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2015 Workers’ Compensation Manual Webinar
Presented by
FSASC
Saul R. Epstein, MBA
Peter Lohrengel
December 9, 2015
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Introduction
How the 2015 Manual came to be: Attempt to simplify to enhance correct payments from
Carriers Concerns about ASC’s overbilling Workers’
Compensation and possible 3MP and Legislative changes
Surprise introduction in January 2015 Nearly every page of 2011 Manual has been re-written
in some manner
…. continued
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Introduction (continued)
How the Manual came to be: Negotiating various points (FSASC involvement)
FSASC Written and Verbal Comments Letter to Division 1/12/15 – 11 Pages Letter to Division 2/25/15 – 8 Pages
Attendance/Testimony at Tallahassee Meetings/Workshops 2/24/15 2/26/15 5/04/15
Rule 69L-7.100, F.A.C., 2015 Edition Effective DOS 1/1/16 http://www.myfloridacfo.com/Division/WC/pdf/2015_ASCRM_effective-
01.01.16.pdf
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The New Reimbursement Methodology
Schedule of Maximum Reimbursement Allowances (MRAs) Expanded from 29 to 92 Set at 60% percentile of arrayed Median charge of each CPT
code in Division database 7/1/11 thorough 6/30/13 100 submitted charges per CPT
MRA or 60% of Billed Charge if not on MRA and not agreed to by contract price – no multiple procedure reductions
Single procedure Multiple procedures Bilateral procedure Unilateral performed bilaterally (2 lines & 50 modifier)
…… continued
The New Reimbursement Methodology (continued)
Not lower of billed charge or MRA If billed charge is less
than MRA, paid at MRA (if MRA is basis of payment)
Updated annually Based on 60% of median
billed charges if in Division data base of CPT code billed 50+ times
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New Reimbursement Methodology (continued)
Current 2011 Manual
• 1st Procedure: MRA or 70% of billed charge if not on MRA
• Subsequent Procedure(s): Lower of 50% of billed charge or MRA (limited to reimbursement primary procedure)
• Modifier 51 required
New 2015 Manual
• 1st Procedure: MRA or 60% of billed charge if not on MRA
• Subsequent Procedure(s): MRA or 60% of billed charge if not on MRA (not limited)
• Modifier 51 required
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New Reimbursement Methodology (continued)
Current 2011 Manual
• Bilateral codes: Same as 1st/subseq. Codes
• Unilateral done bilaterally: Code billed 2 lines with 50 modifier each line, if primary, both lines MRA or 70% of billed
• Bilateral done Unilateral: 50% of normal
• Modifier: 52
New 2015 Manual
• Bilateral codes: Same as 1st/subseq. Codes
• Unilateral done bilaterally: Code billed 2 lines. No special instructions
• Bilateral done unilateral: 50% of normal
• Modifier: 52
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New Reimbursement Methodology (continued)
Current 2011 Manual• Imaging: 70% of billed charge
• Modifier: TC
• 2010 CPT codes• ICD-9 DX codes• HCPCS Level II codes allowed
• Implants/ADI/S&H: 150%/120%/100% of Invoice Amount
• Rev code: 278• CPT code: 99070• Modifiers IM/DI/SH required• Certification required
• Box 80 UB-04 Claim
New 2015 Manual
• Imaging: MRA or 60% of billed charge if not on MRA
• Modifier: TC• Fluoro 1 Unit/spinal region not
level• 2015 CPT codes • ICD-10 DX codes• HCPCS Level II codes not allowed• CPT Category II and III require prior
auth• Implants/ADI/S&H: 150%/120%/100%
of Invoice Amount• Rev code: 278• CPT code: 99070• Modifiers IM/DI/SH required• Certification required
• Box 80 UB-04 Claim
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The New Reimbursement Methodology (continued)
Surgical Implants and Associated Disposable Instrumentation (ADI) Must be “purchased by, billed by and only reimbursed to the
ASC” ADI “is only reimbursable for those surgeries requiring Surgical
Implants” If not “Certified” properly, “may be adjusted or disallowed” vs.
“shall not be reimbursed”(2011 Manual) Total requested reimbursement by each of 3 categories (w modifier) and In Box 80 of UB-04 by each category; or
Submit copies of Implant Log or Tracking Sheet with invoices Signed, written statement that reimbursement amount requested is correct
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The New Reimbursement Methodology (continued)
Surgical Implants and Associated Disposable Instrumentation (ADI) (continued_
2015 vs. 2011… No change in reimbursement amounts No change in Surgical Implant definition No substantive change in ADI definition (“same implant invoice”)
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Billing and Collections
New location for the billing references Changed former Billing, Filing and Reporting Rule
69L-7.602 F.A.C. to Reimbursement and Utilization Rule Chapter 69L-7, F.A.C. 69L-7.710 - Florida Workers’ Compensation Medical Services Billing, Filing
and Reporting Rule 69L-7.720 – Forms Incorporated by Reference for Medical Billing, Filing and
Reporting 69L-7.730 – Health Care Provider Medical Billing and Reporting
Responsibilities 69L-7.740 – Insurer Authorization and Medical Bill Review Responsibilities
EOBR Code 85 shall not be used in lieu of EOBR 93
69L-7.750 – Insurer Electronic Medical Report Filing to the Division …. continued
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Billing and Collections (continued)
Materials Incorporated by Reference, which listed all such Materials in 2011Manual, now referenced to Rule Chapter 69L-8, F.A.C. 69L-8.072 - Materials for use with the Workers’ Compensation
Reimbursement Manual for Ambulatory Surgical Centers (1)(e) The CPT 2015 Current Procedural Terminology Professional
Edition, Copyright 2014, American Medical Association; and (1)(i) The 2015 CPT Assistant, Copyright American Medical
Association - CCI not applicable
69L-8.074 – Materials for use throughout Rule Chapter 69L-7, F.A.C.
….continued
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DISPUTE RESOLUTION PROCESS
Medical Services Section of Division responsible for resolution of reimbursement disputes: Rule Chapter 69L-31 F.A.C. & Chapter 440.13(7) F.S.
Within 45 days after receipt of notice of disallowance or adjustment of payment, petition must be filed with division to resolve the dispute The petitioner must serve a copy of the petition on the carrier and on all
affected parties by certified mail The petition must be accompanied by all documents and records that
support the allegations contained in the petition. Failure of a petitioner to submit such documentation to the division results in dismissal of the petition.
Carrier must submit within 30 days after receipt of the petition all documentation substantiating the carrier’s disallowance or adjustment. Failure of the carrier to timely submit such documentation within 30 days constitutes a waiver of all objections to the petition
…..continued
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DISPUTE RESOLUTION PROCESS (continued)
Carrier must submit within 30 days after receipt of the petition all documentation substantiating the carrier’s disallowance or adjustment. Failure of the carrier to timely submit such documentation within 30 days constitutes a waiver of all objections to the petition.
Within 120 days after receipt of all documentation, the division must provide to the petitioner, the carrier, and the affected parties a written determination of whether the carrier properly adjusted or disallowed payment. The division must be guided by standards and policies set forth in this chapter, including all applicable reimbursement schedules, practice parameters, and protocols of treatment, in rendering its determination.
If the division finds an improper disallowance or improper adjustment of payment by an insurer, the insurer shall reimburse the health care provider, facility, insurer, or employer within 30 days, subject to the penalties provided in this subsection.
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Helpful Links
The current “billing” rule (two parts): 69L-7.602 Part I:
https://www.workcompcentral.com/wiki/index.php/Florida_Regulations_69L-7.602pt1 Part 2: https://
www.workcompcentral.com/wiki/index.php/Florida_Regulations_69L-7.602pt2
The current ASC reimbursement Manual: 69L-7.100 (current reimbursement manual) http://www.myfloridacfo.com/Division/WC/pdf/2011ASCRM.pdf
The future “billing” rule: 69L-7.710 https://www.flrules.org/Gateway/View_notice.asp?id=15979603
The future “reference” rule: 69L-8 https://www.flrules.org/gateway/View_Notice.asp?id=15979700
The January 1, 2016 effective ASC reimbursement Manual: 69L-7.100 http://www.myfloridacfo.com/Division/WC/pdf/2015_ASCRM_effective-01.01.16.pdf
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Q&A
Saul R. Epstein, MBA
Vice President, FSASC
(954) 312-3503 direct voice
(954) 312-3203 direct efax
Peter Lohrengel
Executive Director, FSASC
(850) 222-3000 ext 5 voice
(850) 222-3019 fax
