Template

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• Division of Workers CompensationOffice of Data
  Quality Collection
• Don Davis, Manager
• Data Quality Collection
• [phone]
• Davisd1_at_dfs.state.fl.us
• Data Quality and How to Avoid Form Rejection
• Florida Workers Compensation Medical
• Services, Billing, Filing and Reporting Rule
• (69L-7.602)

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Data Quality Procedures for Filing Documents
Proposed Rule 69L-3.003 (1) The Division shall
return to the claims-handling entity any document
on which the appropriate information required
does not appear, and will notify the
claims-handling entity of its error or
omissionThe claims-handling entity shall make
the correction, include a revised Sent to
Division Date and resubmit the document to the
Division. The document will be considered
completed and in compliancewhen the corrected
document is resent to the Division.
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Document Returned by Division Due to
Non-compliance with Rule 69L-3.003 Reviewer
______________ Date ____________
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Top Reasons for Rejecting the First Report
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Top Reasons for Rejecting the 13
Medical Only No Indemnity Reflected
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Section 440.20(2)(b), Florida Statutes
Pursuant to the above statute, the division is
now required to monitor 100 percent of all
submitted medical bills to evaluate insurer
performance. This new requirement will result in
the division monitoring approximately 3.5 million
medical bills annually in order to assess timely
insurer performance standards pursuant to
s.440.20(6)(b), F.S.
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Florida Workers Compensation Medical Services,
Billing, Filing and Reporting Rule
(69L-7.602) Effective Date July 4, 2004
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Important Highlights for Insurer Responsibilities

• Medical claim bills are required to be filed
  with the
• Division for all medical only and lost time
  cases.

• 45-calendar day requirement includes initial
• submission, correction and re-submission of all
• errors identified in the Medical Claims
  Processing
• Reports. A form is not considered filed unless
  it
• passes division structure and quality edits.

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Important Highlights for Insurer Responsibilities

• Required data to be filed with division must be
• accurate and in compliance with the Medical
• EDI Implementation Guide (MEIG)

• Medical bills must be returned to the provider
• with explanation when services billed on
  incorrect
• billing form, invalid code used and is the only
• line-item billed, and required information is
• illegible or not provided 

• Insurer must report Explanation of Bill
• Review (EOBR) codes

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Important Highlights for Insurer Responsibilities

•  Insurer must pay, adjust and pay, disallow or
• deny bill within 45 calendar days from date
• received s. 440.20(2)(b)

• Insurer must correct and re-file all rejected
• medical bills within the 45-day filing timeline

• Insurer must report to the division actual
  dollar
• amount paid to the health care provider or
• reimbursed to the injured employee

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CONVERSION SCHEDULE TO THE MEDICAL DATA SYSTEM
Insurers who are electronically filing any
medical bills (one or more) with the division as
of the effective date of this rule must
successfully meet transmission test requirements
and be approved by the division for production
transmission according to these
dates Submitters with names beginning with A
E Aug 2 Sept 15, 2004 Submitters with
names beginning with F Z Sept 16 Oct
29, 2004
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CONVERSION SCHEDULE TO THE MEDICAL DATA SYSTEM
Insurers filing only paper-document medical bills
with the division as of November 1, 2004 must
complete a test transmission and be approved by
the division for production transmission
according to these dates Submitters with names
beginning with A H Nov 1 Dec 15,
2004 Submitters with names beginning with I Q
Dec 16 Jan 31, 2005 Submitters with
names beginning with R Z Feb 1 March
15, 2005
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Methods for Submission Until Your Scheduled
Conversion Date
1. Electronic Submission in Compliance with MEIG
EDI Submission
2. Paper-Batches
3. Medical Summary Report via approved Excel
spreadsheet ssmedrequest_at_dfs.state.fl.us
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Catastrophic Event Preventing Electronic
Submission

• Insurers may file paper-forms in certain cases
• of catastrophic events causing data-
• transmission failure or total system failure

• Must obtain approval from the division

• Approval period cannot exceed
• 30 calendar days

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Insurer Responsibilities For Those Filing Medical
Paper Batches

• Must complete and attach coversheet to each
• paper-form batch submitted to the division

• Must report to the division procedure, diagnosis
• or modifier code(s) or amount(s) charged by the
• health care provider

• Must legibly date stamp forms with
• date received and date paid

• Must include division assigned carrier
• code number in upper right hand corner

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Paper-Forms Must be Submitted to the Division in
Batches

• Must have accurate batch
• sheet with required information

• Each batch must be
• separated by form type into
• 100-count batches (if
• insurers process less than
• 100 forms in 30 calendar
• days, separate form types
• and submit batches of less
• than 100)

• Separate and band each of
• the following into groups
• within the batch
• - medical bills untimely paid
• to the provider
• - medical bills untimely
• reported to the Division

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Functioning Process of Medical Data System

• Insurers will be notified by the division on the
• Medical Claim Processing Report of accepted
  medical bills and any necessary corrections for
  rejected electronically filed medical bills

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Functioning Process of Medical Data System

• Potential duplicate bills will be identified in
• the new system and denoted for correction in
• the Medical Claims Processing Report.

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Functioning Process of Medical Data System

• An email report process is currently being
• developed that will alert the submitter twice
• a month of past due rejected medical bills

• The Division is developing an Internet Website
• that will allow for direct online entry,
  validation,
• submission, correction, and resubmission of
• medical data. This website will be available
  in
• November 2004.

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Rejected medical data errors and rejected medical
bills can lead to penalties if not properly and
timely addressed.
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Top 3 Data Elements Causing Rejection of
DFS-F5-DWC-9
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Rejected Medical Bills

• For calendar year 2003, over 43,000 medical
• bills were rejected by the division for quality
• issues, and were never corrected and
• resubmitted by the insurer.

• Those rejected bills would have amounted
• to substantial administrative penalty
• assessments pursuant to the Medical Billing
• Rule 69L-7.602

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Data Results for First Six Months of 2004
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DFS-F5-DWC-9 and DFS-F5-DWC-90 Late payments to
Healthcare Provider by the Industry as a Whole
1/1/04 through 6/30/04

• Over 1.5 million medical bills accepted into the
  
• divisions database
• Nearly 60,000 medical bills untimely paid to
  the HCP
• Corresponding potential penalty assessment of
  650,375
• preliminary data

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DFS-F5-DWC-9 and DFS-F5-DWC-90 Late Filing to
Division by Industry as a Whole 1/1/04 through
6/30/04

• Over 1.5 million medical bills accepted into the
• divisions medical data base
• Nearly 325,000 medical bills filed late
• Represent an untimely filing percentage of over
  20
• Preliminary data

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• Update on the Reimbursement Manuals
• Effective July 4, 2004

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Location of Reimbursement Manuals www.fldfs.com/WC
/ Publications
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Reimbursement Manuals

• Effective July 4, 2004, insurers must use the
  2004 2nd Edition for both the Health Care
  Provider Reimbursement Manual and the Hospital
  Reimbursement Manual

• Health Care Provider Reimbursement Manual can
  now be downloaded in ASCII text file

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Reimbursement Manuals

• Due to statutory language in s.440.13(12)(b),
  F.S., Reimbursement Manuals will be updated when
  the Federal Government releases their Relative
  Value
• Schedule for Medicare. This update occurs once a
  year.

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Thank you!