1 a guide to workers compensation health care networks hwcn division texas department of insurance
TRANSCRIPT
1
A Guide to Workers’ CompensationHealth Care Networks
HWCN Division
Texas Department of Insurance
2
Goals of House Bill (HB) 7
Each employee shall be treated with dignity and respect when injured on the job
Each injured employee shall have access to a fair and accessible dispute resolution process
Each injured employee shall have access to prompt, high-quality medical care within the framework established by the Texas Workers’ Compensation Act
Each injured employee shall receive services to facilitate the employee’s return to employment as soon as it is considered safe and appropriate by the employee’s health care provider
3
Goals for WC Networks
Authorize the establishment of workers’ compensation health care networks for the provision of workers’ compensation medical benefits
Provide standards for the certification, administration, evaluation, and enforcement of the delivery of health care services to injured employees by networks
4
What is a “Workers' Compensation Health Care Network”?
An organization that is:Formed to provide health care services
to injured employeesCertified in accordance with Insurance
Code Chapter 1305 and Commissioner rules
Established by, or operating under contract with, an insurance carrier
5
Who can be a WC network?
Examples include: Individual Partnership Association Corporation Organization Trust Limited liability companies and partnership Hospital district Community mental health centers, mental health and mental
retardation center HMO PPO
6
Certification Process
Application – 26 pendingTwo certified networks
Texas Star Network/ConcentraConcentra HCN
60-day review by TDIApplicant may request an extensionTDI may deny request for extension
7
Major Components of Application
Major components of application Officers and directors biographical affidavits Insurance carrier, provider & third-party contracts Management contracts Financial information including a business plan Service area description and maps List of contracted, credentialed providers Proof of accessible, available, comprehensive care Treatment and return to work guidelines Monitoring plan for providers Doctor and health care practitioner financial
disclosure
8
Texas Star Network Service Area
9
Concentra HCN Service Area
10
Provider Contracts
Network application includes:Copy of the form of any contract with
ProvidersGroup of Providers
Contracts are confidentialContracts are not subject to disclosure
as an open record
11
Requirements for Provider Contracts
No transfer of risk Hold-harmless clause for injured employees Provider agrees to network treatment guidelines No denial based solely on treatment not listed on
treatment guidelines Continuity of treatment/90 days Provider appeal process for terminations Advance notice of economic profiling No retaliation for filing complaints or appeals on
behalf of injured employees
12
Requirements for Provider Contracts
Advance notice to provider of termination Notices to injured employees of provider
termination Reimbursement fee schedules In-office provider notices re: complaints to TDI Agreement to participate in certified network
Financial incentives are not allowedNetwork doesn’t have to accept applications of
providers if sufficient number contracted
13
How will we know which doctors are in which network?
Networks are required to create provider directories to include all of their contracted providers
Providers could be in more than one network
It will be up to the networks to maintain current directories for TDI to access as needed
14
Is there a limit on how far someone will be required to travel to see a network doctor?
In urban areas, there are limits of 30 miles for treating providers and 75 miles for specialists
In rural areas, the mileage limit is 60 miles for treating providers and 75 miles for specialists
There may be some areas where the standard of care is to travel farther for routine care
If a network cannot demonstrate that it has access to treating providers and specialists within the required mileage radii, an access plan must be filed with TDI
There are specific requirements for the network to include in its access plan
TDI will not certify a network that is arranging care solely through access plans
15
Changes to the Network
Once a network is certified, changes to the original application must be filed with TDI
Two types of changes: For approval 30 days prior to implementing:
Changes to management contractsChanges to physical location of books & recordsMaterial modification of network configurationChange to existing service area or addition of
new service area All other changes within 30 days of implementation
16
Network Access Requirements
All services must be provided by a provider who holds a current appropriate license
Unless the provider is exempt from license requirements
17
Network Access Requirements
The provider panel must: Include an adequate number of treating providers (doctors
and specialists) Be available 24 hours a day, seven days a week, within the
network service area
Necessary hospital services within the service area must be: Available and accessible
24 hours a day 7 days a week
Provided by contracts with general, special, and psychiatric hospitals
18
Network Access Requirements
Other services required to be available and accessible in the service area are:
Physical and occupational therapy Chiropractic
19
Network Access Requirements
Emergency careEmergency care must be available and accessible: 24 hours a day 7 days a week Without restrictions = where the services are rendered
Except for emergencies, Except for emergencies, the network shall: Not later than 21 calendar days after the date of the
original request, arrange for services on a timely basis (includes Specialist Referrals)
20
Employee Information and Responsibilities
Written notice for employees must include in a clear, complete, and accurate format: Statement that entity is a WC network Network’s toll-free number and address Statement that injury event requires selection of
treating doctor All care from network providers except ER or
approved out-of-network services Explanation of hold-harmless Statement of employee liability for out-of-network
care not approved by network Emergency care information
21
Employee Information and Responsibilities
Written notice must include in a clear, complete, and accurate format: List of services requiring preauthorization or
concurrent review Continuity of treatment provisions Description of complaint system; no retaliation Summary of procedures relating to adverse
determination and Independent Reviews List of network providers, access limitations and
providers accepting new patients Description of network’s service area Timely provision of health care services
22
Employee Acknowledgement Form
Carrier and employer may use a form that complies with this section or a sample form available from TDI
Form must include: Statement of employee’s responsibility to obtain
network services If employee is injured and lives in service area, then
the employee must:Must select a treating doctorMay ask HMO PCP to be treating doctorMust obtain all services from network providers
except emergency care
23
Insurance Carrier Liability for Out-of-Network Health Care
Emergency care Health care provided to an injured employee who does
not live within the service area of any network established by the carrier or with which the carrier has a contract
Health care provided by an out-of-network provider pursuant to a referral from the injured employee’s treating doctor that has been approved by the network
Health care services provided to an injured employee before the employee received notice of network requirements and information about the appropriate network and service area
24
Treating Doctor Selection
The network determines which specialties can serve as treating doctors
If dissatisfied with choice, employee may choose an alternate & must notify the network in the manner prescribed
Network may not deny a selection of an alternate treating doctor
Specialists and HMO PCP as treating doctor
25
Special Issues
What is not considered initial selection of treating doctor:A doctor providing emergency careA doctor salaried by the employerAny doctor who provides care before the
employee is notified of the network, except for a doctor selected under 1305.105 (HMO PCP)
26
Special Issues
Employee lives outside network service area Referral outside network
Specialty care Service not available in network Timely referrals TDI will monitor
Treating doctor dies, retires, or leaves network
27
Treatment Parameters
Must adopt treatment guidelines, return-to-work guidelines, and individual treatment protocols
Treatment guidelines and protocols must be evidence-based, scientifically valid, outcome- focused, and designed to reduce inappropriate or unnecessary health care while safeguarding necessary care
28
Payment Structure
Reimbursement determined by contractBilling by and reimbursement to
contracted and out-of-network providers must be done in accordance with the Texas Workers’ Compensation Act and applicable rules
Carriers must notify network providers in writing if an injury is not compensable
29
Preauthorized Treatment
Network is required to list procedures that require preauthorization
If preauthorized, then the treatment cannot subsequently be denied based on medical necessity
Treatment could be denied for other reasons
30
Network’s Complaint Process
Must include:Reasonable procedures for resolving oral
and written complaintsNotify complaint of right to complain to TDI
May use 90-day deadline for filing a complaint Complaint information must be saved for three
years from date the complaint was received Networks must keep complaint logs for each
complaint
31
How to Complain to TDI
Anyone may submit a complaint Use online complaint form at www.tdi.state.tx.us Send complaint to:
HWCN Division, Mail Code 103-6A Texas Department of Insurance PO Box 149104, Austin, Texas 78714-9104
Fax complaint to 512-490-1012 Send e-mail complaint to:
32
Rules to Review
http://www.tdi.state.tx.us/wc/rules/planning/ruleschart.html
33
WC Network Web Resource Page
http://www.tdi.state.tx.us/wc/wcnet/index.html
34
Workers’ Compensation Working Group (WCWG)
http://www.tdi.state.tx.us/consumer/wcnetiwg.html
35
WCWG
All stakeholders represented Web resource page includes meeting agendas
and summaries Topics discussed:
WC network development All networks including “tailored networks” must be certified
separately
Silent PPO panel discussion Performance-based oversight Outreach to providers, employees, employers
36
Questions?
Send an e-mail to [email protected] include your contact information
and phone numberCall TDI Health and Workers’
Compensation Network (HWCN) staff800-252-3439 or 512-322-4266