Insurer Regulatory Compliance

Regulatory Compliance

Pursuant to s. 440.525, Florida Statutes, the Division of Workers’ Compensation (DWC) is responsible for ensuring all carriers, self-insured employers, and self-insurance funds providing Workers’ Compensation coverage in Florida are complying with the statutory and regulatory claims-handling performance standards. The DWC performs this duty by annually conducting 50-60 claim audits of insurer entities and monitoring the electronic filing of medical bills, indemnity payments, and First Reports of Injuries through its Centralized Performance System (CPS). The claim audits are generally performed in a week and are now primarily performed virtually. However, some audits still may be performed at the physical location of the claims-handling entity.

The following penalties can be assessed against insurer entities who fail to meet the claims-handling performance standards.

Penalties Assessed on Audit

Category	Penalty Amount	Statute	Rule
Untimely Indemnity Payments	$50 for each payment that is below the minimum 95% performance standard and equal to or greater than a 90% timely performance and $100 for each payment below the 90% timely performance standard.	440.20(8)	69L-24.006(1)(a)
Untimely filing of First Reports of Injury (FROI) – DFS-F2-DWC-1	For each FROI: 1-7 calendar days late = $100 8-14 calendar days late = $200 15-21 calendar days late = $300 22-28 calendar days late = $400 Over 28 calendar days late = $500	440.185(8)	69L-24.006(1)(b)
Untimely filing Notices of Action/Change – DFS-F2-DWC-4	For falling below the 90% timely compliance standard: $2,500 penalty for a non-willful pattern and practice violation, not to exceed an aggregate of $10,000 for all pattern and practice violations arising from the same action.	440.525	69L-24.007
Untimely filing Notices of Denial – DFS-F2-DWC-12	For falling below the 90% timely compliance standard: $2,500 penalty for a non-willful pattern and practice violation, not to exceed an aggregate of $10,000 for all pattern and practice violations arising from the same action.	440.525	69L-24.007
Untimely fling of Claim Cost Reports – DFS-F2-DWC-13	For falling below the 90% timely compliance standard: $2,500 penalty for a non-willful pattern and practice violation, not to exceed an aggregate of $10,000 for all pattern and practice violations arising from the same action.	440.525	69L-24.007
Untimely letter sent to employee about services of the Employee Assistance and Ombudsman Office	For falling below the 90% timely compliance standard: $2,500 penalty for a non-willful pattern and practice violation, not to exceed an aggregate of $10,000 for all pattern and practice violations arising from the same action.	440.185(10)	69L-24.007
Untimely informational brochure sent to the employee	For falling below the 90% timely compliance standard: $2,500 penalty for a non-willful pattern and practice violation, not to exceed an aggregate of $10,000 for all pattern and practice violations arising from the same action.	440.185(3)	69L-24.007

In addition to the penalties associated with untimely indemnity payments, penalties and interests are payable to the injured employee for untimely indemnity payments, pursuant to s. 440.20(6)(8).

Pursuant to s. 440.525 and Rule 69L-24.007, the DWC may asses a penalty for a willful violation for a pattern or practice if the regulated entity that committed the pattern or practice:

(a) Did so intentionally and with knowledge of the act’s unlawfulness or with disregard to the unlawfulness of the act; or

(b) Failed to comply with an order of the Department and the insurer has exhausted all appellate rights.

The penalties assessed shall be $20,000 for a single willful violation and not exceed an aggregate of $100,000 for all pattern or practice violations arising out of the same action.

Penalties Assessed Through CPS

Category	Penalty Amount	Statute	Rule
Untimely Initial Indemnity Payment	$50 for each payment that is below the minimum 95% performance standard and equal to or greater than a 90% timely performance and $100 for each payment below the 90% timely performance standard.	440.20(8)	69L-24.006(1)(a)
Untimely filing of First Reports of Injury (FROI) – DFS-F2-DWC-1	For each FROI: 1-7 calendar days late = $100 8-14 calendar days late = $200 15-21 calendar days late = $300 22-28 calendar days late = $400 Over 28 calendar days late = $500	440.185(8)	69L-24.006(1)(b)
Untimely payment, disallowance, or denial of medical bills (physician, hospital, Ambulatory Surgical Center, pharmacy, dental)	$25 for each bill below the 95 percent timely performance standard, but meeting a 90 percent timely performance standard. $50 for each bill below a 90 percent timely performance standard.	440.20(6)(b)	69L-24.006(2)(a)
Untimely filing of medical bills (physician, hospital, Ambulatory Surgical Center, pharmacy, dental)	For each untimely filed medical bill which falls below the 95% standard: 1-30 calendar days late = $5 31-60 calendar days late = $10 61-90 calendar days late = $25 91 or greater calendar days late = $50	440.525	69L-24.006(2)(b)
Rejected medical bills not resubmitted	If the medical bill remains rejected and the insurer does not correctly resubmit the bill within 90 calendar days of the original rejected date, an administrative fine shall be assessed against the insurer in the amount of $50 for each such medical bill.	440.525	69L-24.006(2)(c)