HB 5045

1	A bill to be entitled
2	An act relating to workers' compensation medical services
3	and supplies; providing for a type two transfer of
4	responsibilities with respect to the provision of workers'
5	compensation medical services and supplies from the Agency
6	for Health Care Administration to the Department of
7	Financial Services; amending s. 440.13, F.S.; revising
8	terminology, to conform; providing an effective date.
9
10	Be It Enacted by the Legislature of the State of Florida:
11
12	Section 1.  All powers, duties, functions, rules, records,
13	personnel, property, and unexpended balances of appropriations,
14	allocations, and other funds of the Agency for Health Care
15	Administration with respect to the agency's responsibilities for
16	the provision of workers' compensation medical services and
17	supplies are transferred intact by a type two transfer, as
18	defined in s. 20.06(2), Florida Statutes, from the Agency for
19	Health Care Administration to the Department of Financial
20	Services.
21	Section 2.  Subsections (1), (3), (6) through (9), and (11)
22	through (13) of section 440.13, Florida Statutes, are amended to
23	read:
24	440.13  Medical services and supplies; penalty for
25	violations; limitations.--
26	(1)  DEFINITIONS.--As used in this section, the term:
27	(a)  "Alternate medical care" means a change in treatment
28	or health care provider.
29	(b)  "Attendant care" means care rendered by trained
30	professional attendants which is beyond the scope of household
31	duties. Family members may provide nonprofessional attendant
32	care, but may not be compensated under this chapter for care
33	that falls within the scope of household duties and other
34	services normally and gratuitously provided by family members.
35	"Family member" means a spouse, father, mother, brother, sister,
36	child, grandchild, father-in-law, mother-in-law, aunt, or uncle.
37	(c)  "Carrier" means, for purposes of this section,
38	insurance carrier, self-insurance fund or individually self-
39	insured employer, or assessable mutual insurer.
40	(d)  "Certified health care provider" means a health care
41	provider who has been certified by the department agency or who
42	has entered an agreement with a licensed managed care
43	organization to provide treatment to injured workers under this
44	section. Certification of such health care provider must include
45	documentation that the health care provider has read and is
46	familiar with the portions of the statute, impairment guides,
47	practice parameters, protocols of treatment, and rules which
48	govern the provision of remedial treatment, care, and
49	attendance.
50	(e)  "Compensable" means a determination by a carrier or
51	judge of compensation claims that a condition suffered by an
52	employee results from an injury arising out of and in the course
53	of employment.
54	(f)  "Emergency services and care" means emergency services
55	and care as defined in s. 395.002.
56	(g)  "Health care facility" means any hospital licensed
57	under chapter 395 and any health care institution licensed under
58	chapter 400 or chapter 429.
59	(h)  "Health care provider" means a physician or any
60	recognized practitioner who provides skilled services pursuant
61	to a prescription or under the supervision or direction of a
62	physician and who has been certified by the department agency as
63	a health care provider. The term "health care provider" includes
64	a health care facility.
65	(i)  "Independent medical examiner" means a physician
66	selected by either an employee or a carrier to render one or
67	more independent medical examinations in connection with a
68	dispute arising under this chapter.
69	(j)  "Independent medical examination" means an objective
70	evaluation of the injured employee's medical condition,
71	including, but not limited to, impairment or work status,
72	performed by a physician or an expert medical advisor at the
73	request of a party, a judge of compensation claims, or the
74	department agency to assist in the resolution of a dispute
75	arising under this chapter.
76	(k)  "Instance of overutilization" means a specific
77	inappropriate service or level of service provided to an injured
78	employee that includes the provision of treatment in excess of
79	established practice parameters and protocols of treatment
80	established in accordance with this chapter.
81	(l)  "Medically necessary" or "medical necessity" means any
82	medical service or medical supply which is used to identify or
83	treat an illness or injury, is appropriate to the patient's
84	diagnosis and status of recovery, and is consistent with the
85	location of service, the level of care provided, and applicable
86	practice parameters. The service should be widely accepted among
87	practicing health care providers, based on scientific criteria,
88	and determined to be reasonably safe. The service must not be of
89	an experimental, investigative, or research nature.
90	(m)  "Medicine" means a drug prescribed by an authorized
91	health care provider and includes only generic drugs or single-
92	source patented drugs for which there is no generic equivalent,
93	unless the authorized health care provider writes or states that
94	the brand-name drug as defined in s. 465.025 is medically
95	necessary, or is a drug appearing on the schedule of drugs
96	created pursuant to s. 465.025(6), or is available at a cost
97	lower than its generic equivalent.
98	(n)  "Palliative care" means noncurative medical services
99	that mitigate the conditions, effects, or pain of an injury.
100	(o)  "Pattern or practice of overutilization" means
101	repetition of instances of overutilization within a specific
102	medical case or multiple cases by a single health care provider.
103	(p)  "Peer review" means an evaluation by two or more
104	physicians licensed under the same authority and with the same
105	or similar specialty as the physician under review, of the
106	appropriateness, quality, and cost of health care and health
107	services provided to a patient, based on medically accepted
108	standards.
109	(q)  "Physician" or "doctor" means a physician licensed
110	under chapter 458, an osteopathic physician licensed under
111	chapter 459, a chiropractic physician licensed under chapter
112	460, a podiatric physician licensed under chapter 461, an
113	optometrist licensed under chapter 463, or a dentist licensed
114	under chapter 466, each of whom must be certified by the
115	department agency as a health care provider.
116	(r)  "Reimbursement dispute" means any disagreement between
117	a health care provider or health care facility and carrier
118	concerning payment for medical treatment.
119	(s)  "Utilization control" means a systematic process of
120	implementing measures that assure overall management and cost
121	containment of services delivered, including compliance with
122	practice parameters and protocols of treatment as provided for
123	in this chapter.
124	(t)  "Utilization review" means the evaluation of the
125	appropriateness of both the level and the quality of health care
126	and health services provided to a patient, including, but not
127	limited to, evaluation of the appropriateness of treatment,
128	hospitalization, or office visits based on medically accepted
129	standards. Such evaluation must be accomplished by means of a
130	system that identifies the utilization of medical services based
131	on practice parameters and protocols of treatment as provided
132	for in this chapter.
133	(3)  PROVIDER ELIGIBILITY; AUTHORIZATION.--
134	(a)  As a condition to eligibility for payment under this
135	chapter, a health care provider who renders services must be a
136	certified health care provider and must receive authorization
137	from the carrier before providing treatment. This paragraph does
138	not apply to emergency care. The department agency shall adopt
139	rules to implement the certification of health care providers.
140	(b)  A health care provider who renders emergency care must
141	notify the carrier by the close of the third business day after
142	it has rendered such care. If the emergency care results in
143	admission of the employee to a health care facility, the health
144	care provider must notify the carrier by telephone within 24
145	hours after initial treatment. Emergency care is not compensable
146	under this chapter unless the injury requiring emergency care
147	arose as a result of a work-related accident. Pursuant to
148	chapter 395, all licensed physicians and health care providers
149	in this state shall be required to make their services available
150	for emergency treatment of any employee eligible for workers'
151	compensation benefits. To refuse to make such treatment
152	available is cause for revocation of a license.
153	(c)  A health care provider may not refer the employee to
154	another health care provider, diagnostic facility, therapy
155	center, or other facility without prior authorization from the
156	carrier, except when emergency care is rendered. Any referral
157	must be to a health care provider that has been certified by the
158	department agency, unless the referral is for emergency
159	treatment, and the referral must be made in accordance with
160	practice parameters and protocols of treatment as provided for
161	in this chapter.
162	(d)  A carrier must respond, by telephone or in writing, to
163	a request for authorization from an authorized health care
164	provider by the close of the third business day after receipt of
165	the request. A carrier who fails to respond to a written request
166	for authorization for referral for medical treatment by the
167	close of the third business day after receipt of the request
168	consents to the medical necessity for such treatment. All such
169	requests must be made to the carrier. Notice to the carrier does
170	not include notice to the employer.
171	(e)  Carriers shall adopt procedures for receiving,
172	reviewing, documenting, and responding to requests for
173	authorization. Such procedures shall be for a health care
174	provider certified under this section.
175	(f)  By accepting payment under this chapter for treatment
176	rendered to an injured employee, a health care provider consents
177	to the jurisdiction of the department agency as set forth in
178	subsection (11) and to the submission of all records and other
179	information concerning such treatment to the department agency
180	in connection with a reimbursement dispute, audit, or review as
181	provided by this section. The health care provider must further
182	agree to comply with any decision of the department agency
183	rendered under this section.
184	(g)  The employee is not liable for payment for medical
185	treatment or services provided pursuant to this section except
186	as otherwise provided in this section.
187	(h)  The provisions of s. 456.053 are applicable to
188	referrals among health care providers, as defined in subsection
189	(1), treating injured workers.
190	(i)  Notwithstanding paragraph (d), a claim for specialist
191	consultations, surgical operations, physiotherapeutic or
192	occupational therapy procedures, X-ray examinations, or special
193	diagnostic laboratory tests that cost more than $1,000 and other
194	specialty services that the department agency identifies by rule
195	is not valid and reimbursable unless the services have been
196	expressly authorized by the carrier, or unless the carrier has
197	failed to respond within 10 days to a written request for
198	authorization, or unless emergency care is required. The insurer
199	shall authorize such consultation or procedure unless the health
200	care provider or facility is not authorized or certified, unless
201	such treatment is not in accordance with practice parameters and
202	protocols of treatment established in this chapter, or unless a
203	judge of compensation claims has determined that the
204	consultation or procedure is not medically necessary, not in
205	accordance with the practice parameters and protocols of
206	treatment established in this chapter, or otherwise not
207	compensable under this chapter. Authorization of a treatment
208	plan does not constitute express authorization for purposes of
209	this section, except to the extent the carrier provides
210	otherwise in its authorization procedures. This paragraph does
211	not limit the carrier's obligation to identify and disallow
212	overutilization or billing errors.
213	(j)  Notwithstanding anything in this chapter to the
214	contrary, a sick or injured employee shall be entitled, at all
215	times, to free, full, and absolute choice in the selection of
216	the pharmacy or pharmacist dispensing and filling prescriptions
217	for medicines required under this chapter. It is expressly
218	forbidden for the department agency, an employer, or a carrier,
219	or any agent or representative of the department agency, an
220	employer, or a carrier, to select the pharmacy or pharmacist
221	which the sick or injured employee must use; condition coverage
222	or payment on the basis of the pharmacy or pharmacist utilized;
223	or to otherwise interfere in the selection by the sick or
224	injured employee of a pharmacy or pharmacist.
225	(6)  UTILIZATION REVIEW.--Carriers shall review all bills,
226	invoices, and other claims for payment submitted by health care
227	providers in order to identify overutilization and billing
228	errors, including compliance with practice parameters and
229	protocols of treatment established in accordance with this
230	chapter, and may hire peer review consultants or conduct
231	independent medical evaluations. Such consultants, including
232	peer review organizations, are immune from liability in the
233	execution of their functions under this subsection to the extent
234	provided in s. 766.101. If a carrier finds that overutilization
235	of medical services or a billing error has occurred, or there is
236	a violation of the practice parameters and protocols of
237	treatment established in accordance with this chapter, it must
238	disallow or adjust payment for such services or error without
239	order of a judge of compensation claims or the department
240	agency, if the carrier, in making its determination, has
241	complied with this section and rules adopted by the department
242	agency.
243	(7)  UTILIZATION AND REIMBURSEMENT DISPUTES.--
244	(a)  Any health care provider, carrier, or employer who
245	elects to contest the disallowance or adjustment of payment by a
246	carrier under subsection (6) must, within 30 days after receipt
247	of notice of disallowance or adjustment of payment, petition the
248	department agency to resolve the dispute. The petitioner must
249	serve a copy of the petition on the carrier and on all affected
250	parties by certified mail. The petition must be accompanied by
251	all documents and records that support the allegations contained
252	in the petition. Failure of a petitioner to submit such
253	documentation to the department agency results in dismissal of
254	the petition.
255	(b)  The carrier must submit to the department agency
256	within 10 days after receipt of the petition all documentation
257	substantiating the carrier's disallowance or adjustment. Failure
258	of the carrier to timely submit the requested documentation to
259	the department agency within 10 days constitutes a waiver of all
260	objections to the petition.
261	(c)  Within 60 days after receipt of all documentation, the
262	department agency must provide to the petitioner, the carrier,
263	and the affected parties a written determination of whether the
264	carrier properly adjusted or disallowed payment. The department
265	agency must be guided by standards and policies set forth in
266	this chapter, including all applicable reimbursement schedules,
267	practice parameters, and protocols of treatment, in rendering
268	its determination.
269	(d)  If the department agency finds an improper
270	disallowance or improper adjustment of payment by an insurer,
271	the insurer shall reimburse the health care provider, facility,
272	insurer, or employer within 30 days, subject to the penalties
273	provided in this subsection.
274	(e)  The department agency shall adopt rules to carry out
275	this subsection. The rules may include provisions for
276	consolidating petitions filed by a petitioner and expanding the
277	timetable for rendering a determination upon a consolidated
278	petition.
279	(f)  Any carrier that engages in a pattern or practice of
280	arbitrarily or unreasonably disallowing or reducing payments to
281	health care providers may be subject to one or more of the
282	following penalties imposed by the department agency:
283	1.  Repayment of the appropriate amount to the health care
284	provider.
285	2.  An administrative fine assessed by the department
286	agency in an amount not to exceed $5,000 per instance of
287	improperly disallowing or reducing payments.
288	3.  Award of the health care provider's costs, including a
289	reasonable attorney's fee, for prosecuting the petition.
290	(8)  PATTERN OR PRACTICE OF OVERUTILIZATION.--
291	(a)  Carriers must report to the department agency all
292	instances of overutilization including, but not limited to, all
293	instances in which the carrier disallows or adjusts payment or a
294	determination has been made that the provided or recommended
295	treatment is in excess of the practice parameters and protocols
296	of treatment established in this chapter. The department agency
297	shall determine whether a pattern or practice of overutilization
298	exists.
299	(b)  If the department agency determines that a health care
300	provider has engaged in a pattern or practice of overutilization
301	or a violation of this chapter or rules adopted by the
302	department agency, including a pattern or practice of providing
303	treatment in excess of the practice parameters or protocols of
304	treatment, it may impose one or more of the following penalties:
305	1.  An order of the department agency barring the provider
306	from payment under this chapter;
307	2.  Deauthorization of care under review;
308	3.  Denial of payment for care rendered in the future;
309	4.  Decertification of a health care provider certified as
310	an expert medical advisor under subsection (9) or of a
311	rehabilitation provider certified under s. 440.49;
312	5.  An administrative fine assessed by the department
313	agency in an amount not to exceed $5,000 per instance of
314	overutilization or violation; and
315	6.  Notification of and review by the appropriate licensing
316	authority pursuant to s. 440.106(3).
317	(9)  EXPERT MEDICAL ADVISORS.--
318	(a)  The department agency shall certify expert medical
319	advisors in each specialty to assist the department agency and
320	the judges of compensation claims within the advisor's area of
321	expertise as provided in this section. The department agency
322	shall, in a manner prescribed by rule, in certifying,
323	recertifying, or decertifying an expert medical advisor,
324	consider the qualifications, training, impartiality, and
325	commitment of the health care provider to the provision of
326	quality medical care at a reasonable cost. As a prerequisite for
327	certification or recertification, the department agency shall
328	require, at a minimum, that an expert medical advisor have
329	specialized workers' compensation training or experience under
330	the workers' compensation system of this state and board
331	certification or board eligibility.
332	(b)  The department agency shall contract with one or more
333	entities that employ, contract with, or otherwise secure expert
334	medical advisors to provide peer review or expert medical
335	consultation, opinions, and testimony to the department agency
336	or to a judge of compensation claims in connection with
337	resolving disputes relating to reimbursement, differing opinions
338	of health care providers, and health care and physician services
339	rendered under this chapter, including utilization issues. The
340	department agency shall by rule establish the qualifications of
341	expert medical advisors, including training and experience in
342	the workers' compensation system in the state and the expert
343	medical advisor's knowledge of and commitment to the standards
344	of care, practice parameters, and protocols established pursuant
345	to this chapter. Expert medical advisors contracting with the
346	department agency shall, as a term of such contract, agree to
347	provide consultation or services in accordance with the
348	timetables set forth in this chapter and to abide by rules
349	adopted by the department agency, including, but not limited to,
350	rules pertaining to procedures for review of the services
351	rendered by health care providers and preparation of reports and
352	testimony or recommendations for submission to the department
353	agency or the judge of compensation claims.
354	(c)  If there is disagreement in the opinions of the health
355	care providers, if two health care providers disagree on medical
356	evidence supporting the employee's complaints or the need for
357	additional medical treatment, or if two health care providers
358	disagree that the employee is able to return to work, the
359	department agency may, and the judge of compensation claims
360	shall, upon his or her own motion or within 15 days after
361	receipt of a written request by either the injured employee, the
362	employer, or the carrier, order the injured employee to be
363	evaluated by an expert medical advisor. The opinion of the
364	expert medical advisor is presumed to be correct unless there is
365	clear and convincing evidence to the contrary as determined by
366	the judge of compensation claims. The expert medical advisor
367	appointed to conduct the evaluation shall have free and complete
368	access to the medical records of the employee. An employee who
369	fails to report to and cooperate with such evaluation forfeits
370	entitlement to compensation during the period of failure to
371	report or cooperate.
372	(d)  The expert medical advisor must complete his or her
373	evaluation and issue his or her report to the department agency
374	or to the judge of compensation claims within 15 days after
375	receipt of all medical records. The expert medical advisor must
376	furnish a copy of the report to the carrier and to the employee.
377	(e)  An expert medical advisor is not liable under any
378	theory of recovery for evaluations performed under this section
379	without a showing of fraud or malice. The protections of s.
380	766.101 apply to any officer, employee, or agent of the
381	department agency and to any officer, employee, or agent of any
382	entity with which the department agency has contracted under
383	this subsection.
384	(f)  If the department agency or a judge of compensation
385	claims orders the services of a certified expert medical advisor
386	to resolve a dispute under this section, the party requesting
387	such examination must compensate the advisor for his or her time
388	in accordance with a schedule adopted by the department agency.
389	If the employee prevails in a dispute as determined in an order
390	by a judge of compensation claims based upon the expert medical
391	advisor's findings, the employer or carrier shall pay for the
392	costs of such expert medical advisor. If a judge of compensation
393	claims, upon his or her motion, finds that an expert medical
394	advisor is needed to resolve the dispute, the carrier must
395	compensate the advisor for his or her time in accordance with a
396	schedule adopted by the department agency. The department agency
397	may assess a penalty not to exceed $500 against any carrier that
398	fails to timely compensate an advisor in accordance with this
399	section.
400	(11)  AUDITS.--
401	(a)  The department Agency for Health Care Administration
402	may investigate health care providers to determine whether
403	providers are complying with this chapter and with rules adopted
404	by the department agency, whether the providers are engaging in
405	overutilization, whether providers are engaging in improper
406	billing practices, and whether providers are adhering to
407	practice parameters and protocols established in accordance with
408	this chapter. If the department agency finds that a health care
409	provider has improperly billed, overutilized, or failed to
410	comply with department agency rules or the requirements of this
411	chapter, including, but not limited to, practice parameters and
412	protocols established in accordance with this chapter, it must
413	notify the provider of its findings and may determine that the
414	health care provider may not receive payment from the carrier or
415	may impose penalties as set forth in subsection (8) or other
416	sections of this chapter. If the health care provider has
417	received payment from a carrier for services that were
418	improperly billed, that constitute overutilization, or that were
419	outside practice parameters or protocols established in
420	accordance with this chapter, it must return those payments to
421	the carrier. The department agency may assess a penalty not to
422	exceed $500 for each overpayment that is not refunded within 30
423	days after notification of overpayment by the department agency
424	or carrier.
425	(b)  The department shall monitor carriers as provided in
426	this chapter and the Office of Insurance Regulation shall audit
427	insurers and group self-insurance funds as provided in s.
428	624.3161, to determine if medical bills are paid in accordance
429	with this section and rules of the department and Financial
430	Services Commission, respectively. Any employer, if self-
431	insured, or carrier found by the department or Office of
432	Insurance Regulation not to be within 90 percent compliance as
433	to the payment of medical bills after July 1, 1994, must be
434	assessed a fine not to exceed 1 percent of the prior year's
435	assessment levied against such entity under s. 440.51 for every
436	quarter in which the entity fails to attain 90-percent
437	compliance. The department shall fine or otherwise discipline an
438	employer or carrier, pursuant to this chapter or rules adopted
439	by the department, and the Office of Insurance Regulation shall
440	fine or otherwise discipline an insurer or group self-insurance
441	fund pursuant to the insurance code or rules adopted by the
442	Financial Services Commission, for each late payment of
443	compensation that is below the minimum 95-percent performance
444	standard. Any carrier that is found to be not in compliance in
445	subsequent consecutive quarters must implement a medical-bill
446	review program approved by the department or office, and an
447	insurer or group self-insurance fund is subject to disciplinary
448	action by the Office of Insurance Regulation.
449	(c)  The department agency has exclusive jurisdiction to
450	decide any matters concerning reimbursement, to resolve any
451	overutilization dispute under subsection (7), and to decide any
452	question concerning overutilization under subsection (8), which
453	question or dispute arises after January 1, 1994.
454	(d)  The following department agency actions do not
455	constitute agency action subject to review under ss. 120.569 and
456	120.57 and do not constitute actions subject to s. 120.56:
457	referral by the entity responsible for utilization review; a
458	decision by the department agency to refer a matter to a peer
459	review committee; establishment by a health care provider or
460	entity of procedures by which a peer review committee reviews
461	the rendering of health care services; and the review
462	proceedings, report, and recommendation of the peer review
463	committee.
464	(12)  CREATION OF THREE-MEMBER PANEL; GUIDES OF MAXIMUM
465	REIMBURSEMENT ALLOWANCES.--
466	(a)  A three-member panel is created, consisting of the
467	Chief Financial Officer, or the Chief Financial Officer's
468	designee, and two members to be appointed by the Governor,
469	subject to confirmation by the Senate, one member who, on
470	account of present or previous vocation, employment, or
471	affiliation, shall be classified as a representative of
472	employers, the other member who, on account of previous
473	vocation, employment, or affiliation, shall be classified as a
474	representative of employees. The panel shall determine statewide
475	schedules of maximum reimbursement allowances for medically
476	necessary treatment, care, and attendance provided by
477	physicians, hospitals, ambulatory surgical centers, work-
478	hardening programs, pain programs, and durable medical
479	equipment. The maximum reimbursement allowances for inpatient
480	hospital care shall be based on a schedule of per diem rates, to
481	be approved by the three-member panel no later than March 1,
482	1994, to be used in conjunction with a precertification manual
483	as determined by the department, including maximum hours in
484	which an outpatient may remain in observation status, which
485	shall not exceed 23 hours. All compensable charges for hospital
486	outpatient care shall be reimbursed at 75 percent of usual and
487	customary charges, except as otherwise provided by this
488	subsection. Annually, the three-member panel shall adopt
489	schedules of maximum reimbursement allowances for physicians,
490	hospital inpatient care, hospital outpatient care, ambulatory
491	surgical centers, work-hardening programs, and pain programs. An
492	individual physician, hospital, ambulatory surgical center, pain
493	program, or work-hardening program shall be reimbursed either
494	the agreed-upon contract price or the maximum reimbursement
495	allowance in the appropriate schedule.
496	(b)  It is the intent of the Legislature to increase the
497	schedule of maximum reimbursement allowances for selected
498	physicians effective January 1, 2004, and to pay for the
499	increases through reductions in payments to hospitals. Revisions
500	developed pursuant to this subsection are limited to the
501	following:
502	1.  Payments for outpatient physical, occupational, and
503	speech therapy provided by hospitals shall be reduced to the
504	schedule of maximum reimbursement allowances for these services
505	which applies to nonhospital providers.
506	2.  Payments for scheduled outpatient nonemergency
507	radiological and clinical laboratory services that are not
508	provided in conjunction with a surgical procedure shall be
509	reduced to the schedule of maximum reimbursement allowances for
510	these services which applies to nonhospital providers.
511	3.  Outpatient reimbursement for scheduled surgeries shall
512	be reduced from 75 percent of charges to 60 percent of charges.
513	4.  Maximum reimbursement for a physician licensed under
514	chapter 458 or chapter 459 shall be increased to 110 percent of
515	the reimbursement allowed by Medicare, using appropriate codes
516	and modifiers or the medical reimbursement level adopted by the
517	three-member panel as of January 1, 2003, whichever is greater.
518	5.  Maximum reimbursement for surgical procedures shall be
519	increased to 140 percent of the reimbursement allowed by
520	Medicare or the medical reimbursement level adopted by the
521	three-member panel as of January 1, 2003, whichever is greater.
522	(c)  As to reimbursement for a prescription medication, the
523	reimbursement amount for a prescription shall be the average
524	wholesale price plus $4.18 for the dispensing fee, except where
525	the carrier has contracted for a lower amount. Fees for
526	pharmaceuticals and pharmaceutical services shall be
527	reimbursable at the applicable fee schedule amount. Where the
528	employer or carrier has contracted for such services and the
529	employee elects to obtain them through a provider not a party to
530	the contract, the carrier shall reimburse at the schedule,
531	negotiated, or contract price, whichever is lower. No such
532	contract shall rely on a provider that is not reasonably
533	accessible to the employee.
534	(d)  Reimbursement for all fees and other charges for such
535	treatment, care, and attendance, including treatment, care, and
536	attendance provided by any hospital or other health care
537	provider, ambulatory surgical center, work-hardening program, or
538	pain program, must not exceed the amounts provided by the
539	uniform schedule of maximum reimbursement allowances as
540	determined by the panel or as otherwise provided in this
541	section. This subsection also applies to independent medical
542	examinations performed by health care providers under this
543	chapter. In determining the uniform schedule, the panel shall
544	first approve the data which it finds representative of
545	prevailing charges in the state for similar treatment, care, and
546	attendance of injured persons. Each health care provider, health
547	care facility, ambulatory surgical center, work-hardening
548	program, or pain program receiving workers' compensation
549	payments shall maintain records verifying their usual charges.
550	In establishing the uniform schedule of maximum reimbursement
551	allowances, the panel must consider:
552	1.  The levels of reimbursement for similar treatment,
553	care, and attendance made by other health care programs or
554	third-party providers;
555	2.  The impact upon cost to employers for providing a level
556	of reimbursement for treatment, care, and attendance which will
557	ensure the availability of treatment, care, and attendance
558	required by injured workers;
559	3.  The financial impact of the reimbursement allowances
560	upon health care providers and health care facilities, including
561	trauma centers as defined in s. 395.4001, and its effect upon
562	their ability to make available to injured workers such
563	medically necessary remedial treatment, care, and attendance.
564	The uniform schedule of maximum reimbursement allowances must be
565	reasonable, must promote health care cost containment and
566	efficiency with respect to the workers' compensation health care
567	delivery system, and must be sufficient to ensure availability
568	of such medically necessary remedial treatment, care, and
569	attendance to injured workers; and
570	4.  The most recent average maximum allowable rate of
571	increase for hospitals determined by the Health Care Board under
572	chapter 408.
573	(e)  In addition to establishing the uniform schedule of
574	maximum reimbursement allowances, the panel shall:
575	1.  Take testimony, receive records, and collect data to
576	evaluate the adequacy of the workers' compensation fee schedule,
577	nationally recognized fee schedules and alternative methods of
578	reimbursement to certified health care providers and health care
579	facilities for inpatient and outpatient treatment and care.
580	2.  Survey certified health care providers and health care
581	facilities to determine the availability and accessibility of
582	workers' compensation health care delivery systems for injured
583	workers.
584	3.  Survey carriers to determine the estimated impact on
585	carrier costs and workers' compensation premium rates by
586	implementing changes to the carrier reimbursement schedule or
587	implementing alternative reimbursement methods.
588	4.  Submit recommendations on or before January 1, 2003,
589	and biennially thereafter, to the President of the Senate and
590	the Speaker of the House of Representatives on methods to
591	improve the workers' compensation health care delivery system.
592
593	The agency and the department, as requested, shall provide data
594	to the panel, including, but not limited to, utilization trends
595	in the workers' compensation health care delivery system. The
596	department agency shall provide the panel with an annual report
597	regarding the resolution of medical reimbursement disputes and
598	any actions pursuant to s. 440.13(8). The department shall
599	provide administrative support and service to the panel to the
600	extent requested by the panel.
601	(13)  REMOVAL OF PHYSICIANS FROM LISTS OF THOSE AUTHORIZED
602	TO RENDER MEDICAL CARE.--The department agency shall remove from
603	the list of physicians or facilities authorized to provide
604	remedial treatment, care, and attendance under this chapter the
605	name of any physician or facility found after reasonable
606	investigation to have:
607	(a)  Engaged in professional or other misconduct or
608	incompetency in connection with medical services rendered under
609	this chapter;
610	(b)  Exceeded the limits of his or her or its professional
611	competence in rendering medical care under this chapter, or to
612	have made materially false statements regarding his or her or
613	its qualifications in his or her application;
614	(c)  Failed to transmit copies of medical reports to the
615	employer or carrier, or failed to submit full and truthful
616	medical reports of all his or her or its findings to the
617	employer or carrier as required under this chapter;
618	(d)  Solicited, or employed another to solicit for himself
619	or herself or itself or for another, professional treatment,
620	examination, or care of an injured employee in connection with
621	any claim under this chapter;
622	(e)  Refused to appear before, or to answer upon request
623	of, the department agency or any duly authorized officer of the
624	state, any legal question, or to produce any relevant book or
625	paper concerning his or her conduct under any authorization
626	granted to him or her under this chapter;
627	(f)  Self-referred in violation of this chapter or other
628	laws of this state; or
629	(g)  Engaged in a pattern of practice of overutilization or
630	a violation of this chapter or rules adopted by the department
631	agency, including failure to adhere to practice parameters and
632	protocols established in accordance with this chapter.
633	Section 3.  This act shall take effect July 1, 2008.

CODING: Words stricken are deletions; words underlined are additions.