RULE CHAPTER 69L-34
FLORIDA ADMINISTRATIVE CODE
(F.A.C.)
CARRIER REPORT
OF
HEALTH CARE PROVIDER VIOLATIONS
WEB TRAINING
Office of Medical Services
Bureau of Monitoring and Audit
Division of Workers’ Compensation
Department of Financial Services
Rule Chapter 69L-34, F.A.C.
Carrier Report of Health Care Provider Violation
(HCP Violation Rule)
 Web Training Objectives
• To discuss the scope of the HCP Violation Rule
and the process by which industry partners
may report HCP violations of Chapter 440, Florida
Statutes (F.S.), to the Division
• To establish the Division may use paid medical
claims data and HCP violation reports to
initiate a Division investigation, pursuant
to s. 440.13(11), F.S.
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Rule Chapter 69L-34, F.A.C. - HCP Violation Rule
 Purpose & Effect
• To clarify that carriers satisfy the mandatory
overutilization reporting requirements in s.
440.13(8), F.S., when in compliance with
reporting requirements of Rule 69L-7.602(5)and
(6), F.A.C., Florida Workers’ Compensation
Medical Services Billing, Filing and Reporting Rule
(Billing Rule)
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HCP Violation Rule - Purpose & Effect continued
• To introduce an elective/discretionary process to
report HCP violations of Chapter 440, F.S., and
applicable administrative rules
• To incorporate “Health Care Provider Violation
Referral Form, DFS-F6-DWC-2000” (Referral
Form), effective September 6, 2011, for reporting
health care provider violations
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Rule 69L-34.001 - Definitions
 Health Care Provider (Provider)
• Physician or recognized practitioner as defined
in s.440.13(1)(h), F.S., who is certified by the
Division to receive reimbursement under
Chapter 440, F.S., for services rendered to
injured employees
• Providers who, pursuant to s.440.13(3)(f), F.S.,
consent to the jurisdiction of the Division by
accepting payment under Chapter 440, F.S.
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Rule Definitions continued
 Instance of Overutilization
• A specific inappropriate service or level of
service provided to an injured employee…
NOTE: Overutilization is related to treatment
rendered; therefore, a recommendation for
treatment that would constitute overutilization
is not a violation.
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Rule Definitions continued
 Supportive Documentation
• All documents and records that reasonably support
an allegation of a violation of this Rule Chapter
 Verifiable Delivery Process
• The ability to document a common carrier’s pick-up
and delivery date or a US Postal Service postmark
date
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Rule Definitions continued
 HCP Violation
A health care provider’s non-compliance with
Chapter 440, F.S. and Division rules such as:
• Failing to refund an overpayment of
reimbursement pursuant to s. 440.13(11)(a),
F.S.
• Failing to submit medical records and reports
pursuant to s. 440.13(4)(a) and (c), F.S., or
69L-7.602(4), F.A.C.
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Rule Definitions continued
 HCP Violation cont’d.
• Collecting or receiving payment from an injured
employee in violation of s. 440.13(14)(a), F.S.
• Failing to follow Standards of Care, pursuant to
s. 440.13(16), F.S., including overutilization of
services
• Failing to properly bill medical services,
pursuant to the Billing Rule
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Rule Definitions continued
 Improper Billing and Billing Errors
• Non-compliance with the Billing Rule and
applicable reimbursement manual(s);
 Improper form completion
 Filing of incorrect medical claim form
 Use of invalid or incorrect billing codes,
modifiers, REV codes, etc…
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Rule 69L-34.002 - Mandatory Carrier Reporting
of Overutilization of Services
 Carrier satisfies requirement to report all instances
of overutilization of treatment rendered or
recommended pursuant to s. 440.13(8), F.S., when
carrier complies with the:
• Explanation of Bill Review (EOBR) requirements in
the Billing Rule
or
• Notice of Denial requirements in
Rule 69L-3.012, F.A.C.
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Mandatory Carrier Reporting continued
 Rule 69L-7.602(5)(o), F.A.C., requires Carriers to file
medical data elements to include EOBR codes
documenting the carrier’s bill review process for:
 Disallowing and adjusting reimbursement for
overutilization of services
 Explaining the reimbursement of each billed
line item adjudicated
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Mandatory Carrier Reporting continued
 Rule 69L-3.012, F.A.C., requires Carriers to issue a
DFS-F2-DWC-12, Notice of Denial form to the
Provider and injured employee to deny
authorization of recommended treatment that
otherwise constitutes overutilization of services
NOTICE OF DENIAL
DFS-F2-DWC-12 FORM
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Rule 69L-34.003
Elective Referral of Alleged HCP Violation
 Filing a Referral to report a HCP violation is
DISCRETIONARY and SHALL:
• Be on a Health Care Provider Violation Referral
Form, DFS-F6-DWC 2000 Form (“Referral” form)
• Be accompanied by supportive documents (e.g.
DWC- 25 forms, peer review reports, medical bills,
collection letters, etc…)
• Identify one (1) violation per referral form
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Elective Referral of Alleged HCP Violation continued
•
Be filed with the DWC Office of Medical Services in
Tallahassee, FL
NOTE: The elective reporting of an overutilization
violation neither satisfies nor negates the carrier’s
obligation for reporting instances of overutilization
pursuant to s. 440.13(8), F.S.
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Rule 69L-34.004 - Timeliness of a Referral
 Properly completed Referrals and supportive
documentation related to a Provider’s billing
practice SHALL be filed within 180 days after:
• Issuance of an EOBR identifying the reported
violation, such as:
 A Billing error
 Overutilization of services
 The Failure to submit medical records reports
required for the adjudication of a medical bill
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Timeliness of a Referral continued
 Referrals related to a Provider billing an injured
employee or failing to provide requested medical
records and reports shall be filed within 180 days of:
• The date of written notice to Provider identifying
violation
• The carrier’s received date of a copy of a bill
collection notice to injured employee for payment
of covered treatment
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Rule 69L-34.005- Referral Investigation
 The Division MAY initiate an investigation of
an alleged Provider violation based on:
• An audit of paid medical claim data filed with
the Division
and/or
• Receipt of a completed Referral form and all
supportive documentation
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Referral Investigation continued
 The Division MAY request additional documentation
from Carrier and Provider to support its investigation
 A Provider or Carrier must submit, to the Division,
within 45 days of receipt of a written request:
• The requested documentation
or
• A written explanation why the documentation is
not available
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Referral Investigation continued
 The Carrier’s or Provider’s failure to submit
documentation within 45 days of receipt of
request SHALL result in:
 Issuance of Division finding(s) based on
documentation filed with referral or received
subsequent to document request deadline
or
 Termination of Division’s investigation
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Referral Investigation continued
 A finding of a provider violation SHALL result in
one or more of the following administrative
sanctions pursuant to s. 440.13(8),(11) and (13), F.S.:
 Removal from the DWC provider database
 Barring future payment under Chapter 440
 Administrative fine not to exceed $5,000 per
instance of overutilization
 Referral to licensing authority for further review
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Rule 69L-34.006 - Invalid Referrals
 Complaints related to the following issues are not
subject to agency action under this rule and shall
be dismissed:
• Reimbursement dispute issues pending a
Determination, pursuant to s. 440.13(7), F.S.;
or
• Medical benefit dispute issues pending a
Judge of Compensation Claims order
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HCP Violation Rule Summary
• Rule effective September 6, 2011
• Carrier satisfies mandatory reporting of “Instances
of Overutilization” requirements of s. 440.13(8),
F.S., by:
 Filing medical claims data as required in Billing Rule
or
 Denying authorization of a recommended medical
benefit, pursuant to Rule 69L-3.012, F.A.C.
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HCP Violation Rule Summary continued
• Filing an HCP Referral:
 Is OPTIONAL
 Is not A SUBSTITUTE for mandatory reporting
requirements of statute and rule
 Must be filed within 180 days of notification of
violation
 Must be filed on a “Health Care Provider Violation
Referral Form, DFS-F6-DWC-2000”
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HCP Violation Rule Summary continued
• Alleged violation must be related to rendered
services that are:
 Not properly billed
 Not properly reported
 Not appropriate for compensable condition
 Reimbursed in error due to HCP billing error or
overutilization of services
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HCP Violation Rule Summary continued
• The following types of referrals will be dismissed in
accordance with the Rule:
 Reimbursement dispute issues addressed in petitions
filed with Division
 Medical benefit issues addressed in Petition for
Benefits filed with JCC’s office
 Untimely filed referrals will also be dismissed
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Questions and Policy Clarification
Inquiries regarding the HCP Violation Rule may be
directed to:
[email protected]
The HCP Violation Rule and Referral Form are available on
the Division’s website at:
http://www.myfloridacfo.com/wc/provider/hcp-compliance.html
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