Florida Senate - 2012 COMMITTEE AMENDMENT Bill No. SB 668 Barcode 409686 LEGISLATIVE ACTION Senate . House Comm: RE . 02/23/2012 . . . . ————————————————————————————————————————————————————————————————— ————————————————————————————————————————————————————————————————— The Committee on Health Regulation (Garcia) recommended the following: 1 Senate Substitute for Amendment (766998) (with title 2 amendment) 3 4 Delete everything after the enacting clause 5 and insert: 6 Section 1. Paragraph (a) of subsection (3) and paragraph 7 (c) of subsection (12) of section 440.13, Florida Statutes, are 8 amended, paragraph (k) is added to subsection (3), paragraphs 9 (d) and (e) of subsection (12) are redesignated as paragraphs 10 (c) and (d), respectively, present subsections (15) through (17) 11 are renumbered as subsections (16) through (18), respectively, 12 and a new subsection (15) is added to that section, to read: 13 440.13 Medical services and supplies; penalty for 14 violations; limitations.— 15 (3) PROVIDER ELIGIBILITY; AUTHORIZATION.— 16 (a) As a condition for
toeligibility for payment under 17 this chapter, a health care provider who renders services must 18 be a certified health care provider and must receive 19 authorization from the carrier before providing treatment. This 20 paragraph does not apply to emergency care. An employer or a 21 carrier may not refuse to authorize a physician to treat an 22 injured employee solely because the physician is a dispensing 23 practitioner, as defined in s. 465.0276. The department shall 24 adopt rules to administer implementthe certification of health 25 care providers. 26 (k) If a physician who is a dispensing practitioner as 27 defined in s. 465.0276 receives authorization from an employer 28 or a carrier to treat a claimant pursuant to paragraph (a), the 29 physician may dispense and fill prescriptions for medicines 30 under this chapter. For purposes of dispensing and filling 31 prescriptions for medicines, the department, employer, or 32 carrier, or an agent or representative of the department, 33 employer, or carrier, may not select the pharmacy, pharmacist, 34 or dispensing practitioner that the claimant must use. 35 (12) CREATION OF THREE-MEMBER PANEL; GUIDES OF MAXIMUM 36 REIMBURSEMENT ALLOWANCES.— 37 (c) As to reimbursement for a prescription medication, the38 reimbursement amount for a prescription shall be the average39 wholesale price plus $4.18 for the dispensing fee, except where40 the carrier has contracted for a lower amount. Fees for41 pharmaceuticals and pharmaceutical services shall be42 reimbursable at the applicable fee schedule amount. Where the43 employer or carrier has contracted for such services and the44 employee elects to obtain them through a provider not a party to45 the contract, the carrier shall reimburse at the schedule,46 negotiated, or contract price, whichever is lower. No such47 contract shall rely on a provider that is not reasonably48 accessible to the employee.49 (15) REIMBURSEMENT FOR PRESCRIPTION MEDICATION.—The 50 reimbursement amount for prescription medication shall be the 51 average wholesale price plus $4.18 for the dispensing fee, 52 unless the carrier and the provider seeking reimbursement have 53 directly contracted with each other for a lower reimbursement 54 amount. 55 (a) If a prescription has been repackaged or relabeled, the 56 provider shall give a $15 credit to the insurance carrier or 57 self-insured employer for each prescription that costs more than 58 $25. The credit shall be reflected in the Explanation of Bill 59 Review provided by the carrier or employer. The credit does not 60 apply if the carrier and the provider seeking reimbursement have 61 directly contracted with each other for a lower reimbursement 62 amount. 63 (b) A physician or the physician’s assignee may not hold an 64 ownership interest in a licensed pharmaceutical repackaging 65 entity and may not set or cause to be set a repackaged 66 pharmaceutical average wholesale price. 67 (c) An insurance carrier or self-insured employer that 68 improperly denies or delays payment of a valid claim for 69 reimbursement of a prescription medication is subject to an 70 administrative fine of $250 per instance of improper 71 reimbursement. If the department determines that a carrier or 72 employer has improperly denied or delayed reimbursement claims 73 more than 15 times in any one calendar year, the administrative 74 penalty increases to $1,000 per instance of improper 75 reimbursement. If the department determines that a carrier or 76 employer has improperly denied or delayed reimbursement claims 77 more than 100 times in any one calendar year, the insurer or 78 employer must show cause to the department as to why its 79 certificate of authority to underwrite workers’ compensation 80 insurance should not be revoked or suspended. The penalties in 81 this paragraph are not exclusive and are in addition to remedies 82 provided under part IX of chapter 626. 83 (d) Pursuant to subsection (7), a provider may challenge a 84 disallowance, denial, or adjustment of payment by filing a 85 petition for dispute resolution with the department within 30 86 days after receiving the final Explanation of Bill Review issued 87 by the insurance carrier or self-insured employer. The carrier 88 or self-insured employer must clearly state on the face of the 89 final Explanation of Bill Review when the 30-day period for 90 filing a petition for dispute resolution with the department 91 commences. 92 Section 2. This act shall take effect July 1, 2012. 93 94 ================= T I T L E A M E N D M E N T ================ 95 And the title is amended as follows: 96 Delete everything before the enacting clause 97 and insert: 98 A bill to be entitled 99 An act relating to workers’ compensation medical 100 services; amending s. 440.13, F.S.; prohibiting an 101 employer or carrier from refusing to authorize a 102 physician who is a prescribing physician; prohibiting 103 the Department of Financial Services, the employer, or 104 the carrier from selecting a claimant’s pharmacy; 105 revising requirements for determining the amount of a 106 reimbursement for prescription medications; 107 prohibiting a physician from having an ownership 108 interest in a pharmacy repackaging entity or setting 109 pharmaceutical wholesale prices; providing penalties 110 for an employer or carrier’s improper delay or denial 111 of payment and procedures for a provider to challenge 112 a disallowance, denial, or adjustment of payment; 113 providing an effective date.