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Cases Focus On Workers’ Comp Payment Disputes

Stethoscope and gavel against a white backdrop.
Wikimedia Commons
The Florida Channel
Leon County Judge John Cooper on June 30, 2022, in a screen grab from The Florida Channel.

Ambulatory-surgical centers and a major player in the hospital industry are challenging a state proposal that could affect payment disputes in the workers' compensation insurance system.
The Florida Society of Ambulatory Surgical Centers and two affiliates of the HCA hospital chain filed challenges last week against the state Division of Workers' Compensation. Also filing a challenge was Automated HealthCare Solutions, a firm that submits claims to insurers after doctors dispense medications to injured workers.

Administrative Law Judge D.R. Alexander has scheduled hearings in late June in the cases, which were filed in the state Division of Administrative Hearings.

The issues center, at least in part, on disputes between health-care providers and workers' compensation insurers about payment amounts for treating injured workers. When providers do not think they are being properly reimbursed for care, state law includes a process for resolution of disputes by the Division of Workers' Compensation, which is part of the state Department of Financial Services.

The Division of Workers' Compensation has moved forward in recent months with a proposed rule that would make changes in resolving disputes — and spurred the new legal challenges.

Ambulatory-surgical centers and the HCA affiliates, for example, are fighting part of the proposal that deals with situations in which insurers or health-care providers say reimbursement amounts are determined by contracts or by managed-care arrangements. In such circumstances, the Division of Workers' Compensation would not issue findings about whether costs have been improperly disallowed or need to be adjusted, under the proposed rule.

“Instead, the determination will only indicate the reimbursement amount for the treatment established by the appropriate reimbursement schedules, practice parameters, and protocols of treatment under (a chapter of state law) to assist the health care provider and the carrier in the independent application of the provisions of the contract or the workers' compensation managed care arrangement to resolve the dispute,” the proposed rule says.

The challenges contend that state law doesn't give the agency authority to make such a change.

“The Florida Legislature clearly and unambiguously intended for the Department (of Financial Services) to resolve all reimbursement disputes under all circumstances wherein a reimbursement dispute petition is filed by a health care provider against a carrier,” the Florida Society of Ambulatory Surgical Centers said in its challenge. “It did not intend for there to be some `independent application' by a health care provider and a carrier to resolve their own dispute which, by the very nature of submitting a reimbursement dispute petition to the department, the parties, obviously, could not resolve the reimbursement dispute on their own.”

The challengers in the HCA case are Oak Hill Hospital, which is part of the chain; and Parallon Business Performance Group, which acts on behalf of HCA hospitals in workers' compensation payment disputes, according to a document posted on the Division of Administrative Hearings website.