THE DIVISION RECENTLY HELD ITS INSURANCE CARRIER QUARTERLY MEETING
The Division of Workers’ Compensation held the Insurance Carrier Quarterly Meeting on January 22, 2020. A copy of the meeting’s agenda and Division’s presentation can be found at: https://www.tdi.texas.gov/wc/ci/index.html. The following is a summary of highlights from the meeting.
- The Division is also planning to conduct utilization review audits and is in the process of developing standards associated with that audits as well as a return to work program for healthcare providers in an effort to encourage injured employees’ return to work.
- Regarding workers’ compensation fraud, for 2019, the Division received 2,062 fraud referrals. For the same year, eight referrals were referred for prosecution. In response to questions, it was suggested carriers should feel free to contact the Division when making fraud referrals to address what materials the Division may find helpful.
- Both system and individual carrier scorecards are now available on the Division website. Additionally, if there are questions as to the data utilized in developing the scorecards, the Division has developed a new form, DWC-29 (Standard Request for Information) to be used by system participants in obtaining this information.
- The first medical bill from a Federal Military Treatment Facilities received by a carrier in a claim should be faxed to the Division. The fax number to send the bill is located on the Division website and is 512-804-4673.
The Division also addressed performance-based oversight, noting it is preparing to assess carriers’ performance. There have been some changes regarding the PBO process. Selection will be based on volume of the assessment period. There Division has also modified the weight it affords specific criteria as follows: (1)Timely payment of initial TIBs – 50%; (2) Timely processing of medical bills – 30%; (3) Timely processing of requests for reconsideration of medical bills – 10%; (4) Timely submission of initial payment data via EDI – 5% and (5) Timely submission of medical bill processing data – 5%. The Division will assess Carriers for a specific period, January 2020 through June 2020. As noted in the weighted scheme described above, the Division is particularly concerned with the initial payment of TIBs and will continue to monitor carriers to ensure TIBs are timely paid.
Various Division staff members addressed a few unrelated, specific concerns regarding the following issues:
- It is important that carriers timely provide information responsive to ongoing and future data calls, including the most recent, for which responses were due by January 31, 2020.
- Carriers were encouraged to have adjusters available by telephone during Benefit Review Conferences to encourage resolution.
- The Dallas field office has changed and its new address can be found on the Division website.
- Injured employee travel reimbursement involves the submission of a DWC-48 (Request to Get Reimbursed for Travel Costs) by the injured employee. Carriers are encouraged, when either approving or denying the DWC-48, to complete the second page of the form where a space is provided for the carrier to explain its actions.
- Carriers are encouraged to make sure their contact information is up to date on the claims administrative contact system at the Division.
- There have been some concerns regarding carriers requesting treating physicians to provide DWC-69s to place the injured employee at MMI, particularly when there has been an abandonment of care by the injured employee. Division staff explained it was at the doctor’s discretion whether an injured employee reached MMI and whether a DWC-69 is appropriate.
- A concern was raised regarding pain pumps and the preauthorization process for refills. Division staff reminded Carriers that pain pump refills consisting of an “N” drug only require pre-authorization on a yearly basis under the Division’s formulary.
DIVISION REVIEW OF RULES
As required by the Texas Government Code, the Division is reviewing its rules, Chapters 120 (concerning Compensation Procedure – Employers), 122 (concerning Compensation Procedure – Claimants), and 124 (concerning Carriers: Required Notices and Mode of Payment) to address whether the rules still apply or should be repealed, readopted, or readopted with amendments. The Division has requested comments from system participants. Comments must be in writing and submitted by 5 p.m., Central Time, on Tuesday, March 3, 2020. Comments may be submitted to firstname.lastname@example.org or by mail to: Texas Department of Insurance, Division of Workers’ Compensation Cynthia Guillen Legal Services, and MS – 4D 7551 Metro Center Drive, Suite 100 Austin, Texas 78744-1645.
DIVISION TO CONDUCT MEDICAL QUALITY REVIEW AUDITS IN 2020
The Division of Workers’ Compensation is preparing to conduct Medical Quality Review Audits in 2020. The purposes of the audits are to (1) Promote health care that is cost-effective and will serve the goals of all workers’ compensation system participants; (2) Ensure that health care providers adhere to the Official Disability Guidelines (ODG) and medically accepted standards of care; and (3) Support return-to-work outcomes and avoid unnecessary disability. The Division anticipates reviewing the following categories:
- Reasonableness of doctor’s decisions and recordkeeping regarding return to work; and
- Insurance Carriers, Utilization Review Agents (URAs), or peer review doctors – potentially includes the reasonableness of medical necessity decisions and the reasonableness of the professional certification of the URA peer reviewer.