THE FLORIDA WORKERS’ COMPENSATION SYSTEM

1
THE FLORIDA WORKERS COMPENSATION SYSTEM
TUTORIAL for EXPERT MEDICAL ADVISORS
2
This tutorial will provide the reader with
highlights from each of the pertinent medical
sections of the Florida Statutes.The Department
of Financial Services - Division of Workers
Compensations internet site offers a complete
copy of Chapter 440, F.S. on the home web page
http//www.fldfs.com/wc. (Click on Ch. 440
FL Statutes located in thetopics listed on the
left side of the home page.)
3
Through this program

• THE EXPERT MEDICAL ADVISOR WILL BE ABLE TO
  UNDERSTAND HIS/HER RESPONSIBILITIES FOR PROVIDING
  EXPERT OPINION TO FACILITATE THE RESOLUTION OF
  MEDICAL CARE ISSUES AND DISPUTES PENDING BEFORE
  THE DIVISION OR A JUDGE OF COMPENSATION CLAIMS

4
The Florida Workers Compensation System Goals
provide for the following

• A Self Executing System
• Quick Efficient Delivery of Medical Benefits
• Medically Necessary Treatment
• Facilitation of Return to Work

5
WHAT ARE WORKERS COMPENSATION BENEFITS?

• MEDICAL -
• MEDICALLY NECESSARY
• MEDICAL CARE
• INDEMNITY -
• WAGE REPLACEMENT BENEFITS
• REEMPLOYMENT -
• VOCATIONAL REHABILITATION BENEFITS TO
  FACILITATE EARLY RETURN TO SUITABLE GAINFUL
  EMPLOYMENT

6
WHAT IS THE ROLE OF THE PHYSICIAN WHO RENDERS
CARE AND SERVICES TO INJURED WORKERS IN THE
FLORIDA WORKERS COMPENSATION SYSTEM?
7
THE ROLE OF THE PHYSICIAN

• TO ESTABLISH AN ACCURATE DIAGNOSIS
• The Clinical Evaluation must be based
  on History/Physical/Diagnostics, Diagnosis
  Treatment, Studies and Consultations
• TO PRESCRIBE MEDICALLY NECESSARY TREATMENT
• Definition - s.440.13(1)(m), F.S.
• The Proposed Treatment Plan MUST BE
  submitted on
• Form DFS-F5-DWC-25 (DWC-25)
• TO COMMUNICATE THE PATIENTS FUNCTIONAL STATUS
• Identify Medical Restrictions/Limitations
  relating to work full time or transitional duty
  
• Prescribe Restrictions/Limitations and
  submit to the insurer on DWC-25

8
STANDARDS OF CARE s.440.13(16), F.S.
The health care providers care and treatment
shall be based on the following standards of care.

• Treatment is inherently scientifically logical
• Treatment focuses on clinical dysfunction
• High intensity, short duration treatment approach
• Treatment plan, therapies, medication, functional
  limitations/restrictions periodic review
• Additionally, the treatment plan is reviewed upon
  receiving information from other health care
  providers no less than every 30 days

9
STANDARDS OF CARE (continued) s.440.13(16), F.S.

• Treatment MATCHES physiologic and clinical
  problem
• Treatment SHALL match type, intensity, duration
  of service necessary for identified problem
• Restrictions / Limitations are based on objective
  RELEVANT medical findings
• Restrictions / Limitations are reviewed
  continuously and at EACH and EVERY visit
• Return to work (RTW) is an integral part of the
  treatment plan

10
THE ROLE OF THE PHYSICIAN(continued)

• WHEN PROVIDING SPECIFIC LIMITATIONS /
  RESTRICTIONS
• The health care provider shall identify
• Specific Parameters (i.e. load, frequency,
  duration, position)
• Measured inabilities
• Detriments to recovery
• Imminent danger to self or others
• Alternative methods of function

• THE HEALTH CARE PROVIDER IS TO IDENTIFY THE
  EMPLOYEES PHYSICAL LIMITATIONS, AND ADDRESS
  RETURN TO WORK STATUS

11
STANDARDS OF CARE (continued) s.440.13(16), F.S.
The Standards of Care shall be followed in
providing medical care under Chapter 440
(a) Abnormal anatomical findings alone, in the
absence of objective relevant medical findings,
shall not be an indicator of injury or illness, a
justification for the provision of remedial
medical care or the assignment of restrictions,
or the foundation for limitations.
12
STANDARDS OF CARE (continued) s.440.13(16), F.S.
(b) At all times during evaluation and treatment,
the provider shall act on the premise that
returning to work is an integral part of the
treatment plan. The assignment of restrictions
and limitations shall be reviewed with each
patient exam and upon receipt of new information

• The health care provider shall report changes in
  restrictions and limitations on the Form DWC-25.

13
STANDARDS OF CARE (continued) s.440.13(16), F.S.
(c) Reasonable, necessary medical care of injured
employees shall in all situations 1. Utilize a
high intensity, short duration treatment
approach 2. Include reassessment of treatment
plans, regimes, therapies, prescriptions, and
functional limitations or restrictions
prescribed by the provider every 30 days 3.
Be focused on treatment of the individual
employees specific clinical dysfunction or
status
14
STANDARDS OF CARE (continued) s.440.13(16), F.S.
All treatment shall be inherently scientifically
logical, and the evaluation or treatment
procedure must match the documented physiologic
and clinical problem. Treatment shall match the
type, intensity, and duration of service required
by the problem identified.

• The carrier may disallow reimbursement for a
  procedure when the treatment procedure does not
  match the problem identified.

15
THE ROLE OF THE PHYSICIAN (continued)

• TO ESTABLISH THE DATE OF MAXIMUM MEDICAL
  MPROVEMENT
• MMI is reached when no further recovery is
  anticipated or when
  maximum improvement is a reasonable medical
  probability s.440.02(10), F.S.
• TO DOCUMENT THE PERMANENT IMPAIRMENT RATING (PIR)
• The physician shall
• calculate PIR at the time of MMI
• identify anatomical/functional abnormalities or
  losses resulting from work-related
  injury or illness
• identify the injured workers permanent
  restrictions/limitations

16
PERMANENT IMPAIRMENT RATING s.440.15(3)(b), F.S.

• Pursuant to the Florida Statutes, only physicians
  licensed under Florida Statute Chapters, as
  appropriate (considering the nature of the
  injury), are authorized to render an opinion
  regarding the permanent impairment rating of an
  injured employee
• 458 Medical 469 Osteopathic
• 460 Chiropractors 461 Podiatrists
• 463 Optometrists 466 Dentists

17
TEMPORARY TOTAL DISABILITY s.440.15(2)(a), F.S.
When does the healthcare provider assign MMI
PIR?
once the employee reaches the maximum number of
weeks allowed, or the employee reaches the date
of maximum medical improvement, whichever occurs
earlier, temporary disability benefits shall
cease and the injured workers permanent
impairment shall be determined.

• Once the physician determines the employee has
  achieved maximum medical improvement, the
  physician SHALL calculate the permanent
  impairment rating.

18
PERMANENT IMPAIRMENT RATING s.440.15(3)(d), F.S.
After the employee has been certified by a
doctor as having reached maximum medical
improvement the certifying doctor shall evaluate
the condition of the employee and assign an
impairment rating, using the impairment schedule
on the following slide.

• Maximum medical improvement and impairment rating
  shall be reported by the physician to the carrier
  on the Form DWC-25.

19
PERMANENT IMPAIRMENT RATING/ MAXIMUM MEDICAL
IMPROVEMENTs.440.15(3)(d)1., F.S.

• The certifying doctor shall issue a written
  report to the employee and the carrier certifying
  that maximum medical improvement has been
  reachedand providing any other information
  required by the department by rule.
• (report MMI/PIR on Form DWC-25, specifying
  permanent restrictions / limitations pursuant to
  69L-7.602, F.A.C.)

The carrier shall establish an overall maximum
medical improvement date and permanent impairment
rating, based on all such reports.
20
PERMANENT IMPAIRMENT RATING s.440.15(3)(d), F.S.
If the certification and evaluation are performed
by a doctor other than the employees treating
doctor, the certification and evaluation must be
submitted to the treating doctor, the employee,
and the carrier within 10 days after the
evaluation. The treating doctor must indicate to
the carrier agreement or disagreement with the
other doctors certification and evaluation.

• The certifying doctor who is not the employees
  treating doctor must submit a completed Form
  DWC-25 to the treating doctor, the employee and
  the carrier within 10 days after the evaluation.

21
SUBSEQUENT INJURYAPPORTIONMENT s.440.15(5)(b),
F.S.
The degree of permanent impairment or disability
attributable to the accident or injury shall be
compensated in accordance with this section,
apportioning out the preexisting permanent
condition based on the anatomical impairment
rating attributable to the preexisting condition.
22
RATING PERMANENT IMPAIRMENT s.440.15(3)(b), F.S.
The health care provider shall use the following
resources to calculate a permanent impairment
rating (based on the date of injury or accident
DOI)

• AMA, 3RD EDITION
• for DOI prior to 07/01/90
• MINNESOTA GUIDE
• for DOI 07/01/90 to 06/20/93
• 1993 Florida Impairment Rating Guide (FIRG)
• for DOI 06/21/93 to 01/07/97
• 1996 FL Uniform P.I.R. Schedule
• for DOI 01/08/97 and thereafter

Impairment Rating
23
Florida Statutes
Chapter 440, Florida Statutes, identifies the
employer, health care provider and insurer/
carrier duties and responsibilities related to
the provision of care for Florida injured
workers. The health care provider should review
the following excerpts to be familiar with the
Florida Statutes pertaining to medical services.

24
Florida Statutes

• 440.02 Definitions.
• 440.09 Coverage.
• 440.093 Mental and nervous injuries.
• 440.102 Drug-free workplace program
  requirements.
• 440.105 Prohibited activities reports
  penalties limitations. (Fraud)
• 440.13 Medical services and supplies penalty
  for violations limitations

25
Florida Statutes

• 440.134 Workers compensation managed care
  arrangement
• 440.15(3) Permanent impairment benefits/ rating
• 440.15(5) Subsequent injury apportionment
• 440.151 Occupational diseases
• 440.20 Time for payment of compensation and
  medical bills penalties for late payment
• 440.491 Reemployment of injured workers
  rehabilitation

26
Florida Statutes s.440.02 Definitions

• (10) Date of maximum medical improvement
  means the date after which further recovery from,
  or lasting improvement to, an injury or disease
  can no longer reasonably be anticipated, based
  upon reasonable medical probability.
• (15)(a) Employee means any person who receives
  remuneration from an employer for the performance
  of any work or service while engaged in any
  employment and includes, but is not limited to,
  aliens and minors.

27
Florida Statutes s.440.09 Coverage
The following factors impact whether an injury or
illness is compensable under Floridas workers
compensation.

• (1) Major Contributing Cause means the cause
  which is more than 50 responsible for the injury
  as compared to all other causes combined for
  which treatment or benefits are sought.
• (1) Pain or other subjective complaints alone,
  in the absence of objective relevant medical
  findings, are not compensable.
• (1) Objective relevant medical findings are
  those objective findings that correlate to the
  subjective complaints of the injured employee and
  are confirmed by physical examination findings or
  diagnostic testing.

28
Florida Statutes s.440.09 Coverage (continued)

• (1)(a) Subsequent Injury No compensation or
  benefits for any subsequent injury the employee
  suffers as a result of an original work injury
  unless the original injury is the major
  contributing cause of the subsequent injury.
• (1)(b) If a work injury combines with a
  preexisting disease or condition to cause or
  prolong disability or need for treatment, the
  employer must pay compensation or benefits only
  to the extent that the work injury remains more
  than 50 responsible for the injury as compared
  to all other causes combined.
• MAJOR CONTRIBUTING CAUSE must be demonstrated by
  medical evidence only.

29
Florida Statutes s.440.09 Coverage (continued)

• (3) Compensation is not payable if the injury
  was occasioned primarily by the intoxication of
  the employee by the influence of any drugs not
  prescribed by a physician or by the willful
  intention of the employee to injure or kill
  himself, herself, or another.
• (7)(c) If the injured worker refuses to submit
  to a drug test, it shall be presumed in the
  absence of clear and convincing evidence to the
  contrary that the injury was occasioned primarily
  by the influence of drug.

30
Review of Coverage s.440.09(1)(a)(b), F.S.

• The treatment must be based on objective RELEVANT
  medical findings
• The work-related injury must be the MAJOR
  CONTRIBUTING CAUSE
• The diagnosis must be determined by MEDICAL
  EVIDENCE only
• Pain and/or a subjective complaint without
  objective RELEVANT medical findings is NOT
  COMPENSABLE

31
Florida Statutes s.440.093 Mental and nervous
injuries

• (1) A mental or nervous injury due to stress,
  fright, or excitement only is not an injury by
  accident arising out of the employment. A
  physical injury resulting from mental or nervous
  injuries unaccompanied by physical trauma
  requiring medical treatment shall not be
  compensable under this chapter.
• (2) Mental and nervous injuries occurring as a
  manifestation of an injury compensable under this
  chapter shall be demonstrated by clear and
  convincing medical evidenceThe compensable
  physical injury must be and remain the major
  contributing causeCompensation is not payable
  for the mental, psychological or emotional injury
  arising out of depression

32
Florida Statutes s.440.093 Mental and nervous
injuries (cont.)

• (3) Subject to the payment of permanent benefits
  under s.440.15, in no event shall temporary
  benefits for a compensable mental or nervous
  injury be paid for more than 6 months after the
  date of maximum medical improvement for the
  injured employees physical injury or injuries

33
Florida Statutes s.440.102 Drug-free workplace
program requirements

• (1)(c) Drug means alcohol, including a
  distilled spirit, wine, a malt beverage or an
  intoxicating liquor an amphetamine a
  cannabinoid cocaine phencyclidine (PCP) a
  hallucinogen methaqualone an opiate a
  barbiturate a benzodiazepine a synthetic
  narcotic a designer drug or a metabolite of any
  of the substances listed. An employer may test
  an individual for any or all of such drugs.

34
Florida Statutes s.440.102 Drug-free workplace
program requirements

• (5)(e)2. A specimen for a drug test may be taken
  or collected by a physician, a physician
  assistant, a registered professional nurse, a
  licensed practical nurse, or a nurse practitioner
  or a certified paramedic who is present at the
  scene of an accident for the purpose of rendering
  emergency medical service or treatment.
• (5)(m) An employer shall pay the cost of all
  drug tests, initial and confirmation, which the
  employer requires of employees. An employee or
  job applicant shall pay the costs of any
  additional drug tests not required by the
  employer.

35
Florida Statutes s.440.102 Drug-free workplace
program requirements

• (5)(p) All authorized remedial treatment, care
  and attendance provided by a health care provider
  to an injured employee before medical and
  indemnity benefits are denied under this section
  must be paid for by the carrier or self-insured.
  However, the carrier or self-insurer must have
  given reasonable notice to all affected health
  care providers that payment for treatment, care
  and attendance provided to the employee after a
  future date certain will be denied.

36
Florida Statutes s.440.105 Prohibited
activities reports penalties limitations

• (1)(a) any professional practitioner licensed
  or regulated by the Department of Healthor any
  employee thereof, having knowledge or who
  believes that a fraudulent act or any other act
  or practice which, upon conviction, constitutes a
  felony or misdemeanor under this chapter is being
  or has been committed shall send to the Division
  of insurance Fraud, Bureau of Workers
  Compensation Fraud, a report or information
  pertinent to such knowledge or belief and such
  additional information relative thereto as the
  bureau may require.

37
Florida Statutes s.440.105 Prohibited
activities reports penalties limitations

• (4)(c) It shall be unlawful for any physician
  licensed under chapter 458, osteopathic physician
  licensed under chapter 469L, chiropractic
  physician licensed under chapter 460, podiatric
  physician licensed under chapter 461, optometric
  physician licensed under chapter 463, or any
  practitioner licensed under the laws of this
  state to knowingly and willfully assist, conspire
  with, or urge any person to fraudulently violate
  any of the provisions of this chapter.

38
Florida Statutes s.440.105(7) Fraud Statement

• Fraud Statement - An injured employee or any
  other party making a claim under this chapter
  shall provide his or her personal signature
  attesting that he or she has reviewed,
  understands, and acknowledges the following
  statement

Any person who, knowingly and with intent to
injure, defraud, or deceive any employer or
employee, insurance company, or self-insured
program, files a statement of claim containing
any false or misleading information commits
insurance fraud, punishable as provided in s.
817.234.
39
Florida Administrative Code Rule 69L-3.0047,
F.A.C. Fraud Statement

• (2) A party who makes claims for services
  provided to the claims-handling entity on a
  recurring basis may make one personally signed
  attestation to the claims-handling entity as
  required by Section 440.105(7), F.S., which will
  satisfy the requirement for all claims submitted
  to the claims-handling entity for the calendar
  year in which the attestation is submitted.

• Health Care Providers must submit a signed fraud
  statement once per calendar year to each insurer
  / carrier from which they are requesting
  reimbursement.

40
Florida Statutes 440.105(7)

• Fraud Statement

If the injured employee or other party refuses to
sign the document attesting that he or she has
reviewed, understands, and acknowledges the
statement, benefits, or payments under this
chapter shall be suspended until such signature
is obtained.

• The insurer may disallow payment for a medical
  bill if the health care provider fails to have a
  signed Fraud Statement on file with the insurer.

41
Florida Statutes 440.13 Medical Services
Each subsection of the following Florida Statutes
is presented in detail to familiarize the health
care provider with the Florida Statutes pertinent
to treatment rendered to injured workers in the
Florida Workers Compensation system.


42
Florida Statutes 440.13 Medical Services

• DEFINITIONS
• 440.13(1)(d) Health care provider
  certification
• 440.13(1)(h) Health care provider who renders
  care pursuant to a prescription or under the
  supervision of a physician
• 440.13(1)(l) Medical necessity
• 440.13(1)(q) Physician

43
Florida Statutes 440.13 Medical Services

• 440.13(2)(d) Carrier right to transfer care
• 440.13(3)(a) Provider certification
  Authorization prior to provision of care
• 440.13(3)(b) Emergency care authorization
• 440.13(3)(c) Provider referrals
• 440.13(3)(g) Employee liability for payment

44
Florida Statutes 440.13 Medical Services

• 440.13(3)(d) (i) Carrier authorization
• 440.13(4)(a) Form DFS-F5-DWC-25
• 440.13(4)(b) Provision of medical records
• 440.13(4)(c) Physician-patient privilege
• 440.13(5)(a) Independent medical
  examinations (IME)

45
Florida Statutes 440.13 Medical Services

• 440.13(5)(d) IME No-show provisions
• 440.13(7)(a) Reimbursement disputes
• 440.13(8)(b) Overutilization statute or rule
  violations health care provider
  penalties/sanctions
• 440.13(9) Expert Medical Advisors
• 440.13(10) Witness (deposition) fees

46
Florida Statutes 440.13 Medical Services

• 440.13(12) Reimbursement allowances
• 440.13(13) Removal of physicians from the list
  of certified health care providers
• 440.14(14)(c) Co-payment after assignment of
  MMI
• 440.13(15) Practice Parameters
• 440.13(16) Standards of Care - reasonable
  necessary medical care

47
Florida Statutes 440.13(1)

• Definitions

• Carrier means, for purposes of this section,
  insurance carrier, self-insurance fund or
  individually self-insured employer, or assessable
  mutual insurer.
• Certified health care provider means a health
  care provider who has been certified by the
  Division or who has entered an agreement with a
  licensed managed care organization to provide
  treatment to injured workers under this section.
  Certification of such health care provider must
  include documentation that the health care
  provider has read and is familiar with the
  portions of the statute, impairment guides,
  practice parameters, protocols of treatment, and
  rules which govern the provision of remedial
  treatment, care, and attendance.

48
Florida Statutes 440.13(1)

• Definitions

• Health care provider means a physician or any
  recognized practitioner who provides skilled
  services pursuant to a prescription or under the
  supervision or direction of a physician and who
  has been certified by the Division as a health
  care provider
• (l) Medically necessary or medical necessity
  means any medical service or medical supply which
  is used to identify or treat an illness or
  injury, is appropriate to the patients diagnosis
  and status of recovery, and is consistent with
  the location of service, the level of care
  provided, and applicable practice parametersThe
  service must not be of an experimental,
  investigative, or research nature.

49
Florida Statutes 440.13(1)

• Definitions

• (o) Pattern or practice of overutilization
  means repetition of instances of overutilization
  within a specific medical case or multiple cases
  by a single health care provider.
• (q) Physician or doctor means a physician
  licensed under chapter 458, an osteopathic
  physician licensed under chapter 469L, a
  chiropractic physician licensed under chapter
  460, a podiatric physician licensed under chapter
  461, an optometrist licensed under chapter 463,
  or a dentist licensed under chapter 466, each of
  whom must be certified by the Division
• (r) Reimbursement dispute means any
  disagreement between a health care provider or
  health care facility and carrier concerning
  payment for medical treatment.

50
CARRIER TRANSFER OF CAREs.440.13(2)(d), F.S.

• The carrier has the right to transfer the care of
  an injured employee from the attending health
  care provider if an independent medical
  examination determines that the employee is not
  making appropriate progress in recuperation.

51
CERTIFICATION INSURER AUTHORIZATIONNon-Emergenc
y Cares. 440.13(3)(a), F.S.

• Conditions of eligibility for reimbursement
• The health care provider must have
• Certification from the Division and
• Insurer/Carrier authorization prior to provision
  of services
• Notice of Injury Filing the DWC-1 is the
• responsibility of the Employer.

52
CERTIFIED HEALTH CARE PROVIDER

• Certified Health Care Provider means a health
  care provider who has been certified by the
  Division or who has entered an agreement with a
  licensed managed care organization to provide
  treatment to injured workers under Chapter 440,
  pursuant to s.440.13(1)(d), Florida Statutes.

53
CERTIFIED HEALTH CARE PROVIDER
How does a physician become a Certified Health
Care Provider?

• The physician must meet the qualifications
  specified in Rule 69L-29, F.A.C.
• The physician must submit an accurately completed
  application for Health Care Provider
  Certification to the Division
• The application may be printed from the following
  link
• http//www.fldfs.com/wc/pdf/DFS-3160-0020.pdf

54
CERTIFICATION INSURER AUTHORIZATIONEMERGENCY
CAREs.440.13(3)(b), F.S.

• For emergency care services
• Pre-authorization use of a certified HCP is
  not required
• The HCP must notify the carrier by
• close of 3rd business day
• The treatable condition must arise from
  work-related accident

55
Emergency is defined. . .

• In s. 395.002(9), F.S.
• As an acute, severe (includes pain), causes
  impairment, death, or dysfunction
• And covers screening, exam, evaluation, care,
  treatment, or surgery to relieve / alleviate
  symptoms

56
EXPERIMENTAL, INVESTIGATIVE OR RESEARCH IN
NATURE
How does a health care provider gain approval for
treatment that may be deemed experimental,
investigative or research in nature?

• Effective October 1, 2003, the insurer / carrier
  has statutory authority to determine if a
  treatment procedure is experimental,
  investigative or research in nature.
• Effective October 1, 2003, all requests for
  determination of coverage for treatment
  procedures that may be experimental,
  investigative or research in nature shall be
  submitted by the health care provider to the
  carrier.

57
PROVIDER REFERRALSs.440.13(3)(c),F.S.

• A health care provider may not refer the
  employee to another health care provider,
  diagnostic facility, therapy center, or other
  facility without prior authorization from the
  carrier, except when emergency care is rendered.
  

• Referrals must be made to another certified
  health care provider, unless the referral is for
  emergency treatment.

58
EMPLOYEE LIABILITYFOR PAYMENT
Can the injured employee be billed for services
provided in relation to a compensable work
injury?

• The employee is not liable for payment of
  medical treatment or services provided pursuant
  to this section except as otherwise provided in
  this section. s.440.13(3)(g), F.S.
• )

• providers have recourse against the employer or
  carrier for payment for services rendered in
  accordance with this chapter. s.440.13(14)(a),
  F.S.

59
PAYMENT OF MEDICAL FEES s.440.13(14)(a), F.S.
Except for emergency care treatment, fees for
medical services are payable only to a health
care provider certified and authorized to render
remedial treatment, care or attendance under this
chapter A health care provider may not collect
or receive a fee from an injured employee within
this state, except as otherwise provided by this
chapter Such providers have recourse against the
employer or carrier for payment for services
rendered in accordance with this chapter.
60
PAYMENT OF MEDICAL FEES Patient
Copayment s.440.13(14)(c), F.S.
When may the healthcare provider collect payment
from the injured employee?
Notwithstanding any other provision of this
chapter, following overall maximum medical
improvement from an injury compensable under this
chapter, the employee is obligated to pay a
copayment of 10 per visit for medical services.
The copayment shall not apply to emergency care
provided to the employee.
61
SUBSEQUENT INJURYAPPORTIONMENT s.440.15(5)(b),
F.S.
If a compensable injury, disability, or need for
medical care, or any portion thereof, is a result
of aggravation or acceleration of a preexisting
condition, or is the result of merger with a
preexisting condition, only the disabilities and
medical treatment associated with such
compensable injury shall be payable under this
chapter

• The carrier may reduce reimbursement for medical
  services by the percentage of impairment or
  disability attributed to the preexisting
  condition.

62
OCCUPATIONAL DISEASES s.440.151(1)(a), F.S.
in no case shall an employer be liable for
compensation under the provisions of this section
unless such disease has resulted from the nature
of the employment in which the employee was
engaged under such employerand the nature of the
employment was the major contributing cause of
the disease. Major contributing cause must be
shown by medical evidence only, as demonstrated
by physical examination findings and diagnostic
testing.
63
OCCUPATIONAL DISEASES s.440.151(2), F.S.
Whenever used in this section the term
occupational disease shall be construed to mean
only a disease which is due to causes and
conditions which are characteristic of and
peculiar to a particular trade, occupation,
process , or employment than for the general
public. Occupational disease means only a
disease for which there are epidemiological
studies showing that exposure to the specific
substance involved, at the levels to which the
employee was exposed, may cause the precise
disease sustained by the employee.
64
PAYMENT OF MEDICAL BILLS s.440..20, F.S.
How long does an insurer/carrier have to pay a
bill?
(2)(b) The carrier must pay, disallow, or deny
all medical, dental, pharmacy, and hospital bills
submitted to the carrier in accordance with
department rule no later than 45 calendar days
after the carriers receipt of the bill. (4)
If the carrier is uncertain of its obligation to
provide all benefits or compensation, the carrier
shall immediately and in good faith commence
investigation of the employees entitlement to
benefits under this chapter and shall admit or
deny compensability within 120 after the initial
provision of compensation or benefits
65
INSURER / CARRIER AUTHORIZATIONs.440.13(3)(d),
F.S.
How long does an insurer/carrier have to
authorize or disallow a physicians written
request for treatment?

• A carrier must respond to a written request
  for authorization from an authorized health care
  provider by close of the third business day after
  receipt of the request.
• Prior authorization is NOT REQUIRED for
  EMERGENCY SERVICES.

66
INSURER / CARRIER AUTHORIZATION(continued) s.440.
13(3)(i), F.S.

• A carrier must respond to a written request for
  specialist consultations, surgical operations,
  physiotherapeutic or occupational therapy
  procedures, X-ray examinations or special
  diagnostic or laboratory tests that cost more
  than 1000 within 10 days after receipt of the
  request.

• Completion and submission of the DFS-F5-DWC-25
  is considered a written request for authorization
  of treatment.

67
FORM DWC-25Rule 69L-7.602, F.A.C.

• DFS-F5-DWC-25 -- Florida Workers Compensation
  Uniform Medical Treatment/Status Reporting Form
• (adopted for use July 4, 2004)

A copy of the DWC-25 can be obtained from the
Division website at the following link
http//www.fldfs.com/wc/pdf/DWC-25.pdf
68
FORM DWC-25s.440.13(4)(a), F.S.

• Any health care provider providing necessary
  remedial treatment, care, or attendance to any
  injured worker shall submit treatment reports to
  the carrier in a format prescribed by the
  department.

• The format prescribed by the department is the
  Form DFS-F5-DWC-25 (DWC-25).

69
FORM DWC-25s.440.13(4)(a), F.S.

• A claim for medical or surgical treatment is not
  valid or enforceable unless, by the close of the
  third business day following the first treatment,
  the physician providing treatment furnishes to
  the employer or carrier
• a Form DWC-25

An insurer/carrier may disallow payment for
services if the health care provider does not
submit a Form DWC-25, pursuant to Rule 69L-7.602,
F.A.C.
70
FORM DWC-25Rule 69L-7.602, F.A.C.

• Insurers and providers shall utilize ONLY the
  Form DWC-25 for physician reporting of the
  injured employees medical treatment / status.

• Any other reporting form MAY NOT be used in lieu
  of or supplemental to the Form DWC-25

Therefore, the physician is not required to
complete any other insurer/carrier forms.
71
FORM DWC-25Rule 69L-7.602, F.A.C.
The Form DWC-25

• Must be signed by the authorized physician
• Does not replace physician notes, medical records
  or required billing forms
• Information must be consistent with medical
  notes, medical records, diagnostic testing, etc.
• Becomes a part of the patients medical record
  maintained by the physician
• Must be submitted to the employer upon request

72
FORMS SUBMITTED TO CARRIERRule 69L-7.602, F.A.C.

• Health Care Providers who render direct billable
  services shall submit to the carrier a medical
  bill for reimbursement of services using the Form
  DFS-F5-DWC-9 (CMS 1500) regardless of employment
  arrangement.

A copy of the DFS-F5-DWC-9 can be obtained from
the CMS website http//www.cms.hhs.gov/cmsforms/
73
PROVISION OF MEDICAL RECORDSs.440.13(4)(b), F.S.
Medical records must be produced upon request.
Upon the request of the department, each medical
report or bill obtained or received by the
employer, the carrier, or the injured employee,
including any report of an examination, diagnosis
, or disability evaluation, must be produced by
the health care provider to the department
pursuant to rules adopted by the department.

• Health care providers who willfully refuse to
  provide medical records or discuss the medical
  condition of the injured employee are subject to
  the penalties set forth in s.440.13(8)(b), F.S.

74
PROVISION OF MEDICAL RECORDS s.440.13(4)(b), F.S.
The health care provider shall also furnish to
the injured employee or his or her attorney and
the employer or carrier or its attorney, on
demand, a copy of his or her office chart,
records, and reports, and may charge the injured
employee no more than 50 cents per page for
copying the records and the actual direct cost to
the health care provider or health care facility
for x rays, microfilm, or any other nonpaper
records..
75
PHYSICIAN-PATIENT PRIVILEGE s.440.13(4)(c), F.S.
A release of information is not required for
the health care provider to release medical
records, unless otherwise specified in the
Florida Statutes.

• An employee who reports an injury or illness
  alleged to be work-related waives any
  physician-patient privilege with respect to any
  condition or complaint reasonably related to the
  condition for which the employee claims
  compensation.

Release of medical information by the health
care provider or other physician does not require
the authorization of the injured employee.
76
INDEPENDENT MEDICAL EXAMINATIONS (IME)
s.440.13(5)(a), F.S.

• The physician performing the IME shall complete
• A physical examination of the injured employee
• A review of medical records
• Determination of functional limitations and
  restrictions
• Calculation of Permanent Impairment Rating if at
  Maximum Medical Improvement
• Report to Carrier and Employee (a Form DWC-25 and
  written medical report)

77
INDEPENDENT MEDICAL EXAMINATIONS (IME)
s.440.13(5)(a), F.S.

• In any dispute concerning overutilization,
  medical benefits, compensability, or disability
  under this chapter, the carrier or the employee
  may select an independent medical examiner.

• Although a physician may be certified as an EMA,
  when an IME is requested the EMA is functioning
  as health care provider, not as an EMA.

78
INDEPENDENT MEDICAL EXAMINATIONS (IME)
s.440.13(5)(a), F.S.

• If the parties agree, the examiner may be a
  health care provider treating or providing other
  care to the employee.
• The independent medical examiner may not provide
  follow-up care if such recommendation for care is
  found to be medically necessary.

79
INDEPENDENT MEDICAL EXAMINATIONS (IME)
s.440.13(5)(a), F.S.

• The employer and employee shall be entitled to
  only one independent medical examination per
  accident and not one independent medical
  examination per medical specialty.
• The party requesting and selecting the
  independent medical examination shall be
  responsible for all expenses associated with said
  examination

80
IME NO-SHOW PROVISIONSFOR PAYMENT
s.440.13(5)(d), F.S.

• If the employee fails to appear for the
  independent medical examination scheduled by the
  employer or carrier the employee is barred from
  recovering compensation for any period during
  which he or she has refused to submit to such
  examination.
• Further, the employee shall reimburse the
  employer or carrier 50 percent of the physicians
  cancellation or no-show fee

81
REIMBURSEMENT DISPUTESs.440.13(7), F.S.

• What is a health care provider to do if he/she is
  improperly reimbursed for services?
• A health care provider may file a petition for
  reimbursement dispute resolution with the
  Division, pursuant to s.440.13(7), F.S.
  and Rule 69LA-31, F.A.C.
• The form for filing a Petition for Resolution of
  Reimbursement Dispute may be printed from the
  following link http//www.fldfs.com/wc/pdf/DFS-31
  60-0023.pdf

82
REIMBURSEMENT DISPUTESs.440.13(7), F.S.

• Any health care providerwho elects to contest
  the disallowance or adjustment of payment by a
  carrier under subsection (6) must, within 30 days
  after receipt of notice of disallowance or
  adjustment of payment, petition the Division to
  resolve the dispute.
• The petition must be accompanied by all
  documents and records that support the
  allegations contained in the petition. Failure
  of a petitioner to submit such documentation to
  the Division results in dismissal of the
  petition.

83
CARRIER UTILIZATION REVIEW s.440.13(6), F.S.

• All insurer/carriers are responsible to perform
  utilization review.
• Carriers shall review all bills, invoices, and
  other claims for payment submitted by health care
  providers in order to identify overutilization
  and billing errors
• If a carrier finds that overutilization of
  medical services or a billing error has
  occurredit must disallow or adjust payment for
  such services

84
OVERUTILIZATION, STATUTE OR RULE VIOLATIONS,
HCP PENALTIES / SANCTIONS s.440.13(8)(b), F.S.

If the Division determines that a health care
provider has engaged in a pattern or practice of
overutilization or a violation of this chapter or
rules adopted by the Division, including a
pattern or practice of providing treatment in
excess of the practice parameters or protocols of
treatment, it may impose one or morepenalties.
85
DIVISION OF WORKERS COMPENSATION JURISDICTION
s.440.13(11)(c), F.S.
The Division has exclusive jurisdiction to
decide any matters concerning reimbursement, to
resolve any overutilization dispute under
subsection (7), and to decide any question
concerning overutilization under subsection (8)
which question or dispute arises after January 1,
1994.
86
POTENTIAL PROVIDER PENALTIES s.440.13(8)(b),
F.S.

• An order barring the provider from payment under
  this chapter.
• Deauthorization of care under review.
• Denial of payment for care rendered in the
  future.
• Decertification of a health care provider as an
  expert medical advisor
• A fine assessed by the Division not to exceed
  5000 per instance of overutilization or
  violation.
• Notification of and review by the appropriate
  licensing authority.

87
WITNESS (Deposition) FEES s.440.13(10), F.S.
What reimbursement is made to the health care
provider acting as a witness?
Any health care provider who gives a deposition
shall be allowed a witness fee. The amount
charged by the witness may not exceed 200 per
hour. An expert witness who has never provided
direct professional services to a party but has
merely reviewed medical records and provided an
expert opinion or has provided only direct
professional services that were unrelated to the
workers compensation case may not be allowed a
witness fee in excess of 200 per day.
88
PROVIDER AUDITS s.440.13(11)(a), F.S.
What happens to the health care provider who
fails to comply with the laws and rules that
apply to Florida workers compensation?
The Division of Workers Compensation may
investigate health care providers to determine
whether providers are complying with this chapter
and with rules adopted by the DivisionIf the
Division finds that a health care provider has
improperly billed, overutilized, or failed to
comply with Division rules or the requirements of
this chaptermay impose penalties as set forth in
subsection (8) or other sections of this chapter.
89
REIMBURSEMENT FOR MEDICAL SERVICES s.440.13(12)(a)
, F.S.
How is the reimbursement schedule determined?
The panel (Three Member Panel) shall determine
statewide schedules of maximum reimbursement
allowances for medically necessary treatment,
care, and attendance provided by physicians and
durable medical equipment. An individual
physician, hospitalshall be reimbursed either
the agreed-upon contract price or the maximum
reimbursement allowance in the appropriate
schedule.
90
REIMBURSEMENT FOR MEDICAL SERVICES s.440.13(12)(b)
, F.S.
4. Maximum reimbursement for a physician
licensed under chapter 458 or 469L shall be
increased to 110 percent of the reimbursement
allowed by Medicare, using appropriate codes and
modifiers or the medical reimbursement level
adopted by the three-member panel as of January
1, 2003, whichever is greater. 5. Maximum
reimbursement for surgical procedures shall be
increased to 140 percent of the reimbursement
allowed by Medicare or the medical reimbursement
level adopted by the three member panel as of
January 1, 2003, whichever is greater.
91
REIMBURSEMENT Rule 69L-7.020, F.A.C.
Where can a health care provider locate the
maximum reimbursement allowances for services?
The Florida Workers Compensation Health Care
Provider Reimbursement Manual, 2005
Editioncontains reimbursement policies ,
guidelines, codes and maximum reimbursement
allowances for services and supplies provided by
health care providers.

• The appropriate Health Care Provider
  Reimbursement Manual is determined by the manual
  in effect on the date the service is provided.

92
REIMBURSEMENT Rule 69L-7.020, F.A.C.
Reimbursement manuals may be viewed on or printed
from the Division website www.fldfs.com/wc
93
EXPERT MEDICAL ADVISOR(EMA)

• How does a physician become a Florida workers
  compensation Expert Medical Advisor?
• What are the Expert Medical Advisors duties and
  responsibilities within the Florida Workers
  Compensation system?
• Who can select the Expert Medical Advisor?

94
EXPERT MEDICAL ADVISORS s.440.13(9), F.S.
How does a physician become an Expert Medical
Advisor?

• The physician must meet the qualifications
  specified in Rule 69LA-30.003, F.A.C.
• The physician must submit a completed application
  for Expert Medical Advisor Certification to the
  Division.
• The application may be printed from the following
  link
• http//www.fldfs.com/wc/pdf/DFS-3160-0021.pdf

95
EXPERT MEDICAL ADVISOR CERTIFICATION Rule
69LA-30, F.A.C.
Expert Medical Advisor certification requires
that the physician attest to knowledge of the
Florida Statutes related to workers
compensation, specifically Sections 440.02,
440.09, 440.093, 440.102, 440.105, 440.13,
440.134, 440.15(3), 440.15(5), 440.151, 440.20
and 440.091 and knowledge of the Florida
Administrative Code Rules 69L-7.602 and 69L-7.020
or complete this tutorial.
96
EXPERT MEDICAL ADVISORSRule 69LA-30.003, F.A.C.
To be certified as an Expert Medical Advisor, a
physician shall meet the following qualifications

• Must have been certified as a health care
  provider by the Division for not less than 12
  months prior to the date of application and
• Must hold valid licensure, issued by the Florida
  Department of Health, with clear and active
  status and
• Must hold specialty-board certification or
  specialty-board eligibility and

97
EXPERT MEDICAL ADVISORSQualifications
(continued)

• Must demonstrate experience in the assignment of
  permanent impairment ratings greater than zero
  (0) and
• Must demonstrate experience in performing
  independent medical examinations and
• Must have completed twenty hours of continuing
  medical education, specifically related to the
  practitioners field of specialty, within two
  years prior to the date of application and
• Must possess knowledge of the Florida Statutes
  and Florida Administrative Code related to
  workers compensation.

98
EXPERT MEDICAL ADVISORSRule 69LA-30.004, F.A.C.

• Throughout the certification period, the Expert
  Medical Advisor shall notify the Division
• If specialty-board certification has expired
• If Florida Department of Health license status is
  changed from clear and active
• Of any change in address or contact information

99
EXPERT MEDICAL ADVISORSRule 69LA-30.007, F.A.C.
CONFLICT OF INTEREST
Upon receiving notice of selection by the
Division or judge of compensation claims as an
Expert Medical Advisor the physician shall
disclose any conflict of interest related to the
case for which the physician was selected and
shall decline selection as an Expert Medical
Advisor.

• An Expert Medical Advisor shall decline selection
  as an EMA if a conflict of interest exists.

100
EXPERT MEDICAL ADVISORSs.440.13(9), F.S.

• An EMA may ONLY be contracted by the Division or
  Judges of Compensation Claims
• EMAs are contracted to settle disputes related
  to
• - Reimbursement allowances
• - Differing health care provider opinions
• - Medical necessity of services rendered

101
EXPERT MEDICAL ADVISORS s.440.13(9), F.S.

• The Division shall certify expert medical
  advisors in each specialty to assist the Division
  and the judges of compensation claims
• As a prerequisite for certification or
  recertification, the Division shall require, at a
  minimum, that the expert medical advisor have
  specialized workers compensation training or
  experience under the workers compensation system
  of this state and board certification or board
  eligibility.

102
EXPERT MEDICAL ADVISORS s.440.13(9), F.S.

• The Division shall contract with one or more
  entities that employ, contract with, or otherwise
  secure expert medical advisors to provide peer
  review or expert medical consultation, opinions,
  and testimony to the Division or to a judge of
  compensation claims in connection with resolving
  disputes relating to reimbursement, differing
  opinions of health care providers, and health
  care and physician services rendered under this
  chapter, including utilization issues.

103
EXPERT MEDICAL ADVISORS s.440.13(9), F.S.

• Expert medical advisors contracting with the
  Division shall, as a term of such contract, agree
  to provide consultation or services in accordance
  with the timetables set forth in this chapter and
  to abide by rules adopted by the
  Divisionpertaining to procedures for review of
  services rendered by health care providers and
  preparation of reports and testimony or
  recommendations for submission to the Division or
  the judge of compensation claims.

104
EXPERT MEDICAL ADVISORS s.440.13(9), F.S.

• If there is a disagreement in the opinions of
  the health care providersThe opinion of the
  expert medical advisor is presumed to be correct
  unless there is clear and convincing evidence to
  the contrary as determined by the judge of
  compensation claims.
• The expert medical advisor appointed to conduct
  the evaluation shall have free and complete
  access to the medical records of the employee.

105
EXPERT MEDICAL ADVISORS s.440.13(9)(d), F.S.

• The expert medical advisor must complete his or
  her evaluation and issue his or her report to the
  Division or to the judge of compensation claims
  within 15 days after receipt of all medical
  records. The expert medical advisor must furnish
  a copy of the report to the carrier and to the
  employee.

• The expert medical advisor shall submit an
  accurately completed Form DWC-25 to the insurer/
  carrier by close of the following business day
  when a patient physical examination is performed.

106
EXPERT MEDICAL ADVISORS s.440.13(9)(f), F.S.

• The party ordering the services of an expert
  medical advisor to resolve a dispute must
  compensate the advisor for his or her time in
  accordance with a schedule adopted by the
  Division.

If the employee prevails in a dispute based on
the expert medical advisors findings, the
employer or carrier shall pay for the costs
The Division may assess a penalty not to exceed
500 against any carrier that fails to timely
compensate an advisor in accordance with this
section.
107
EXPERT MEDICAL ADVISORS s.440.13(9)(f), F.S.
Who reimburses for the services of an Expert
Medical Advisor?

• The party ordering the services of an expert
  medical advisor to resolve a dispute must
  compensate the advisor for his or her time .

If the employee prevails in a dispute based on
the expert medical advisors findings, the
employer or carrier shall pay for the costs

• An Expert Medical Advisor shall submit his/her
  bill on an invoice approved by the Judge of
  Compensation Claims or the Division.

108
EXPERT MEDICAL ADVISORSRule 69LA-30.008(5),
F.A.C.
REIMBURSEMENT SCHEDULE FOR SERVICES CONTRACTED
BY Judges of Compensation Claims - 300.00
per hour for no more than 8 hours per
case Division of Workers Compensation- 200.00
per hour for no more than 8 hours per case
109
REMOVAL OF PHYSICIANS FROM Division LIST OF
CERTIFIED HEALTH CARE PROVIDERS s.440.13(13),
F.S.
The Division may remove a provider from the
Divisions list of certified health care
providers or Expert Medical Advisors.
The Division shall remove from the list of
physicians authorized to provide remedial
treatment, care and attendance under this chapter
the name of any physicianfound after reasonable
investigation to have
(a) Engaged in professional or other misconduct
or incompetency in connection with medical
services rendered under this chapter
110
REMOVAL OF PHYSICIANS FROM Division LIST
(continued) s.440.13(13), F.S.
(b) Exceeded the limits of hisprofessional
competence or to have made materially false
statements regarding hisqualifications in
hisapplication (c) Failed to transmit copies of
medical reports to the employer or carrier, or
failed to submit full and truthful medical
reports of all hisfindings to the employer or
carrier as required (d) Solicited, or employed
another to solicit for himself professional
treatment, examination, or care of an injured
employee in connection with any claim
111
REMOVAL OF PHYSICIANS FROM Division LIST
(continued) s.440.13(13), F.S.
(e) Refused to appear before, or to answer upon
request of, the Divisionany legal question, or
to produce any relevant book or paper concerning
hisconduct under any authorization granted to
himunder this chapter (f) Self-referred in
violation of this chapter or other laws of this
state or (g) Engaged in a pattern or practice of
overutilization or a violation of this chapter or
rules adopted by the Division
112
Florida Statutes 440.134 WC Managed Care
Arrangements


The following list provides the statutes related
to Workers Compensation Managed Care
Arrangements, including a brief description for
each subsection.

• 440.134(1)(g) Definition of WCMCA
• 440.134(1)(i) Definition of medical care
  coordinator
• 440.134(1)(j) Definition of provider network
• 440.134(1)(k) Definition of primary care provider

113
Florida Statutes 440.134 WC Managed Care
Arrangements (continued)

• 440.134(4) AHCA authorization as WCMCA
• 440.134(6) Plan of Operation elements - WCMCA
• 440.134(7) Provision of Records to insurer/
  carrier - WCMCA
• 440.134(8) Training and education of HCP
  and Administrative Staff

114
Florida Statutes 440.134 WC Managed Care
Arrangements (continued)

• Complete information regarding Workers
  Compensation Managed Care Arrangements may be
  viewed at the Divisions home webpage (listed
  under CH. 440, FL Statutes) at the following
  link
• www.fldfs.com/wc

115
Florida Administrative CodeRules pertaining to
Medical Services

• Chapter 69L
• Rule 69L-3.0047 Fraud Statement
• Rule 69L-7.602 Billing, Filing and Reporting
  of Medical Services
• Rule 69L-7.020 Health Care Provider
  Reimbursement Manual

116
Florida Administrative Code Rules pertaining to
Medical Services

• Chapter 69L
• Rule 69LA-29 - Health Care Provider Certification
• Rule 69LA-30 - Expert Medical Advisor
  Certification
• Rule 69LA-31 - Reimbursement Disputes

117
Florida Administrative Code

• Florida Administrative Code rules may be viewed
  at or printed from the following Internet
  address
• http//fac.dos.state.fl.us/

118
? QUESTIONS ?
Contact the Specialist On-Call [phone]
Workers Compensation Medical Services Unit
119
CONGRATULATIONS!
YOU HAVE SUCCESSFULLY COMPLETED THE EXPERT
MEDICAL ADVISOR TUTORIAL
120
This concludes the Florida Workers Compensation
Tutorial for Expert Medical Advisors. Completion
of this tutorial fulfills the Expert Medical
Advisor certification criteria requiring the
physician to attest to familiarity with the rules
and statutes relating to the provision of
benefits and services in the Florida Workers
Compensation system.