For better or worse, Florida does not allow providers to treat injured workers without prior authorization from the workers’ comp insurance carrier.

Can this lead to needless delays and denials of care for injured workers? Absolutely. But it’s the world we live in and the reality Florida providers must navigate.

The authorization requirement applies to all treatment and services (outside of emergency care), from a Band-Aid to a Tylenol to spinal surgery.

Critically, authorization is also key to making it financially sustainable for practices to treat injured workers.

There are two important components to Florida’s prior authorization mandate, explained in detail below:

1. No prior authorization = No reimbursement
2. Failure to timely respond to a request for authorization = Authorization is granted automatically

Of course, state statutes and Florida Division of Workers’ Compensation (FL DWC) rules regarding prior authorization can be…less than clear. Below, we explain the most essential requirements.

Protect your practice! Download a helpful PDF of these tips, and follow the rules below to help ensure your bills for workers’ comp treatment are paid in full.

Download PDF here

1. Always Use the DWC-25 Form (and Retain a Copy)

In Florida, solid documentation of all treatment authorization is critical. That begins with using the correct, mandatory form for requesting authorization: the DFS-F5-DWC-25, known as the DWC-25.

According to the FL DWC’s Workers’ Compensation Health Care Provider Reimbursement Manual (“Manual”), p. 369 (emphases ours):

“Physicians must utilize the DWC-25 to request authorization for treatment, to report the injured worker’s medical treatment/status, and:

• No other reporting forms may be used in lieu of the DWC-25;

• Failure to accurately complete and submit the DWC-25 in accordance with the instructions provided in this Manual may result in the Division imposing sanctions or penalties pursuant to section 440.13(8), F.S., or section 440.13(11) F.S., or carrier disallowance of reimbursement”

If the carrier asks, your practice may have to turn over a copy of the DWC-25. The Reimbursement Manual stipulates that providers must furnish a DWC-25 without charge “when requested by the carrier.”

The Manual instructs providers on page 9 that (emphasis ours again):

“Failure of the health care provider to submit documentation requested by the carrier may result in the billed service(s) being disallowed, adjusted, or denied for payment.”

A fillable PDF version of the DWC-25 is available here.

2. Always Document Prior (Written!) Authorization

For billing purposes, it’s just as important to document authorization as it is to obtain it.

As the Reimbursement Manual states on page 7 (emphasis ours):

“...failure to record such authorization documentation may result in the health care provider being ineligible for payment.”

On the same page, the Manual also lays out what information must be included in the authorization documentation as part of the injured worker’s medical record (or the provider’s billing or financial records) in order to satisfy state requirements. That includes all of the following:

• The date(s) on which authorization was requested and received
• The name of the carrier (or a designated representative entity)
• The name of the specific individual authorizing the services

Technically, authorization may be granted verbally or in writing. However, in our vast experience with workers’ comp billing nationwide, we do not recommend accepting verbal authorization alone.

For the purpose of payment appeals, or should anything go awry with the payment process, we strongly encourage providers to insist on written authorization that includes all the information above. This will help preclude any attempt by the carrier to deny payment on the grounds of non-authorization.

3. Failure to Respond = Authorization

Florida statutes offer a very helpful protection for injured workers and their providers: if a provider makes a compliant request for authorization of care to the carrier, and the carrier fails to respond in a timely manner, the care is authorized by default.

Once the carrier receives the DWC-25 from the provider, they have three days to respond. Otherwise, medical necessity for the requested treatment is assumed.

From the provider’s and injured workers’ perspectives, sometimes nothing is the best thing the carrier can say. Florida Statute Section 440.13 lays it out in section (3)(d) (emphases added on the go

od bits):

“A carrier must respond, by telephone or in writing, to a request for authorization from an authorized health care provider by the close of the third business day after receipt of the request. A carrier who fails to respond to a written request for authorization for referral for medical treatment by the close of the third business day after receipt of the request consents to the medical necessity for such treatment.”

4. Remember: Referrals Also Require Authorization

The care your practice renders to an injured worker isn’t the only care that has to be authorized.

In the event a provider needs to refer the injured worker to an appropriate specialist or any other practice, the Statutes clearly state that the provider initially treating the worker must secure authorization for any referrals (unless the referral is for emergency care).

As § 440.13(3)(c) states (with our helpful emphases again):

“A health care provider may not refer the employee to another health care provider, diagnostic facility, therapy center, or other facility without prior authorization from the carrier, except when emergency care is rendered.”

5. In Case of Emergency (Notify the Carrier)

As noted above, one exception to prior authorization for an injured worker’s care is emergency services.

There’s no time for filling out DWC-25’s in a medical crisis. However, that doesn’t mean the provider is off the hook for communicating with the carrier. According to § 440.13(3)(b), a provider has three business days (in most situations) to report to the carrier of having rendered emergency care.

Specifically, the provider:

• Has until the close of the third business day after rendering care to inform the carrier
• If the emergency care results in the injured worker’s admission to a health care facility, the provider must notify the carrier by telephone within 24 hours after initial treatment.

Note that licensed physicians may not decline to offer emergency care to an injured worker, even if workers’ comp is something the practice avoids typically. Per § 440.13(3)(b) refusal of emergency care is “cause for revocation of a license.”

Workers’ comp authorization, as well as billing and payment overall, is a complex beast in Florida and most other states.

daisyBill is here to help with any questions—just reach out to our experts via the pink chat button at the bottom right corner of this page or email us at info@daisybill.com.

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