Report Details Disputed Workers’ Comp Bills

Apr 11, 2018

More than half of the disputed workers’ insurance compensation bills sent to a panel for review last year were either withdrawn or tossed out because services weren’t authorized. 

But nearly 80 percent of the remaining petitions for review that were resolved during fiscal year 2016-2017 were settled on behalf of health-care providers, a new report from the state Division of Workers’ Compensation shows.

The division’s Medical Services Section closed 4,725 petitions for review during the fiscal year, according to the report. Of those, 2,570 were dismissed or the health-care services weren’t authorized under the workers’ compensation system.

Of the other 2,155 petitions, the report noted that the state determined health-care providers had been underpaid in 79.5 percent of the cases. In 18 percent of the cases, the state determined no additional payment was due to the providers.

The report, shared Tuesday at a meeting of the workers’ compensation system’s Three Member Panel, also showed 17 workers’ compensation violation referrals reported to the division by insurance carriers or employers or others for alleged overutilization. Ten of those referrals, for example, related to failure to substantiate the medical necessity of treatment but were closed after reviews showed a lack of documentation to back up the allegations.

Five of the cases involved claims where providers failed to submit required medical records and reports to insurance carriers. Those cases were dropped after providers submitted the proper documentation.

The Three Member Panel is a state board that tracks health-care costs and reimbursement issues associated with the workers’ compensation system. The panel is required to biennially submit recommendations "on methods to improve the workers’ compensation health care delivery system." 

The next report is due to the Legislature in 2019.

Regarding costs of care, the panel heard from Sarasota labor attorney Christine Sensenig, and Corvel Corp. bill manager Marco Wyszkowski, both of whom said there should be a requirement that charges submitted by health-care providers be “reasonable.”

Sensenig would like the Division of Workers’ Compensation to analyze and study billing to see whether a problem exists and whether there should be a “reasonableness” requirement.