Panel seeks changes to workers’ comp billing and new drug formulary

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A state workers’ compensation advisory panel voted Wednesday to ask the Legislature to consider letting regulators establish a drug formulary in hopes of keeping medical costs under control.

The panel also recommended changes to the way Florida’s workers’ compensation system reimburses facilities that treat injured workers, and to tighten the guidelines for authorizing medical care.

Although formally named the Three-Member Panel, the group contains only two members at present — Insurance Commissioner David Altmaier and Tamela Perdue, a senior vice president for Sunshine Health, who represents employers. Gov. Rick Scott has not filled a vacant seat representing workers.

The panel sets reimbursement policies and payment levels for health care providers, pharmacists, and medical suppliers working with workers’ compensation claimants.

The panel will pass its recommendations along to the leaders of the House and Senate for adoption through legislation or — if lawmakers demur — possibly through regulations.

But the recommendations contemplate talks between all the parties to the workers’ compensation system in ironing out the details of any changes.

During the meeting in Tallahassee, Andrew Sabolic, assistant director of the state Division of Workers’ Compensation, said a review of workers’ complaints about the system revealed that nearly all had problems securing authorization for medical treatments.

“There are probably some behavior issues on both sides that need to be addressed,” he told the panel members.

“But, frankly, the division and maybe the Three-Member Panel have to recognize that this is the elephant in the room, possibly, that needs to be examined.”

Although Florida law sets guidelines for carriers to respond to requests for treatment, it doesn’t define “respond,” Sabolic said.

The panel adopted a recommendation to clarify the term, to improve consistency and streamline the process. Additionally, workers would have to wait 30 days to file formal petitions for benefits, to give carriers time to fully consider claims.

“We can do better. Providers can do better. Carriers can do better. They both can be held more accountable for their actions,” Sabolic said.

A number of states use drug formularies, according to a report prepared by the division. The idea is to control costs while also providing medical treatment.

The document noted increased use of compound drugs, mixed by pharmacists and not approved for use by the U.S. Food and Drug Administration.

Florida sets maximum reimbursement allowances for hospital outpatient services and those performed in ambulatory surgical centers, and the process has helped to contain costs, the document says.

But those allowances don’t cover every procedure, and there’s no process in state law to figure out whether these outlier procedures are being billed appropriately. The panel voted to recommend the Legislature either tie these reimbursements to what Medicare pays, or else establish a procedure to allow providers to supply evidence establishing that their bills are reasonable.

Sol Epstein, representing the Florida Society of Ambulatory Surgical Centers, warned that might not be possible, since it’s illegal for centers like the ones he operates in South Florida to know what their competitors charge for procedures.

In any event, he said, outlier procedures tend to be covered under maximum reimbursement allowances as they become more common.

“Although it might sound easy and make some sense,” the proposals would represent a “massive change,” he said.

Michael Moline is a former assistant managing editor of The National Law Journal and managing editor of the San Francisco Daily Journal. Previously, he reported on politics and the courts in Tallahassee for United Press International. He is a graduate of Florida State University, where he served as editor of the Florida Flambeau. His family’s roots in Jackson County date back many generations.