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Workers’ comp reimbursement regulation headed for administrative challenges

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The Division of Workers’ Compensation’s efforts to extract itself from contract disputes between insurance companies and medical providers have drawn administrative challenges, scheduled for hearings next month.

Under regulations proposed by the division’s parent Department of Financial Services, officials would limit their involvement to reviewing “reimbursement schedules, practice parameters, and protocols of treatment.”

Furthermore, they would issue “no findings regarding an improper disallowance or adjustment in reimbursement involving managed care contracts or when the carrier asserts that medical treatment was either not compensable or not medically necessary.”

According to a petition filed by the Florida Society of Ambulatory Surgical Centers, officials argue they have no business policing contact disputes, and lack resources to do so.

That position “is not justified in light of its statutory mandate and the fact that the department has been carrying out this responsibility for many years and is capable of equipping itself with sufficient staff and employees and/or to train existing staff and employees to property and effectively discharge its statutory obligations,” the organization argues.

“Simply ignoring, or otherwise abrogating, its statutory obligations … is not an option.”

The society’s case is set for a hearing on June 22 before administrative law judge D.R. Alexander. A separate petition, filed by HCA Health Services of Florida Inc. and two subsidiaries, goes before Alexander the next day.

A third challenge, by Automated Health Care Solutions Inc., which processes claims for medical providers, is up on June 26.

In their petition, the ambulatory surgical centers argue the regulation would allow carriers to evade scrutiny by asserting the existence of a contract. It refers to these as “ghost” contracts. The alternative to review by the division, the petition says, would be litigation that might cost more than the claim asserted.

The organization argues that state law requires the department to resolve these disputes. The proposed rule “directly and unequivocally contradicts the plain and unambiguous language” of Florida law, its petition says.

“Significantly, the Florida Legislature … requires the department to ‘provide the petitioner, the carrier, and the affected parties, a written determination of whether the carrier properly adjusted or disallowed payment. This statutory responsibility of the department is without any exception or qualification,” the petition reads.

Insurance and business interests attempted to limit medical reimbursement under workers’ compensation reforms debated in the Legislature this year. The House version of the legislation would have tied claims to Medicare reimbursement levels, but the Senate showed little interest in that option. Ultimately, the legislation failed.

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