Division of Workers' Compensation
Frequently Asked Questions
Medical, Medical Provider, Managed Care Arrangement FAQ
- What is Florida Workers' Compensation able and
willing to do to educate/enforce the role of the physician-medical
care coordinator?
- How can more responsibility be placed on the
injured worker to go to the doctor, practice their therapy and do
what the doctor tells them?
- Since Florida Workers' Compensation allows payment
above the fee schedule, can judges discount a doctor's testimony if
he was paid above the fee schedule?
- What doctor can I go to?
- Why can't I go to the doctor of my choice?
- Can I go to an osteopath or a chiropractor?
- The doctor is not helping me. What can I do?
- Can I get copies of all of my records?
- Can the medical provider charge me for obtaining
copies of my medical records?
- What about prescriptions and mileage reimbursement
requests? When should they be submitted? When should they be paid?
- How long can I collect medical benefits?
- Am I entitled to rehabilitation and retraining?
- My health insurance has been terminated. What can
I do?
- Are Workers' Compensation Managed Care
Arrangements limited to using only one provider network or plan of
operation?
- Can a commercially licensed Workers' Compensation
Managed Care Arrangement market more than one product line or plan
of operation using more than one provider network in a county?
- Do amendments, additions, or changes to an already
authorized plan of operation for a Workers' Compensation Managed
Care Arrangement require the payment of an additional $1,000
application filing fee?
- Can a third party administrator (TPA) or managed
care organization (MCO) be authorized as a Workers' Compensation
Managed Care Arrangement?
- Is the Agency for Health Care Administration
requiring all insurers and self-insured employees to sign a
three-party agreement to enter into a managed care arrangement.
- Can self-insured employers utilize their own case
managers to manage medical care for their injured workers?
- Can an existing provider network which has been
previously authorized via another Workers' Compensation Managed Care
Arrangement for a particular service area be customized for an
individual insurer by adding or deleting certain providers?
- Must a Workers' Compensation Managed Care
Arrangement use a previously approved provider network to provide
medical services or can the Workers' Compensation Managed Care
Arrangement construct its own provider network?
- Can a consortium of public entities (e.g., group
of cities, counties, public school boards, community colleges) file
a single application for a Workers' Compensation Managed Care
Arrangement?
- Can a Workers' Compensation Managed Care
Arrangement use a physician with a specialty certification in
orthopedics or psychiatry as a primary care physician?
- Must a medical care coordinator be a primary care
physician?
- Does the Agency for Health Care Administration
require a separate review and approval of Workers' Compensation
Managed Care Arrangement plans offered by previously authorized
commercial insurers which have a large, front end, self-insurance
deductible?
- Can a Workers' Compensation Managed Care
Arrangement use advanced registered nurse practitioners (ARNP's) to
provide primary care services?
- How do I get a copy of the Florida Impairment
Rating Guide (FIRG)?
- How do I get a copy of the medical reimbursement
manual (Florida Fee Schedule)?
- I am a medical provider and proper billing and
supporting documentation has been provided to the carrier but they
have not paid, disallowed, or denied payment of this medical bill to
date. How can I get this medical bill paid?
- I am a medical provider and the carrier has paid
this bill but not according to fee schedule. How do I file a
complaint?
What is Florida Workers' Compensation able
and willing to do to educate/enforce the role of the physician-medical
care coordinator?
Florida Workers' Compensation's focus is to ensure that
carriers' claims handling practices promote the self-executing features
of the system and result in the prompt and accurate delivery of benefits
to injured workers at an affordable cost to employers.
Florida Workers' Compensation interprets the statutory language in s.
440.134(1)(i), Florida Statutes, which defines a "medical care
coordinator" as a key construct in the carrier's plan of operation for
the successful operation of an approved workers' compensation managed
care arrangement. Accordingly, Florida Workers' Compensation will refer
instances to the attention of the Agency for Healthcare Administration
when medical care is delayed or not provided because medical care is not
managed by a physician medical care coordinator as the ultimate,
responsible party. Florida Workers' Compensation is well able to
distinguish the role of the adjuster in determining whether a claim is
compensable and will hold the carrier responsible for properly executing
its right to question liability for benefits under s.
440.20(4), Florida Statutes. Likewise, when a carrier fails to
comply with the law in investigating liability and improperly delegates
to an adjuster (or even another licensed health care provider) the
management of medical care, Florida Workers' Compensation will advise
carriers of practices that it determines as unacceptable claims
handling. Corrective action may range from consultations to improve
internal processes if requested by the carrier or may require more
punitive action based on documentation that a carrier is not complying
with legitimate rules or specific law.
How can more responsibility be placed on
the injured worker to go to the doctor, practice their therapy and do
what the doctor tells them?
Only with all parties within the system working together,
can this be accomplished. The key is open communication among
employees, employers, carriers, and health care providers. The
responsibilities and rights of the injured worker should be explained
and reinforced through constant communication between the employer and
the employee, with the adjuster being available to answer questions
during this uncertain time in the injured worker's life; and with
Florida Workers' Compensation serving as an informational resource.
All parties should take every opportunity to emphasize to the injured
worker the importance of following the doctor's advice and keeping
medical appointments since failure to do so may interfere with the
recovery and return to work and also may jeopardize the payment of
future lost wages.
Since Florida Workers' Compensation allows
payment above the fee schedule, can judges discount a doctor's testimony
if he was paid above the fee schedule?
Judges cannot discount a doctor's testimony if he was paid
above the fee schedule when the injured worker was furnished medically
necessary treatment and care through a managed care arrangement
contractual agreement. As a point of clarification, an insurer
does not have to use the Health Care Provider Fee for Service
Reimbursement Manual as a benchmark when negotiating a contract with a
health care provider in a managed care arrangement. When the terms
of payment with a provider within a workers' compensation managed care
arrangement are established by an insurer, the contract levels of
reimbursement may be provider specific or based on any national
treatment standards and guidelines for authorization and reimbursement
of medically necessary services. However, the contractual terms
must be mutually accepted by both parties.
What doctor can I go to?
Your employer, upon becoming aware of your injury, should
provide medically necessary treatment by a health care provider for such
period as the nature of the injury or the process of recovery may
require. This includes medicines, medical supplies, durable medical
equipment, orthotics, prostheses, and other medically necessary
apparatus. Medical care must be authorized by the employer/carrier and
provided by a physician from a list of those authorized to render
medical care.
- Reference: Section
440.13(2)(a), Florida Statutes
Why can't I go to the doctor of my choice?
The law requires that the employer/carrier provide the
appropriate medical care. However, if an injured worker objects to the
medical treatment furnished by the employer, it shall be the duty of the
employer/carrier to select another physician to treat the injured
worker. Medical care must be authorized by the employer/carrier and
provided by a physician from a list of those authorized to render
medical care.
- Reference: Section
440.13(2)(a), Florida Statutes
Can I go to an osteopath or a chiropractor?
"Physician" includes chiropractors and osteopaths
authorized by the employer/carrier. Chiropractic care is limited to 24
visits or 12 weeks, whichever comes first.
- Reference: Section
440.13, Florida Statutes
The doctor is not helping me. What can I
do?
A: If an injured worker objects to the medical treatment
furnished by the employer/carrier, another physician can be selected by
the employer/carrier to treat the injured worker. The injured worker or
carrier may also select a one time Independent Medical Examination
(IME), per accident.
- Reference: Section
440.13, Florida Statutes
Can I get copies of all of my records?
A: The health care provider must provide the injured
worker or his attorney, on demand, a copy of the medical records and
reports. A health care provider who willfully refuses to provide medical
records shall be subject to one or more of the penalties set forth in
s.440.13(8).
- Reference: Section
440.13(4)(b)and(c), Florida Statutes
Can the medical provider charge me for
obtaining copies of my medical records?
The health care provider must provide the injured worker a
copy of his office chart, records, and reports, and may charge the
injured worker an amount authorized by the division for the copies.
- Reference: Section
440.13(4)(b), Florida Statutes
What about prescriptions and mileage
reimbursement requests? When should they be submitted? When should they
be paid?
In order to receive mileage or prescription drug
reimbursement, a request must be sent to the carrier. Mileage
reimbursement requests must contain a list of the dates the injured
worker went to doctors, physical therapists, or hospitals for tests or
treatments. The names of the medical providers and the total round trip
mileage will also be required on the request. For drug reimbursement the
injured worker needs to submit a completed
DWC-10 form (Statement of Drugs and
Medical Supplies) before reimbursement will be approved.
- Reference: Section
440.13, Florida Statutes
How long can I collect medical benefits?
Medical benefits should be provided by the employer to the
injured worker for such period as the nature of the injury or the
process of recovery may require so long as the 12 month/24 month statute
of limitations has not run.
- Reference: Section
440.13(2)(a), Florida Statutes
Am I entitled to rehabilitation and
retraining?
For dates of accident 10/01/1989 and forward,
rehabilitation is strictly voluntary on the part of the carrier and the
injured worker. However, when an injured worker has suffered an injury
and it appears that the injury will preclude the injured worker from
earning wages equal to wages earned prior to the injury, the injured
worker is entitled to screening for appropriate training and education.
The injured worker may request a screening to determine his entitlement
to reemployment services. Reemployment services may include vocational
counseling, job seeking skills, on-the-job training and formal
retraining. Contact the Department of Education, Division of Vocational
Rehabilitation, Bureau of Rehabilitation and Reemployment Services at
one of the district offices for more details.
My health insurance has been terminated.
What can I do?
If your health insurance is being discontinued you may be
eligible to convert coverage under the Consolidated Omnibus Budget
Reconciliation Act (COBRA). You can contact the US Department of Labor,
Pension Welfare Benefits Administration at (202)219-8776 for additional
information. In instances where health insurance is terminated, the
amount of any employers' contribution would go into a readjusted average
weekly wage and in some instances might increase the indemnity benefit
available to the injured worker.
Are Workers' Compensation Managed Care
Arrangements limited to using only one provider network or plan of
operation?
Workers' Compensation Managed Care Arrangements may be
authorized by the Agency for Health Care Administration to use more than
one plan of operation or managed care provider network. This can be
accomplished either by requesting approval for more than one plan of
operation as part of the initial application process or by requesting
approval of one or more alternative plans of operation in addition to
the original previously authorized plan of operation. However, effective
10/1/2001, employers are no longer required to provide medically
necessary treatment solely through a managed care arrangement. Further
clarification may be obtained from the Agency for Health Care
Administration at (850)922-6481.
Can a commercially licensed Workers'
Compensation Managed Care Arrangement market more than one product line
or plan of operation using more than one provider network in a county?
Workers' Compensation Managed Care Arrangements may market
more than one alternative plan of operation using different provider
networks in the same county provided that the Workers' Compensation
Managed Care Arrangement has obtained authorization of those alternative
plans from the Agency for Health Care Administration and that these
alternative plans have an approved provider network in the counties
where they are marketed. Further clarification may be obtained from the
Agency for Health Care Administration at (850)922-6481.
- Reference: Section
440.134, Florida Statutes
Do amendments, additions, or changes to an
already authorized plan of operation for a Workers' Compensation Managed
Care Arrangement require the payment of an additional $1,000 application
filing fee?
The payment of an additional fee is not required for
amendments, additions, or changes to a previously authorized Workers'
Compensation Managed Care Arrangement plan of operation unless such
changes are being requested as part of the biannual renewal of the
Workers' Compensation Managed Care Arrangement authorization. Further
clarification may be obtained from the Agency for Health Care
Administration at (850)922-6481.
- Reference: Section
440.134, Florida Statutes
Can a third party administrator (TPA) or
managed care organization (MCO) be authorized as a Workers' Compensation
Managed Care Arrangement?
A third party administrator or managed care organization
cannot be authorized as a Workers' Compensation Managed Care Arrangement
unless it meets the definition of insurer according to 440.134(1)(e),
Florida Statutes. Third party administrator's and managed care
organization's do not typically qualify under that definition.
- Reference: Section
440.134(1)(e), Florida Statutes
Is the Agency for Health Care
Administration requiring all insurers and self-insured employers to sign
a three-party agreement to enter into a managed care arrangement.
The subject of a three party agreement arose to address a
potential problem with those situations in which an insurer contracted
with a third party administrator or managed care organization for
Workers' Compensation Managed Care services and the third party
administrator or managed care organization then subcontracted with a
provider network. It was the Agency for Health Care Administration's
concern that the third party administrator or managed care organization
could switch provider networks without adequately informing the
contracted insurers of the change, thereby disrupting medical care for
injured workers. It is in the best interest of all parties involved in a
Workers' Compensation Managed Care Arrangement to clearly understand
what each of their respective responsibilities are in the managed care
arrangement partnering effort. The three party agreement is only one
method of insuring that all parties are knowledgeable about the other
parties involved in the operation of the Workers' Compensation Managed
Care Arrangement. Therefore, the Agency for Health Care Administration
is requesting that in a Workers' Compensation Managed Care Arrangement
in which there are subcontracted relationships, similar to those
described above, the insurer consider the utilization of a three-party
agreement, or include in the contracts, language which clearly defines
the roles, responsibilities, and reporting mechanisms for notification
of affected parties when there is a change of the provider network.
Further clarification may be obtained from the Agency for Health Care
Administration at (850)922-6481.
- Reference: Section
440.134, Florida Statutes
Can self-insured employers utilize their
own case managers to manage medical care for their injured workers?
A self-insured employer may utilize its own appropriately
qualified employees to provide case management services. The Agency for
Health Care Administration does not prohibit any particular arrangement
of in-house or contracted services as long as it ensures the provision
of accessible, timely, high quality, medical services and promotes
return to work for injured workers. Further clarification may be
obtained from the Agency for Health Care Administration at
(850)922-6481.
- Reference: Section
440.134, Florida Statutes
Can an existing provider network which has
been previously authorized via another Workers' Compensation Managed
Care Arrangement for a particular service area be customized for an
individual insurer by adding or deleting certain providers?
A Workers' Compensation Managed Care Arrangement may
customize an existing, previously authorized provider network by adding
or deleting certain providers provided that the customized network still
meets the minimum travel time and provider content requirements of the
Agency for Health Care Administration. Changes made to the content of a
previously authorized provider network within a specific service area
must be identified in the application if the service area is being
customized for a particular insurer and a copy of the customized network
must be filed with the Agency for Health Care Administration. Applicants
must explicitly identify the modified service area in the application or
amendment request as "customized". Further clarification may be obtained
from the Agency for Health Care Administration at (850)922-6481.
- Reference: Section
440.134, Florida Statutes
Must a Workers' Compensation Managed Care
Arrangement use a previously approved provider network to provide
medical services or can the Workers' Compensation Managed Care
Arrangement construct its own provider network?
A Workers' Compensation Managed Care Arrangement may use an
existing provider network, construct its own network by contracting with
and credentialing providers, or customize an existing network to meet
its needs as long as the provider network meets the Agency for Health
Care Administration's minimum travel time and provider content
requirements. Further clarification may be obtained from the Agency for
Health Care Administration at (850)922-6481.
- Reference: Section
440.134, Florida Statutes
Can a consortium of public entities (e.g.,
group of cities, counties, public school boards, community colleges)
file a single application for a Workers' Compensation Managed Care
Arrangement?
A consortium of public entities can file a single Workers'
Compensation Managed Care Arrangement application with a $1,000
application filing fee provided that the entities in the consortium have
an interlocal or similar type of agreement, or language in their by-laws
which meets certain requirements contained in subsection 163.001(5),
Florida Statutes. Minimum content requirements for these agreements are:
- A person/entity designated with responsibility for administering
the consortium. The Agency for Health Care Administration would
prefer the person/entity qualify as a self-insurer;
- The names and addresses of each member of the Board of Directors
or similar governing board;
- The power to apply for and negotiate a workers' compensation
managed care arrangement;
- The method by which the managed care arrangement will be
administered by the consortium;
- The duration of the agreement and the method by which it may be
terminated prior to the stated date of termination;
- The precise organization, composition, and nature of any
separate legal or administrative entity created by the consortium;
- The manner by which the members of the consortium will provide
the financial support to fund the Workers' Compensation Managed Care
Arrangement;
- The manner by which financial obligations incurring under and as
a result of the Workers' Compensation Managed Care Arrangement will
be allocated amongst members of the consortium;
- The manner in which funds may be paid to and disbursed by any
separate legal or administrative entity created by the consortium;
- The manner in which the consortium shall enter into contracts
necessary to establish a Workers' Compensation Managed Care
Arrangement;
- The manner of responding to any liabilities that might be
incurred through performance of the Workers' Compensation Managed
Care Arrangement and insuring against any such liability;
- The adjudication of disputes or disagreements, the effects of
failure of consortium members to pay their shares of the costs and
expenses, and the rights of the other members of the consortium in
such cases;
- How the consortium will be responsible for compliance with the
Agency for Health Care Administration's Workers' Compensation
Managed Care Arrangement requirements including who will bear the
responsibility for any fines or sanctions imposed by the Agency for
Health Care Administration for noncompliance.
Further clarification may be obtained from the Agency for Health Care
Administration at (850)922-6481.
- Reference: Section
440.134, Florida Statutes
Can a Workers' Compensation Managed Care
Arrangement use a physician with a specialty certification in
orthopedics or psychiatry as a primary care physician?
The Agency for Health Care Administration has determined
that, in addition to chiropractors, podiatrists, optometrists, and
dentists, a Workers' Compensation Managed Care Arrangement may also
designate the following type of physicians licensed under chapter 458 or
chapter 459, Florida Statutes, as primary care physicians:
- family practitioner
- general practitioner
- internist
- occupational medicine
- orthopedist
- psychiatrist
Pursuant to a July 1997 policy change, the Agency for Health Care
Administration has determined that specialty physicians licensed under
chapter 458, Florida Statutes, may also be designated as PCP's and MCC's
for specific types of injuries. Further clarification may be obtained
from the Agency for Health Care Administration at (850)922-6481.
- Reference: Section
440.134, Florida Statutes
Must a medical care coordinator be a
primary care physician?
A medical care coordinator must be a primary care
physician. Section
440.134, Florida Statutes, states:
"Medical care coordinator means a primary care provider within a
provider network who is responsible for managing the medical care of
an injured worker....A medical care coordinator shall be a physician
licensed under chapter 458 or an osteopath licensed under chapter
459."
Those physician types licensed under chapter 458 or chapter 459,
Florida Statutes, which are allowed by the Agency for Health Care
Administration to be primary care providers may also be designated as a
medical care coordinator.
Further clarification may be obtained from the Agency for Health Care
Administration at (850)922-6481.
- Reference: Section
440.134, Florida Statutes
Does the Agency for Health Care
Administration require a separate review and approval of Workers'
Compensation Managed Care Arrangement plans offered by previously
authorized commercial insurers which have a large, front end,
self-insurance deductible?
The Agency for Health Care Administration requires a
separate review and approval of large deductible Workers' Compensation
Managed Care Arrangement insurer products only when the plan of
operation for the coordination and provision of medical services to
injured workers differs before and after the deductible requirement has
been met. If the self-insurance deductible only affects which entity
pays for services, then Agency for Health Care Administration review and
approval is not required. Further clarification may be obtained from the
Agency for Health Care Administration at (850)922-6481.
- Reference: Section
440.134, Florida Statutes
Can a Workers' Compensation Managed Care
Arrangement use advanced registered nurse practitioners (ARNP's) to
provide primary care services?
A Workers' Compensation Managed Care Arrangement may use
ARNP's to provide primary care services provided that the ARNP is in
compliance with the requirements of the nurse practice act. This
requires that the ARNP operate under treatment protocols which have been
previously approved by a physician licensed under chapter 458 or chapter
459, Florida Statutes. Further clarification may be obtained from the
Agency for Health Care Administration at (850)922-6481.
- Reference: Section
440.134, Florida Statutes
How do I get a copy of the Florida
Impairment Rating Guide (FIRG)?
The Florida Workers’ Compensation Institute (FWCI) handles
sales of the FIRG. You may purchase a copy by contacting them at (850)
425-8156.
How do I get a copy of the medical
reimbursement manual (Florida Fee Schedule)?
You may fax your request to purchase this manual to the
Department of Financial Services, Division of Administration, Bureau of
Finance and Support, Processing Section at (850) 488-3429. The cost for
this manual is 50 cents per page. Upon receipt of payment, the fee
schedule will be mailed to you. If you should have additional questions
regarding the purchase of this manual, please call the Processing
Section at (850) 413-2622. Access to this manual is also available
through the Division of Workers' Compensation website "Publications"
link at
http://www.myfloridacfo.com/wc/publications.html.
I am a medical provider and proper billing
and supporting documentation has been provided to the carrier but they
have not paid, disallowed, or denied payment of this medical bill to
date. How can I get this medical bill paid?
Please contact the Employee Assistance Office at (850)
413-1610 for instructions on submitting a request related to non-payment
of medical bills.
I am a medical provider and the carrier
has paid this bill but not according to fee schedule. How do I file a
complaint?
Reimbursement disputes, questions about the fee schedule,
and provider certification are all handled by the Agency for Health Care
Administration, Bureau of Medical Quality Assurance, Workers
Compensation Unit at 2727 Mahan Drive, Mail Stop 45, Tallahassee,
Florida 32308. You may reach them at (850) 922-6481 and asking to speak
with the “specialist on call”.
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