2015 Workers’ Compensation Manual Webinar Presented by FSASC Saul R. Epstein, MBA Peter Lohrengel 1 December 9, 2015

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 2

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  pdf pdf 3

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/ 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 4

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 5

New Reimbursement Methodology (continued) 6 Current 2011 Manual 1 st 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 1 st 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

New Reimbursement Methodology (continued) 7 Current 2011 Manual Bilateral codes: Same as 1 st /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 1 st /subseq. Codes Unilateral done bilaterally: Code billed 2 lines. No special instructions Bilateral done unilateral: 50% of normal Modifier: 52

New Reimbursement Methodology (continued) 8 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: 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: Modifiers IM/DI/SH required Certification required Box 80 UB-04 Claim

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 9

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”) 10

Billing and Collections New location for the billing references Changed former Billing, Filing and Reporting Rule 69L F.A.C. to Reimbursement and Utilization Rule Chapter 69L-7, F.A.C. 69L Florida Workers’ Compensation Medical Services Billing, Filing and Reporting Rule 69L – Forms Incorporated by Reference for Medical Billing, Filing and Reporting 69L – Health Care Provider Medical Billing and Reporting Responsibilities 69L – Insurer Authorization and Medical Bill Review Responsibilities  EOBR Code 85 shall not be used in lieu of EOBR 93 69L – Insurer Electronic Medical Report Filing to the Division  …. continued 11

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 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 – Materials for use throughout Rule Chapter 69L-7, F.A.C.  ….continued 12

DISPUTE RESOLUTION PROCESS Medical Services Section of Division responsible for resolution of reimbursement disputes: Rule Chapter 69L-31 F.A.C. & Chapter (7) F.S. Rule Chapter 69L-31 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 13

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. 14

15 69L L Petition Form

16 69L L Petition Form…. cont.

Helpful Links The current “billing” rule (two parts): 69L Part I: pt1https:// pt1 Part 2: pt2https:// pt2 The current ASC reimbursement Manual: 69L (current reimbursement manual) The future “billing” rule: 69L The future “reference” rule: 69L The January 1, 2016 effective ASC reimbursement Manual: 69L pdf pdf 17

Q&A Saul R. Epstein, MBA Vice President, FSASC (954) direct voice (954) direct efax Peter Lohrengel Executive Director, FSASC (850) ext 5 voice (850) fax 18