Under Florida workers’ compensation law, providers can appeal a payment disallowance or adjustment by filing a petition with the Department of Workers’ Compensation (DWC) within 45 days of receiving notice.
How to File a Petition
Providers who wish to contest a payment disallowance or adjustment must file a petition with the DWC within 45 days of the notice date.
Providers must use the Petition For Resolution of Reimbursement Dispute Form to file a petition.
To file a petition, the provider must do the following:
- Include all documentation supporting the allegations stated in the petition
- Serve a copy of the petition on the carrier and all affected parties by certified mail
If the provider fails to submit supporting documentation, the DWC may dismiss the petition.
Carrier’s Obligation
Once the carrier receives the petition, it must respond within 30 days and submit all documentation substantiating its disallowance or adjustment. If the carrier fails to respond within 30 days, the carrier waives all objections to the petition.
Department’s Determination
The DWC must issue a written determination within 120 days after receiving all documentation.
If the DWC finds that the carrier improperly adjusted or disallowed payment, the carrier must reimburse the provider within 30 days.
The carrier may also face the penalties described in Section 440.20(7)(f), including fines up to $5,000 per instance and payment of the provider's costs and attorney's fees.
Penalties for Unreasonable Denials or Reductions
The DWC holds payers accountable when they engage in a pattern or practice of arbitrarily or unreasonably denying or reducing medical bill payments.
To enforce accountability, the DWC may:
- Order Repayment: The DWC can compel the payer to repay the appropriate amount to the health care provider.
- Impose Fines: The DWC can assess an administrative fine of up to $5,000 for each instance of improper denial or reduction.
- Award Costs and Fees: The DWC may award the health care provider costs, including reasonable attorney's fees for prosecuting the petition.
Florida |
Statutes/Rule |
Statute |
|
Section |
440.13 Medical Services and Supplies; Penalty for Violations; Limitations |
Subsection Text |
440.13 (7) (a) Any health care provider who elects to contest the disallowance or adjustment of payment by a carrier under subsection (6) must, within 45 days after receipt of notice of disallowance or adjustment of payment, petition the department 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 department results in dismissal of the petition. (b) The carrier must submit to the department 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 to the department within 30 days constitutes a waiver of all objections to the petition. (c) Within 120 days after receipt of all documentation, the department must provide to the petitioner, the carrier, and the affected parties a written determination of whether the carrier properly adjusted or disallowed payment. The department 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. (d) If the department 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. |
Section |
440.20 Time for payment of compensation and medical bills; penalties for late payment. |
Subsection Text |
440.20 (7) (f) Any carrier that engages in a pattern or practice of arbitrarily or unreasonably disallowing or reducing payments to health care providers may be subject to one or more of the following penalties imposed by the department: 1. Repayment of the appropriate amount to the health care provider. 2. An administrative fine assessed by the department in an amount not to exceed $5,000 per instance of improperly disallowing or reducing payments. 3. Award of the health care provider’s costs, including a reasonable attorney fee, for prosecuting the petition. |
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