q & A

Bureau of Monitoring & Audit

The Bureau of Monitoring and Audit (M&A) is responsible for ensuring that the practices of insurers, claim administrators and providers meet the requirements of Chapter 440, Florida Statutes and the Florida Administrative Code.

Bureau of Monitoring & Audit

The responsibilities are handled through four programmatic areas: – Audit Section – Penalty Section – Permanent Total Disability Section – Medical Services Section

Audit Section

Pursuant to Sections 440.185, 440.20, and 440.525, Florida Statutes and the rules of the Florida Administrative Code, the Audit Section examines claims- handling practices of: – Insurers – Self-insurers – Self-insurance funds – Other claims-handling entities

AUDIT SECTION

During FY 2015-2016, the Audit Section:

• 50 on-site insurer audits
• 5,809 insurer claim files
• Identified 749 files with underpayments
• additional injured worker payments of $337,728

for indemnity benefits, penalties, and interest

AUDIT SECTION

FY 2014/2015

Category Totals Number of Audits 56 Total Files Reviewed 5,303 Files Reviewed for Indemnity Payments 3,597 Underpaid Files 491 Total amount of UP + P&I Identified $310,845 Total Pattern & Practice Penalties Assessed $202,500

FY 2015/2016

Category Totals Number of Audits 50 Total Files Reviewed 5,809 Files Reviewed for Indemnity Payments 4,274 Underpaid Files 749 Total amount of UP + P&I Identified $337,728 Total Pattern & Practice Penalties Assessed $392,500

Untimely Indemnity Payment and FRoI Penalties by Fiscal Year

$64,200 $70,850 $83,300 $102,300 $27,500 $25,800 $60,300 $78,900

$0 $20,000 $40,000 $60,000 $80,000 $100,000 $120,000

FY12-13 (61 Audits) FY 13-14 (52 Audits) FY 14-15 (56 Audits) FY 15-16 (50 Audits)

Total Amount of Penalties Issued for Untimely Indemnity Payments Total Amount of Penalties Issued for Untimely First Reports of Injury or Illness

Total Non-Willful Pattern & Practice Penalties by Fiscal Year 41 64 81 157

$102,500 $160,000 $202,500 $392,500

$0 $50,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 20 40 60 80 100 120 140 160 180

FY12-13 (61 Audits) FY13-14 (52 Audits) FY14-15 (56 Audits) FY 15-16 (50 Audits)

PENALTY SECTION

The Penalty Section is responsible for evaluating and assessing insurer performance of timely payments of initial indemnity benefits and medical bills, and the untimely reporting of First Reports of Injury or Illness and medical bills.

CPS – First Reports Reviewed

Fiscal Year # of First Reports Reviewed FY 11-12 53,211 FY 12-13 51,690 FY 13-14 52,344 FY 14-15 53,929 FY 15-16 54,731

CPS Performance Statistics

Fiscal Year Timely Initial Benefit Payments Timely Filing of First Reports

FY 11-12 95% 95% FY 12-13 95% 95% FY 13-14 95% 95% FY 14-15 95% 93% FY 15-16 93% 95%

CPS Performance Statistics

Fiscal Year Timely Medical Bill Payments Timely Medical Bill Filing

FY 11-12 99% 99% FY 12-13 98% 96% FY 13-14 99% 98% FY 14-15 99% 99% FY 15-16 98% 98%

PERMANENT TOTAL DISABILITY SECTION

Division pays permanent total supplemental benefits on accidents prior to July 1, 1984 to eligible injured workers FY 2015-2016 supplemental benefits for 987 claims totaling $14,624,125 were calculated, approved, and processed

EXPLANATIONS OF BILL REVIEW (EOBRs)

What is an EOBR?

An Explanation of Bill Review is the notice of payment or notice of adjustment, disallowance or denial sent by a carrier, service company/third party administrator

• r any entity acting on behalf of a carrier to

a health care provider containing code(s) and code descriptor(s), in conformance with subsection 69L-7.740(13), Florida Administrative Code.

EXPLANATIONS OF BILL REVIEW (EOBRs)

What is the purpose of the EOBR?

The purpose is to communicate to the provider, the carrier’s decision to pay, disallow or adjust

• reimbursement. The carrier is required to explain the

reimbursement for each billed line item by using the EOBR codes (listed in Rule within subsection 69L- 7.740(13)(b), F.A.C.) that best describe the carrier’s reimbursement decision.

EXPLANATIONS OF BILL REVIEW

• Explanations of Bill Review (EOBRs) must contain

the following elements per rule 69L-7.740, F.A.C.: – Insurer’s name; – Insurer’s mailing address; – Division-issued insurer ID number – EOBR Codes from the Billing Rule – Compliant descriptors – Name of the dispute copy designee – Name of the dispute copy designee’s mailing address – Disallowance language

MEDICAL SERVICES SECTION

• Responsibilities:

– Establishing rules and policy – Implementing the Three-Member Panel’s uniform schedules for Maximum Reimbursement Allowances (MRAs) – Resolving medical reimbursement disputes between providers and payers – Certifying Expert Medical Advisors

MEDICAL SERVICES SECTION

• A Petition for Reimbursement Dispute must

be filed within 45 days from receipt of the carrier’s notice of disallowance or adjustment of payment.

• The carrier must submit, within 30 days of

receipt of the petition, its response and all documentation to the department to substantiate its disallowance or adjustment.

MEDICAL SERVICES SECTION

• Beginning Fiscal Year 15-16, there were 13,064 pending

Petitions for Resolution of Reimbursement Disputes (Petitions)

• During Fiscal Year 15-16, the Medical Services Section:

– Received 5,533 Petitions – Processed 18,133 Petitions

MEDICAL SERVICES SECTION

• The Medical Services Section issues Dismissals or

Determinations for all Petitions received

• In Fiscal Year 2015-2016, the Section issued:

– 9,570 Determinations

– 8,546 Dismissals

Medical Services Data

Petitions Submitted by Provider Type

FY 12-13 FY 13-14 FY 14-15 FY 15-16

Practitioner

7,805 8,412 7,323 3,601

ASC

737 665 331 400

Hospital Inpatient

350 266 453 341

Hospital Outpatient

1,303 1,069 1,550 1,184

Total

10,209 10,483 9,659 5,533

Medical Services Data

Petitions Determination Outcomes by Provider Type

FY 12-13 FY 13-14 FY 14-15 FY 15-16 Practitioner 2,573 2.992 4,326 8,221 ASC 584 512 213 240 Hospital Inpatient 217 183 226 215 Hospital Outpatient 966 767 996 894 Total 4,340 5,454 5,761 9,570

Medical Services Data

Petitions Dismissal Outcomes by Provider Type FY 12-13 FY 13-14 FY 14-15 FY 15-16 Practitioner 2,605 4,432 2,374 7,636 ASC 216 173 104 175 Hospital Inpatient 140 96 181 174 Hospital Outpatient 448 270 432 548 Other 2 13 Total 3,409 4,971 3,093 8,546

Charlene Miller, Bureau Chief (850) 413-1738

• Charlene.Miller@myfloridacfo.com

Derrick Richardson, Audit and PT Manager (850) 413-1671

• Derrick.Richardson@myfloridacfo.com

QU QUESTIONS ESTIONS

When a Notice of Action or Change is Required

Charlene Miller & Lawanna Morrow Bureau of Monitoring and Audit

69L-56.304 & 69L-56.3045 Florida Administrative Code

Electronic Notice of Action or Change, Including Change in Claims Administration

Notices of Action or Change Top 10 Sequencing Errors/Rejections

• Report RTW Info
• Report MMI Info
• Report a Change From TTD to TPD
• Report Adjustment to AWW/CR
• Report Annual Increase of PTD Supplemental Benefits
• Report Suspension of Benefits
• Report a Settlement
• Report Reinstatement of Benefits
• Report a Change From TPD to TTD
• Report an Acquired Claim

EDI Resources

http://www.myfloridacfo.com/division/WC/EDI/default.htm

EDI Resources

http://www.myfloridacfo.com/division/WC/EDI/default.htm

71

Cla laim ims s EDI I questions estions should

• uld be sent

nt via ia email ail to to cla laims.edi ims.edi@myflo @myfloridacfo.com ridacfo.com

Auditing Notice of Action or Change Compliance

• Compliance percentages are documented in

Audit Reports, and Pattern and Practice Penalties are assessed for compliance percentages below 90% per 440.525(4), Florida Statutes and Rule 69L-24.007, Florida Administrative Code.

4,318 4,121 3,735 4,647 2,727 786 521 982 734 1053 912 892 904 922 719

0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00% 45.00% 50.00% 55.00% 60.00% 65.00% 70.00% 75.00% 80.00% 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000 4,500 5,000 5,500 6,000 6,500 FY 11-12 FY 12-13 FY 13-14 FY 14-15 FY 15-16

Notices of Action or Change Compliance by Fiscal Year

Timely Not Sent Sent Late Compliance

Reason Notice of Change was Necessary # of Late Forms Report RTW Info 232 Report MMI Info 127 Report a Settlement 69 Report Suspension of Benefits 64 Report Reinstatement of Benefits 58 Report Adjustment to AWW/CR 53 Report a Change From TTD to TPD 53 Report Annual Increase of PTD Supps 33 Report a Change From TPD to TTD 18

FY 15/16 Notices of Action or Change Filed Late

Reason Notice of Change was Necessary # of Not Filed Forms Report RTW Info

268

Report MMI Info

236

Report a Change From TTD to TPD

121

Report a Settlement

112

Report Suspension of Benefits

72

Report Annual Increase of PTD Supps

69

Report a Change From TPD to TTD

63

Report Adjustment to AWW/CR

52

Report Reinstatement of Benefits

35

Report the Recoupment of Paid Benefits

12

FY 15/16 Notices of Action or Change Not Filed

Contacts:

Charlene.Miller@myfloridacfo.com Bureau Chief, Bureau of Monitoring & Audit (850) 413-1738 Derrick.Richardson@myfloridacfo.com Operations Management Consultant Manager (850) 413-1671 Lawanna.Morrow@myfloridacfo.com Workers’ Compensation Administrator-Tallahassee (850) 413-1791 Kamilah.Knighton@myfloridacfo.com Workers’ Compensation Administrator-Orlando

(407) 835-4492

Division of Workers’ Compensation

Medical & Claims EDI Update

August 2016

Michelle Carter

Bureau of Data Quality and Collection

Florida Medical EDI

• Revision F Phase-In Schedule
• Revision F Testing
• Helpful Resources

Discussion Topics

Revision F Phase-In Schedule

All phase-in schedule dates are based on the effective date of the Workers’ Compensation Medical Reimbursement and Utilization Rule – which took effect on February 18, 2016. Revision F Phase-in Schedule

Group 1 (Submitter ID 001 – 199) Testing began on July 18, 2016 (150 days after the effective date of rule) and must be completed by August 31, 2016 (195 days of the effective date of the rule).

Revision F Phase-in Schedule

Group 2 (Submitter ID 200 – 899) Testing begins on September 1, 2016 (195 days after the effective date of rule) and must be complete within 240 days of the effective date of the rule (October 15, 2016).

Revision F Phase-in Schedule

Group 3 (Submitter ID 900 and above) Testing begins on October 16, 2016 (240 days after the effective date of rule) and must be complete within 285 days of the effective date of the rule (November 29, 2016).

Revision F Phase-in Schedule

Revision F Testing

Revision F Testing

• Electronic files containing five (5) test bills

(for each form type tested) must be transmitted to the Division by current batch submitters.

• Electronic files containing fifteen (15) test

bills (for each form type tested) must be transmitted to the Division by new batch submitters.

Revision F Testing

• The ‘Test/Production Indicator’ in the file

name and ‘Transmission Header Record’ must be set to ‘T’.

Revision F Testing

• Current web submitters must submit five

(5) test bills (for each form type tested) to the Division.

• New web submitters must submit fifteen

(15) test bills (for each form type tested) to the Division.

• There are several test scenarios that must

be completed. Pre-filled “dummy” bills and information pertaining to the scenarios have/will be sent to all submitters prior to the test start date.

• If any changes are made to the information

listed on any of the “dummy” bills provided, a copy must be sent to the Division via fax

• r email.

Revision F Testing

• Revision F testing is not considered

complete until all bills have been accepted by the Medical Data Management System, passed visual comparison to paper bills and all test scenarios have been successfully completed.

• Submitters will be notified via email upon

completion of testing.

Revision F Testing

Please direct any questions related to Medical EDI submissions to:

MedicalDataManagementTeam@myfloridacfo.com Fax number for test bills: (850) 413-1986

Helpful Resources

There have been changes recently made to the Division’s website.

http://www.myfloridacfo.com/Division/WC/

Helpful Resources

Helpful Resources

Helpful Resources

Helpful Resources

Florida Claims EDI

• Triage & Training Team
• TA-FL Errors (Non-Fatal)
• Helpful Resources

Discussion Topics

Triage & Training Team

The Division has expanded its efforts to assist Trading Partners with successfully submitting claims transactions by creating the Triage & Training Team.

Triage & Training Team

In an effort to help minimize rejections and improve the quality of data submitted to the Division, the Triage & Training Team provides training on various Claims EDI related issues by partnering with individual claim administrators.

Triage assistance is provided via:

• Webinars
• Teleconferences
• Onsite visits (claim administrator’s office
• r at the Division)

Triage & Training Team

Triage assistance can be requested by the claim administrator or identified and initiated by the one of the Triage Team members. To request training assistance, please send an email to: Tonya.Granger@myfloridacfo.com

Triage & Training Team

TA-FL Errors (Non-Fatal)

The Division has re-evaluated the TA-FL process to reduce the number of errors received for which the industry and EDI team have to respond. As a result of this, all unresolved errors prior to April 27, 2016 were mass closed.

TA-FL Errors (Non-Fatal)

As you are aware, automated email notifications are sent (next day) regarding the posting of non-fatal errors from the previous night’s transactions. As outlined in Division Rule 69L-56.300(1)(i), the errors should be responded to on or before 21 days after the date the error was posted.

TA-FL Errors (Non-Fatal)

At this time, the Division has staff dedicated to review and respond to all TA-FL errors received in the Claims EDI

• Warehouse. The team will only handle

errors on transactions where notes have been entered into the Claims EDI Warehouse by the claim administrator.

TA-FL Errors (Non-Fatal)

Helpful Resources

Helpful Resources

Helpful Resources

Helpful Resources

Thank You!

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