Division of Workers' Compensation
Rules 69L-5.205 and 69L-5.217, Florida Administrative Code: The Florida Department of Financial Services, Division of Workers' Compensation announces that Rule 69L-5.205 (Loss Data Reporting), F.A.C., and Rule 69L-5.217, (Civil Penalties and Fines), F.A.C., have been adopted with an effective date of December 29, 2011. Rule 69L-5.205, F.A.C., clarifies that former self-insurers must report loss data for the final period of authorization only once. Rule 69L-5.217, F.A.C., reduces the penalties assessed against self-insurers for late filing of required forms, reports and documents.
Both rules may also be found via http://www.myfloridacfo.com/wc/forms.html or https://www.flrules.org/gateway/ChapterHome.asp?Chapter=69L-5
Revisions to Rule 69L-7.100 Florida Administrative Code (F.A.C.) has been adopted with an effective date of November 13, 2011. This rule incorporates by reference the Florida Workers’ Compensation Reimbursement Manual for Ambulatory Surgical Centers (ASC Manual), 2011 Edition. The ASC Manual contains the Maximum Reimbursement Allowances determined by the Three-Member Panel, pursuant to Section 440.13(12), F.S. and establishes reimbursement policies, guidelines, codes and maximum reimbursement allowances (MRAs) for items and services provided to an injured worker in connection with a surgical procedure performed in an Ambulatory Surgical Center. The official rule and ASC Manual can be view at http://www.flrules.org/Gateway/reference.asp?No=Ref-00686. Florida Workers’ Compensation Reimbursement Manual for Ambulatory Surgical Centers, 2011 Edition
Fraud and Consumer Protection
The Division of Consumer Services helps consumers make informed insurance and financial decisions. Our dedicated and experienced staff are continuously trained and informed about any changes that occur in the 26 different categories of insurance. Consumer Assistance and Protection is Our Mission.
The 11-member Medicaid and Public Assistance Fraud Strike Force was created during the 2010 Legislative Session to increase the effectiveness of programs and initiatives that work to prevent, detect and prosecute Medicaid and public assistance fraud. It is CFO Atwater’s goal through the Strike Force to bring all the parties to the table to ensure that the cheats and thieves that are taking Floridians’ hard-earned money end up behind bars.
The Division of Insurance Fraud is the law enforcement arm of the Department of Financial Services and is responsible for investigating insurance fraud, crimes associated with claim fraud, insurance premium fraud, workers’ compensation claim fraud, workers’ compensation premium avoidance and diversions, insurer insolvency fraud, unauthorized insurance entity fraud and insurance agent crimes. The law enforcement detectives of the Division of Insurance Fraud also investigate viatical application fraud, defalcations of escrow funds held in trust by title insurance firms and non-Medicaid related health care fraud.
MONEY SERVICE BUSINESS WORKERS' COMP FRAUD WORK GROUP
The purpose of the work group is to review in depth the practices of the check cashing services industry that aid in workers’ compensation premium fraud. Through research and hearings the work group shall identify the loopholes that allow “shell” construction companies to be established; evaluate the operation of check cashing services; identify any ambiguity related to enforcement of the laws governing these entities; and identify any potential revisions to the statutory framework to eliminate workers’ compensation premium fraud.
The Department of Financial Services is proud of our accomplishments finding and prosecuting fraud but we could use your help. If you are a victim of fraud or suspect fraud is occurring, we want to hear from you. Together we can work to put these criminals out of business and make sure that Floridians are protected from those who seek to defraud their fellow citizens.
PUBLIC ASSISTANCE FRAUD
The Division of Public Assistance Fraud works to prevent, detect and prosecute public assistance fraud. With field offices around the state, the Division of Public Assistance Fraud’s staff is well positioned to take a regional approach to identifying and addressing fraud.
The Division of Workers’ Compensation ensures that Florida’s workers’ compensation system is healthy and useful. The division’s duties include educating the public about their workers’ compensation rights and responsibilities, compiling and monitoring system data and promoting and advocating accident prevention in the workplace.
The Bureau of Fire and Arson Investigations is the law enforcement branch of the division, and is responsible for conducting fire, arson and explosives investigations as well as other associated crimes (i.e. insurance fraud, homicide, motor vehicle theft, terrorism, etc.) across the state, “Suppression of arson and the investigation of the cause, origin, and circumstances of fire.”
FREQUENTLY ASKED QUESTIONS
Regardless of what position you find yourself in, here are some questions that might help you:
Q. How long after an accident do I have to report it to my employer?
You should report it as soon as possible but no later than 30 day or your claim may be denied.
Q. When should my employer report the injury to its insurance company?
Your employer should report the injury as soon as possible, but no later than seven (7) days after knowledge of it. The insurance company must send you an information brochure within three days after receiving notice form your employer. The brochure will explain your rights and responsibilities, as well as provide additional information about the workers’ compensation law.
Q. My employer will not report my injury to the insurance company. What can I do?
You have the right to report to report the injury to its insurance company. However, if you need assistance, contact the Employee Assistance Office (EAO) at (800) 342-1741 or email email@example.com. Q. What kind of medical treatment can I get? The medical provider, authorized by your employer or the insurance company, will provide the necessary medical care, treatment and prescriptions related to your injury.
Q. What kind of medical treatment can I get?
The medical provider, authorized by your employer or the insurance company, will provide the necessary medical care, treatment and prescriptions related to your injury.
Q. Do I have to pay any of my medical bills?
No, all authorized medical bill should be submitted by the medical provider to your employer’s insurance company for payment.
Q. Will I be paid if I lose time from work?
Under Florida law, you are not paid for the first seven day of disability. However, if you lose time because your disability extends to over 21 days, you may be paid for the first seven day by the insurance company. How much will I be paid? In most cases, your benefit check, which is paid biweekly, will be 66 2/3 percent of your average weekly wage. If you were injured before October 1, 2003, this amount is calculated by using wages earned during the 91-day period immediately preceding the date of your injury, not to exceed the state limit. If you worked less that 90 percent of the 91 day period, the wages of a similar employee in the same employment who has worked the whole of the 91 day period or your full-time weekly wage may be used. If you were injured on or after October 1, 2003, your average wage is calculated using wages earned 13 weeks prior to your injury, not counting the week in which you were injured. In addition, if you worked less than 75 percent of the 13-week period, a similar employee in the same employment who has worked 75 percent of the 13-week period or your full time weekly wages shall be used.
Q. Do I have to pay income tax on the money?
No. However, if you go back to work on light or limited duty and are still under the care of the authorized doctor, you will pay taxes on any wages earned while working. For additional information on income tax, you may want to visit the internal Revenue Service website at: www.irs.gov.
Q. When will I get my first check?
You should receive the first check within 21 days after reporting your injury to your employer.
Q. If I’m only temporarily disabled, how long can I get these checks?
You can receive temporary total, temporary partial disability payments or a combination of the two benefits during the continuance of your disability for no more than a maximum of 104 weeks.
Q. Can I receive Social Security benefits and workers’ compensation benefits at the same time?
Yes. However an offset, or reduction in you workers’ compensation check, may be applied because the law states that the two combined may not exceed 0 percent of your average weekly wage earned prior to your injury. For further information on Social Security, you may contact the Social Security Administration at (800) 772-2323 or visit its website at www.ssa.gov.
Q. What can I do if I am not receiving my benefit check?
Call the insurance company and ask for the adjuster or claims representative. If you still have questions and don’t understand why the checks have stopped, call the EAO at (800) 342-1741 or email firstname.lastname@example.org.
Q. If I am unable to return to work until my doctor releases me, does my employer have to hold my job for me?
No, there is no provision in the law that requires your employers to hold the job open for you.
Q. Can my employer fire me if I am unable to work because of an injury and am receiving workers’ compensation benefits?
No. It is against the law to fire you because you have filed or attempted to file a workers’ compensation claim.
Q. If I am unable to return to the type of work I did before I was injured, what can I do?
The law provides at no cost to you, reemployment services to help you return to work. Services include vocational counseling, transferable skills, analysis, job-seeking skills, job placement, on-the-job training, and formal retraining. To find out more about this program, you may contact the Department of Education, Division of Vocation Rehabilitation, Bureau of Rehabilitation and Reemployment Services at (850) 245-3470 or visit it website at: www.rehabworks.org
Q. My employer and the insurance company have denied my claim for workers’ compensation benefits. Do I need legal representation to get my benefits? What should I do?
It is your decision whether or not to hire an attorney. However, the EAO can assist you and attempt to resolve the dispute. If unable to resolve, the EAO can further assist you in completing and filing a petition for benefits. This service is provided at no cost to you. For assistance call: (800) 342-171 or email email@example.com. For location of the nearest EAO, click on: firstname.lastname@example.org/WC/dist_offices.html.
Q. What is the time limit for filing a petition for benefits?
In general, there is a two-year period to file a petition. However, it depends on the type of issue in dispute. You may call the EAO at (800) 342-1741 or email email@example.com for specific information.
Q. Is there period of time after which my claim is no longer open?
If you were injured on o after January 1, 1994, the claim is closed one year from the date of your last medical treatment or payment of compensation. This period of time is referred to as the statute of limitations. If you were injured before January 1, 1994, the period is two years.
Q. Can I get a settlement from my claim?
Settlement may be made under certain circumstances and are voluntary, not automatic or mandatory.
Q. If I settle my claim for medical benefits with the insurance company and my conditions get worse later, who pays for my future medical care, surgeries, etc.?
You are responsible for your future medical needs after your claim for medical benefits is settled.
Q. What can I do when it is difficult to get a prescription filled or I am having problems with the pharmacy where I get my workers’ compensation medication?
In Florida, an injured worker has the right to select a pharmacy or pharmacist. Florida law prohibits interference with your right to choose a pharmacy or pharmacist. However, a pharmacy is not required to participate in the workers’ compensation program. If at any time, your become dissatisfied with your pharmacy or pharmacist’s services, you can seek another pharmacy to fill your prescription.
Q. I am one of the individuals covered by s. 119.071 (4) (d), Florida Statutes who is eligible to have my “personal information” exempt from a public record release. If I am injured on the job, and my first report of injury or illness is reported to your office, will our agency automatically withhold my person information forma public record request?
No. The “personal information” in s.119.071 (4) d), F.S. is defined as your address, telephone number, photographs, and Social Security number. Although photographs are not collected by out office, our Social Security number will always be redacted from any public record request pursuant to s.119.071 (5)5., F.S. However, s. 119.071 (4) (d) 2,. F.S., requires you or your employer to formally write to the custodial agency that is in possession of your personal information in order to claim the exempt status. Our office accepts emails, faxes or written correspondence when claiming the personal information exempt status. You must provide your full name, complete Social Security number, and occupation title. To request exemption of personal information maintained by our division, you should email, fax, or write to the follow person:
Division of Worker’ Compensation
Bureau of Data Quality and Collection
Tonya Ganger 200 E. Gaines Street
Tallahassee, FL 32399-4226
The goal is to ensure that any worker that has involvement with the system; has all the tools needed for a positive outcome. Other government agencies may be enlisted to reach that goal. The FAQ portion answers the most common concerns regarding the worker’s rights to compensation and time limits for filing a claim.
Division of Workers' Compensation. (n.d.). Retrieved April 15, 2016, from http://www.myfloridacfo.com/division/WC/