Insurers challenge proposed hospital patient payment rules

A group of insurance companies is asking the Florida Division of Administrative Hearings to analyze the validity of proposed hospital reimbursement rules and determine whether the methods used by the Division of Workers’ Compensation to establish maximum reimbursement benefits were ” arbitrary and capricious.

Normandy Insurance Co., Zenith Insurance Co., Bridgefield Employers Insurance Co., Bridgefield Casualty Insurance Co., BusinessFirst Insurance Co. and RetailFirst Insurance Co. are asking the Administrative Hearing Division to review certain provisions of the proposed 2020 edition of the Florida Workers’ Compensation Reimbursement Manual for Hospitals, which has not come into effect.

The challenge relates specifically to the newly proposed maximum inpatient reimbursement benefits and the definitions and criteria for their application. Insurers also contest as being too vague a provision dealing with emergency services and care.

The proposed schedule would pay $7,000 per day for hospitalizations not involving surgery or intensive care, $11,000 per day for each day of stay where surgery was performed and $13,000 per day for intensive care .

The current hospital reimbursement manual allows payments ranging from $2,283.40 per day to $3,850.33 per day. It also includes a “stop loss” provision that requires the insurer to pay 75% of billed charges if a hospital charges more than a certain threshold.

The three-member panel approved the new methodology in December 2020.

Insurers generally say they agree with the proposed reimbursement model, but not with the proposed daily payments.

WorkCompCentral is a sister publication to Business Insurance. More stories here.

About Matthew R. Dailey

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