§ 440.134 — Workers’ compensation managed care arrangement

Florida § 440.134

• Jurisdiction: Florida
• Title: XXXI
• Ch. 440: WORKERS’ COMPENSATION

Text

(1) As used in this section, the term: (a) “Agency” means the Agency for Health Care Administration. (b) “Complaint” means any dissatisfaction expressed by an injured worker concerning an insurer’s workers’ compensation managed care arrangement. (c) “Emergency care” means medical services as defined in chapter 395. (d) “Grievance” means a written complaint, other than a petition for benefits, filed by the injured worker pursuant to the requirements of the managed care arrangement, expressing dissatisfaction with the insurer’s workers’ compensation managed care arrangement’s refusal to provide medical care or the medical care provided. (e) “Insurer” means an insurance carrier, self-insurance fund, assessable mutual insurer, or individually self-insured employer. (f) “Service area” means the agency-approved geographic area within which an insurer is authorized to offer a workers’ compensation managed care arrangement. (g) “Workers’ compensation managed care arrangement” means an arrangement under which a provider of health care, a health care facility, a group of providers of health care, a group of providers of health care and health care facilities, an insurer that has an exclusive provider organization approved under s. 627.6472 or a health maintenance organization licensed under part I of chapter 641 has entered into a written agreement directly or indirectly with an insurer to provide and to manage appropriate remedial treatment, care, and attendance to injured workers in accordance with this chapter. (h) “Capitated contract” means a contract in which an insurer pays directly or indirectly a fixed amount to a health care provider in exchange for the future rendering of medical services for covered expenses. (i) “Medical care coordinator” means a primary care provider within a provider network who is responsible for managing the medical care of an injured worker including determining other health care providers and health care facilities to which the injured employee will be referred for evaluation or treatment. A medical care coordinator shall be a physician licensed under chapter 458, an osteopathic physician licensed under chapter 459, a chiropractic physician licensed under chapter 460, or a podiatric physician licensed under chapter 461. (j) “Provider network” means a comprehensive panel of health care providers and health care facilities who have contracted directly or indirectly with an insurer to provide appropriate remedial treatment, care, and attendance to injured workers in accordance with this chapter. (k) “Primary care provider” means, except in the case of emergency treatment, the initial treating physician and, when appropriate, continuing treating physician, who may be a family practitioner, general practitioner, or internist physician licensed under chapter 458; a family practitioner, general practitioner, or internist osteopathic physician licensed under chapter 459; 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.

(2)(a) The self-insured employer or carrier may, subject to the terms and limitations specified elsewhere in this section and chapter, furnish to the employee solely through managed care arrangements such medically necessary remedial treatment, care, and attendance for such period as the nature of the injury or the process of recovery requires and which shall be in accordance with practice parameters and protocols established pursuant to this chapter. For any self-insured employer or carrier who elects to deliver the medical benefits required by this chapter through a method other than a workers’ compensation managed care arrangement, the discontinuance of the use of the workers’ compensation managed care arrangement shall be without regard to the date of the accident, notwithstanding any other provision of law or rule. (b) The agency shall authorize an insurer to offer or utilize a workers’ compensation managed care arrangement after the insurer files a completed application along with the payment of a $1,000 application fee, and upon the agency’s being satisfied that the applicant has the ability to provide quality of care consistent with the prevailing professional standards of care and the insurer and its workers’ compensation managed care arrangement otherwise meets the requirements of this section. No insurer may offer or utilize a managed care arrangement without such authorization. The authorization, unless sooner suspended or revoked, shall automatically expire 2 years after the date of issuance unless renewed by the insurer. The authorization shall be renewed upon application for renewal and payment of a renewal fee of $1,000, provided that the insurer is in compliance with the requirements of this section and any rules adopted hereunder. An application for renewal of the authorization shall be made 90 days prior to expiration of the authorization, on forms provided by the agency. The renewal application shall not require the resubmission of any documents previously filed with the agency if such documents have remained valid and unchanged since their original filing.

(3) An insurer may not directly or indirectly enter into a capitated contract with any person who is not a health care provider, a health care facility, a health maintenance organization licensed under part I of chapter 641, or a health insurer that has an exclusive provider organization approved under s. 627.6472. A capitated contract must provide that the capitated amount for rendering of covered medical services be paid directly to the person who has contracted with the insurer. Such contracts excluding the capitated amount must be filed with the agency for approval prior to use.

(4) An insurer may not offer or utilize a workers’ compensation managed care arrangement in this state until its managed care plan of operation has been approved by the agency and the insurer is authorized by the agency to offer or utilize a workers’ compensation managed care arrangement.

(5) An insurer must file a proposed managed care plan of operation with the agency in a format prescribed by the agency. The plan of operation must contain evidence that all covered services are available and accessible, including a demonstration that: (a) Such services can be provided with reasonable promptness with respect to geographic location, hours of operation, and after-hour care. The hours of operation and availability of after-hour care must reflect usual practice in the local area. Geographic availability must reflect the usual travel times within the community. (b) Unless the agency determines that insufficient numbers of providers are available, the number of providers in the workers’ compensation managed care arrangement service area are sufficient, with respect to current and expected workers to be served by the arrangement, either: 1. By delivery of all required medical services; or 2. Through the ability to make appropriate referrals within the provider network. (c) There are written agreements with providers describing specific responsibilities. (d) Emergency care is available 24 hours a day and 7 days a week. (e) In the case of covered services, there are written agreements with providers prohibiting such providers from billing or otherwise seeking reimbursement from or recourse against any injured worker.

(6) The proposed managed care plan of operation must include: (a) A statement or map providing a clear description of the service area. (b) A description of the grievance procedure to be used. (c) A description of the quality assurance program which assures that the health care services provided to workers shall be rendered under reasonable standards of quality of care consistent with the prevailing standards of medical practice in the medical community. The program shall include, but not be limited to: 1. A written statement of goals and objectives that stresses health and return-to-work outcomes as the principal criteria for the evaluation of the quality of care rendered to injured workers. 2. A written statement describing how methodology has been incorporated into an ongoing system for monitoring of care that is individual case oriented and, when implemented, can provide interpretation and analysis of patterns of care rendered to individual patients by individual providers. 3. Written procedures for taking appropriate remedial action whenever, as determined under the quality assurance program, inappropriate or substandard services have been provided or services that should have been furnished have not been provided. 4. A written plan, which includes ongoing review, for providing review of physicians and other licensed medical providers. 5. Appropriate financial incentives to reduce service costs and utilization without sacrificing the quality of service. 6. Adequate methods of peer review and utilization review. The utilization review process shall include a health care facility’s precertification mechanism, including, but not limited to, all elective admissions and nonemergency surgeries and adherence to practice parameters and protocols established in accordance with this chapter. 7. Provisions for resolution of disputes arising between a health care provider and an insurer regarding reimbursements and utilization review. 8. Availability of a process for aggressive medical care coordination, as well as a program involving cooperative efforts by the workers, the employer, and the workers’ compensation managed care arrangement to promote early return to work for injured workers. 9. A written plan allowing for the independent medical examination provided for in s. 440.13(5). Notwithstanding any provision to the contrary, the costs for the independent medical examination shall be paid by the carrier if such examination is performed by a physician in the provider network. Otherwise, such costs shall be paid in accordance with s. 440.13(5). An independent medical examination requested by a claimant and paid for by the carrier shall constitute the claimant’s one independent medical examination per accident under s. 440.13(5). 10. A provision for the selection of a primary care provider by the employee from among primary providers in the provider network. 11. The written information proposed to be used by the insurer to comply with subparagraph 8.

(7) Written procedures to provide the insurer with timely medical records and information including, but not limited to, work status, work restrictions, date of maximum medical improvement, permanent impairment ratings, and other information as required, including information demonstrating compliance with the practice parameters and protocols of treatment established pursuant to this chapter.

(8) Evidence that appropriate health care providers and administrative staff of the insurer’s workers’ compensation managed care arrangement have received training and education on the provisions of this chapter; the administrative rules that govern the provision of remedial treatment, care, and attendance of injured workers; and the practice parameters and protocols of treatment established pursuant to this chapter.

(9) Written procedures and methods to prevent inappropriate or excessive treatment that are in accordance with the practice parameters and protocols of treatment established pursuant to this chapter.

(10) Written procedures and methods for the management of an injured worker’s medical care by a medical care coordinator including: (a) The mechanism for assuring that covered employees receive all initial covered services from a primary care provider participating in the provider network, except for emergency care. (b) The mechanism for assuring that all continuing covered services be received from the same primary care provider participating in the provider network that provided the initial covered services, except when services from another provider are authorized by the medical care coordinator pursuant to paragraph (d). (c) The policies and procedures for allowing an employee one change to another provider within the provider network as the authorized treating physician during the course of treatment for a work-related injury, in accordance with the procedures provided in s. 440.13(2)(f). (d) The process for assuring that all referrals authorized by a medical care coordinator, in accordance with the practice parameters and protocols of treatment established pursuant to this chapter, are made to the participating network providers, unless medically necessary treatment, care, and attendance are not available and accessible to the injured worker in the provider network. (e) Assignment of a medical care coordinator licensed under chapter 458 or chapter 459 to manage care by physicians licensed under chapter 458 or chapter 459, a medical care coordinator licensed under chapter 460 to manage care by physicians licensed under chapter 460, and a medical care coordinator licensed under chapter 461 to manage care by physicians licensed under chapter 461 upon request by an injured employee for care by a physician licensed under chapter 458, chapter 459, chapter 460, or chapter 461.

(11) A description of the use of workers’ compensation practice parameters and protocols of treatment for health care services.

(12) An insurer must file any proposed changes to the plan of operation, except for changes to the list of providers, with the agency prior to implementing the changes. The changes are considered approved by the agency after 45 days unless specifically disapproved.

(13) An updated list of providers must be filed with the agency at least semiannually.

(14) An insurer must make full and fair disclosure in writing of the provisions, restrictions, and limitations of the workers’ compensation managed care arrangement to affected workers, including at least: (a) A description, including address and phone number, of the providers, including primary care physicians, specialty physicians, hospitals, and other providers. (b) A description of coverage for emergency and urgently needed care provided within and outside the service area. (c) A description of limitations on referrals. (d) A description of the grievance procedure.

(15)(a) A workers’ compensation managed care arrangement must have and use procedures for hearing complaints and resolving written grievances from injured workers and health care providers. The procedures must be aimed at mutual agreement for settlement and may include arbitration procedures. Procedures provided herein are in addition to other procedures contained in this chapter. (b) The grievance procedure must be described in writing and provided to the affected workers and health care providers. (c) At the time the workers’ compensation managed care arrangement is implemented, the insurer must provide detailed information to workers and health care providers describing how a grievance may be registered with the insurer. (d) Grievances must be considered in a timely manner and must be transmitted to appropriate decisionmakers who have the authority to fully investigate the issue and take corrective action. (e) If a grievance is found to be valid, corrective action must be taken promptly. (f) All concerned parties must be notified of the results of a grievance. (g) The insurer must report annually, no later than March 31, to the agency regarding its grievance procedure activities for the prior calendar year. The report must be in a format prescribed by the agency and must contain the number of grievances filed in the past year and a summary of the subject, nature, and resolution of such grievances.

(16) When a carrier enters into a managed care arrangement pursuant to this section the employees who are covered by the provisions of such arrangement shall be deemed to have received all the benefits to which they are entitled pursuant to s. 440.13(2)(a) and (b). In addition, the employer shall be deemed to have complied completely with the requirements of such provisions. The provisions governing managed care arrangements shall govern exclusively unless specifically stated otherwise in this section.

(17) Notwithstanding any other provisions of this chapter, when a carrier provides medical care through a workers’ compensation managed care arrangement, pursuant to this section, those workers who are subject to the arrangement must receive medical services for work-related injuries and diseases as prescribed in the contract, provided the employer and carrier have provided notice to the employees of the arrangement in a manner approved by the agency and the medical services are in accordance with the practice parameters and protocols established pursuant to this chapter. Treatment received outside the workers’ compensation managed care arrangement is not compensable, regardless of the purpose of the treatment, including, but not limited to, evaluations, examinations, or diagnostic studies to determine causation between medical findings and a compensable accident, the existence or extent of impairments or disabilities, and whether the injured employee has reached maximum medical improvement, unless authorized by the carrier prior to the treatment date.

(18) The agency may suspend the authority of an insurer to offer a workers’ compensation managed care arrangement or order compliance within 60 days, if it finds that: (a) The insurer is in substantial violation of its contracts; (b) The insurer is unable to fulfill its obligations under outstanding contracts entered into with its employers; (c) The insurer knowingly utilizes a provider who is furnishing or has furnished health care services and who does not have an existing license or other authority to practice or furnish health care services in this state; (d) The insurer no longer meets the requirements for the authorization as originally issued; or (e) The insurer has violated any lawful rule or order of the agency or any provision of this section.

(19) Revocation of an insurer’s authorization shall be for a period of 2 years. After 2 years, the insurer may apply for a new authorization by compliance with all application requirements applicable to first-time applicants.

(20) Suspension of an insurer’s authority to offer a workers’ compensation managed care arrangement shall be for such period, not to exceed 1 year, as is fixed by the agency. The agency shall, in its order suspending the authority of an insurer to offer workers’ compensation managed care, specify the period during which the suspension is to be in effect and the conditions, if any, that must be met by the insurer prior to reinstatement of its authority. The order of suspension is subject to rescission or modification by further order of the agency prior to the expiration of the suspension period. Reinstatement shall not be made unless requested by the insurer; however, the agency shall not grant reinstatement if it finds that the circumstances for which the suspension occurred still exist or are likely to recur.

(21) Upon expiration of the suspension period, the insurer’s authorization shall automatically be reinstated unless the agency finds that the causes of the suspension have not been rectified or that the insurer is otherwise not in compliance with the requirements of this chapter. If not so automatically reinstated, the authorization shall be deemed to have expired as of the end of the suspension period.

(22) If the agency finds that one or more grounds exist for the revocation or suspension of an authorization issued under this section, the agency may, in lieu of such revocation or suspension, impose a fine upon the insurer. With respect to any nonwillful violation, such fine shall not exceed $2,500 per violation. In no event shall such fine exceed an aggregate amount of $10,000 for all nonwillful violations arising out of the same action. With respect to any knowing and willful violation of a lawful order or rule of the agency or a provision of this section, the agency may impose a fine upon the insurer in an amount not to exceed $20,000 for each such violation. In no event shall such fine exceed an aggregate amount of $100,000 for all knowing and willful violations arising out of the same action.

(23) The agency shall immediately notify the office whenever it issues an administrative complaint or an order or otherwise initiates legal proceedings resulting in, or which may result in, suspension or revocation of an insurer’s authorization.

(24) Nothing in this chapter shall be deemed to authorize any entity to transact any insurance business, assume risk, or otherwise engage in any other type of insurance unless it is authorized as an insurer or a health maintenance organization under a certificate of authority issued under the provisions of the Florida Insurance Code.

(25) The agency shall adopt rules that specify: (a) Procedures for authorization and examination of workers’ compensation managed care arrangements by the agency. (b) Requirements and procedures for authorization of workers’ compensation arrangement provider networks and procedures for the agency to grant exceptions from accessibility of services. (c) Requirements and procedures for case management, utilization management, and peer review. (d) Requirements and procedures for quality assurance and medical records. (e) Requirements and procedures for dispute resolution in conformance with this chapter. (f) Requirements and procedures for employee and provider education. (g) Requirements and procedures for reporting data regarding grievances, return-to-work outcomes, and provider networks.

Legislative History

s. 18, ch. 93-415; s. 46, ch. 97-264; s. 1, ch. 98-127; ss. 189, 260, ch. 98-166; s. 3, ch. 2000-305; s. 13, ch. 2001-91; s. 26, ch. 2002-194; s. 10, ch. 2002-236; s. 478, ch. 2003-261; s. 16, ch. 2003-412.