LIFE, LIFE, HEALTH & HEALTH & LICENSING LICENSING

20072007 Workers’ Workers’ Compensation Compensation Health Care Health Care Network Network WorkshopWorkshop

Texas Department Texas Department of Insuranceof Insurance

What Has What Has NotNot Changed In Changed In Workers’ Compensation?Workers’ Compensation?

Amy LeeAmy Lee

Workers’ Compensation Research and Workers’ Compensation Research and Evaluation Group (REG)Evaluation Group (REG)

Focus of This PresentationFocus of This Presentation

To highlight the key provisions of the WC statute To highlight the key provisions of the WC statute and rules that apply to and rules that apply to allall claims, regardless of claims, regardless of network participationnetwork participation

Key WC Provisions Covered in This Key WC Provisions Covered in This PresentationPresentation

Injury notification and WC claim filing;Injury notification and WC claim filing;

Determinations of compensability/extent of Determinations of compensability/extent of injury;injury;

Payment of income benefits/disputes over Payment of income benefits/disputes over entitlement and amount of benefits;entitlement and amount of benefits;

Impairment ratings, MMI determinations, and use Impairment ratings, MMI determinations, and use of Designated Doctors;of Designated Doctors;

Key WC Provisions Covered in This Key WC Provisions Covered in This PresentationPresentation

Medical bill submission and prompt payment;Medical bill submission and prompt payment;

Medications; andMedications; and

Work status reportsWork status reports

Injury Notification and Claim Filing Injury Notification and Claim Filing RequirementsRequirements

How does the process work?How does the process work?(Workers’ responsibilities)(Workers’ responsibilities)

Within Within 30 days30 days from the date of the injury or 30 days from from the date of the injury or 30 days from the date the worker should have known an occupational the date the worker should have known an occupational disease was work-related, the worker must report the injury disease was work-related, the worker must report the injury to the employer. to the employer.

Within one year, the injured worker must also file a claim Within one year, the injured worker must also file a claim for compensation with the DWC.for compensation with the DWC.

If the worker does not report the injury to the employer or If the worker does not report the injury to the employer or file a claim with the DWC in a timely fashion, then the file a claim with the DWC in a timely fashion, then the worker may lose eligibility to benefits.worker may lose eligibility to benefits.

How does the process work? How does the process work? (Employers’ responsibilities)(Employers’ responsibilities)

Employers must report any work-related injury that results Employers must report any work-related injury that results in more than one-day of lost time, or any occupational in more than one-day of lost time, or any occupational disease claim, to the insurance carrier.disease claim, to the insurance carrier.

Employers must report any work-related injury or Employers must report any work-related injury or occupational disease within 8 days from the date the occupational disease within 8 days from the date the injured worker began to lose time away from work or within injured worker began to lose time away from work or within 8 days from the date that the employer received notice that 8 days from the date that the employer received notice that the worker contracted an occupational disease.the worker contracted an occupational disease.

The employer must provide a copy of the injury report to The employer must provide a copy of the injury report to the injured worker along with a copy of the employee’s the injured worker along with a copy of the employee’s rights and responsibilities under the Act.rights and responsibilities under the Act.

Determinations of Compensability/Determinations of Compensability/Extent of InjuryExtent of Injury

Compensability DeterminationsCompensability Determinations Regardless of whether a claim is part of a network or not, Regardless of whether a claim is part of a network or not,

insurance carriers still have a responsibility to review insurance carriers still have a responsibility to review whether the injury is “work-related” or compensable under whether the injury is “work-related” or compensable under the WC Act;the WC Act;

Insurance carriers, by statute, may investigate and contest Insurance carriers, by statute, may investigate and contest the compensability of an injury within 60 days from the the compensability of an injury within 60 days from the date the carrier received notice of the injury;date the carrier received notice of the injury;

Additionally, insurance carriers may contest the “extent” of Additionally, insurance carriers may contest the “extent” of the compensable injury (e.g., whether a worker’s new the compensable injury (e.g., whether a worker’s new shoulder injury is related to the worker’s compensable neck shoulder injury is related to the worker’s compensable neck injury) at any point during the claim;injury) at any point during the claim;

Compensability DeterminationsCompensability Determinations

***Note: In accordance with Section 1305.153(e), network ***Note: In accordance with Section 1305.153(e), network doctors receive written notice when an insurance carrier doctors receive written notice when an insurance carrier contests the compensability of a network claim (doctors contests the compensability of a network claim (doctors treating non-network claims are not required to receive treating non-network claims are not required to receive such a notice). Payment for services rendered prior to this such a notice). Payment for services rendered prior to this notice cannot be denied based on compensability; however, notice cannot be denied based on compensability; however, they may be denied based on medical necessity. they may be denied based on medical necessity.

If an insurance carrier successfully contests compensability If an insurance carrier successfully contests compensability of a network claim, the carrier’s liability for payment of of a network claim, the carrier’s liability for payment of medical care is capped at $7,000 medical care is capped at $7,000

Treating Doctor Exam to Define the Treating Doctor Exam to Define the Compensable InjuryCompensable Injury

Carriers may request that the worker’s treating doctor Carriers may request that the worker’s treating doctor perform an examination to define the compensable injury perform an examination to define the compensable injury (see DWC Rule 126.14);(see DWC Rule 126.14);

Once an examination is performed by the treating doctor, Once an examination is performed by the treating doctor, the insurance carrier will review the results and either the insurance carrier will review the results and either “accept” or “deny” the injury or diagnoses documented in “accept” or “deny” the injury or diagnoses documented in the doctor’s report;the doctor’s report;

If the carrier denies all or part of the injury documented in If the carrier denies all or part of the injury documented in the doctor’s report, then any care related to the specific the doctor’s report, then any care related to the specific injury or diagnosis denied, must be preauthorized by the injury or diagnosis denied, must be preauthorized by the carrier until the compensability or extent of injury dispute carrier until the compensability or extent of injury dispute can be resolved through dispute resolution or mutual can be resolved through dispute resolution or mutual agreement of the parties agreement of the parties

Payment of Income Benefits Payment of Income Benefits

and Benefit Disputesand Benefit Disputes

Income BenefitsIncome Benefits

Replace a portion of wages lost due to work-Replace a portion of wages lost due to work-related injury or illnessrelated injury or illness

Except for Lifetime Income Benefits, entitlement Except for Lifetime Income Benefits, entitlement to all income benefits ends 401 weeks (7 yrs., 9 to all income benefits ends 401 weeks (7 yrs., 9 mos. and 1 week) from the date of injurymos. and 1 week) from the date of injury

Five Types of Income BenefitsFive Types of Income Benefits

Income benefits are paid by insurance carrier Income benefits are paid by insurance carrier directly to injured employeedirectly to injured employee Temporary Income Benefits (TIBS)Temporary Income Benefits (TIBS)

Impairment Income Benefits (IIBS)Impairment Income Benefits (IIBS)

Supplemental Income Benefits (SIBS)Supplemental Income Benefits (SIBS)

Lifetime Income Benefits (LIBS)Lifetime Income Benefits (LIBS)

Death & Burial BenefitsDeath & Burial Benefits

How are Income Benefit Disputes How are Income Benefit Disputes

Resolved in Texas?Resolved in Texas? Benefit Review Conference (BRC)Benefit Review Conference (BRC) – an informal – an informal

mediation between the parties and a DWC benefit review mediation between the parties and a DWC benefit review officer; officer;

Contested Case Hearing (CCH)Contested Case Hearing (CCH) – a formal hearing – a formal hearing between the parties that is presided over by a Contested Case between the parties that is presided over by a Contested Case Hearing officer; a formal decision is typically rendered at this Hearing officer; a formal decision is typically rendered at this level. level.

Appeals Panel review (AP)Appeals Panel review (AP) – a paper review of the – a paper review of the CCH decision by a panel of three administrative law judges at CCH decision by a panel of three administrative law judges at DWC; the AP may agree, reverse or remand the CCH decision DWC; the AP may agree, reverse or remand the CCH decision (this is the end of DWC’s administrative dispute process).(this is the end of DWC’s administrative dispute process).

Judicial review of DWC decisionJudicial review of DWC decision – if a party is – if a party is still not satisfied with the AP decision, then a party may appeal still not satisfied with the AP decision, then a party may appeal the decision to a district court.the decision to a district court.

Most Common Income Benefit DisputesMost Common Income Benefit Disputes

Existence/duration/extent of disabilityExistence/duration/extent of disability

CompensabilityCompensability

Amount of Average Weekly WageAmount of Average Weekly Wage

Extent of InjuryExtent of Injury

Impairment rating assigned by a Division Impairment rating assigned by a Division Designated DoctorDesignated Doctor

Ombudsmen ProgramOmbudsmen Program

Operated by the Office of Injured Employee Counsel Operated by the Office of Injured Employee Counsel (OIEC)(OIEC)

An Ombudsman primarily assists unrepresented An Ombudsman primarily assists unrepresented injured employees or their beneficiariesinjured employees or their beneficiaries

An Ombudsman meets with injured employees that An Ombudsman meets with injured employees that have a dispute to explain the dispute resolution have a dispute to explain the dispute resolution process and prepare them for the upcoming dispute process and prepare them for the upcoming dispute proceedingproceeding

An Ombudsman assists injured employees at An Ombudsman assists injured employees at administrative hearings onlyadministrative hearings only

Impairment Ratings, MMI Impairment Ratings, MMI Determinations, and Use of Designated Determinations, and Use of Designated

DoctorsDoctors

Maximum Medical Improvement (MMI)Maximum Medical Improvement (MMI)

Maximum Medical Improvement means the Maximum Medical Improvement means the earlier of:earlier of:

the earliest date after which, based on reasonable medical the earliest date after which, based on reasonable medical probability, further material recovery from or lasting probability, further material recovery from or lasting improvement to an injury can no longer reasonably be improvement to an injury can no longer reasonably be anticipated; anticipated;

the expiration of 104 weeks from the date on which the expiration of 104 weeks from the date on which income benefits begin to accrue; or income benefits begin to accrue; or

the date determined by the Division if spinal surgery is the date determined by the Division if spinal surgery is performed within 12 weeks of the 104 week dateperformed within 12 weeks of the 104 week date

Impairment RatingsImpairment Ratings An impairment rating is given after a physical exam to An impairment rating is given after a physical exam to

determine the existence and degree of an employee's determine the existence and degree of an employee's total bodytotal body impairment. impairment.

Impairment is based upon the AMA's fourth edition of Impairment is based upon the AMA's fourth edition of "Guides to the Evaluation of Permanent Impairment”;"Guides to the Evaluation of Permanent Impairment”;

Doctors who perform MMI determinations/impairment Doctors who perform MMI determinations/impairment rating evaluations must fill out the DWC-69 form;rating evaluations must fill out the DWC-69 form;

Network and non-network doctors must complete Network and non-network doctors must complete DWC-approved training and testing on the use of the DWC-approved training and testing on the use of the AMA Guides in order to assign impairment ratingsAMA Guides in order to assign impairment ratings

Designated DoctorsDesignated Doctors

At the request of a carrier, an employee or at At the request of a carrier, an employee or at Division order, a medical exam by a Designated Division order, a medical exam by a Designated Doctor may be ordered. Doctor may be ordered.

The Designated Doctor is not the employee's The Designated Doctor is not the employee's doctor, nor is it one of the employer's choosing.doctor, nor is it one of the employer's choosing.

The Division keeps a list of Designated Doctors The Division keeps a list of Designated Doctors and randomly assigns cases based on geography, and randomly assigns cases based on geography, licensure appropriateness and any conflicts of licensure appropriateness and any conflicts of interest.interest.

Issues a Designated Doctor May ReviewIssues a Designated Doctor May Review Impairment RatingsImpairment Ratings

Maximum Medical ImprovementMaximum Medical Improvement

Extent of InjuryExtent of Injury

Compensability of InjuryCompensability of Injury

Ability to Return to WorkAbility to Return to Work

Issues similar to those described aboveIssues similar to those described above

*****Note: Network doctors cannot serve as a Designated *****Note: Network doctors cannot serve as a Designated Doctor for claims in the same network Doctor for claims in the same network

Medical Bill Submission and Prompt Medical Bill Submission and Prompt PaymentPayment

Medical Bill Submission and Prompt Medical Bill Submission and Prompt Payment RequirementsPayment Requirements

Health care providers must submit medical bills Health care providers must submit medical bills within 95 days after the date of service;within 95 days after the date of service;

Network and non-network health care providers Network and non-network health care providers must use the same billing forms and follow the must use the same billing forms and follow the billing and coding requirements set out in DWC billing and coding requirements set out in DWC rules;rules;

Medical Bill Submission and Prompt Medical Bill Submission and Prompt Payment RequirementsPayment Requirements

Insurance carriers must pay, reduce, deny, or Insurance carriers must pay, reduce, deny, or determine to audit not later than the 45determine to audit not later than the 45thth day day after date of receipt of the bill;after date of receipt of the bill;

Audits must be completed not later than the 160Audits must be completed not later than the 160thth day after receipt of the bill; day after receipt of the bill;

Carrier must pay 85% of the contracted rate Carrier must pay 85% of the contracted rate (network) or of the fee guideline rate (non-(network) or of the fee guideline rate (non-network) no later than the 45network) no later than the 45thth day after date of day after date of receipt if it elects to audit the billreceipt if it elects to audit the bill

MedicationsMedications

Pharmacy ProvisionsPharmacy Provisions

Pharmacy services are statutorily excluded from WC Pharmacy services are statutorily excluded from WC networks so these services will be rendered and paid networks so these services will be rendered and paid the same way for network and non-network claims;the same way for network and non-network claims;

Insurance carriers must pay for the first seven days Insurance carriers must pay for the first seven days of medications regardless of claim status;of medications regardless of claim status;

Doctors must prescribe over-the-counter medications Doctors must prescribe over-the-counter medications and generic prescription drugs whenever clinically and generic prescription drugs whenever clinically appropriate;appropriate;

Carrier may request a statement of medical necessity Carrier may request a statement of medical necessity from the prescribing doctor before denying from the prescribing doctor before denying reimbursement;reimbursement;

Pharmacy ProvisionsPharmacy Provisions

Pharmacy services may be reimbursed in Pharmacy services may be reimbursed in accordance with the DWC rules or by accordance with the DWC rules or by carrier/provider contracts;carrier/provider contracts;

Once the DWC has established its closed Once the DWC has established its closed pharmaceutical formulary and fee guideline, pharmaceutical formulary and fee guideline, those rules will apply to both network and non-those rules will apply to both network and non-network claimsnetwork claims

Work Status ReportsWork Status Reports

Work Status ReportsWork Status Reports

Regardless of network participation, doctors are Regardless of network participation, doctors are supposed to fill out the Work Status Reports (DWC -supposed to fill out the Work Status Reports (DWC -73 form) in the following situations (see DWC Rule 73 form) in the following situations (see DWC Rule 129.5):129.5):

Upon the initial examination of the worker by the doctor, regardless Upon the initial examination of the worker by the doctor, regardless of the worker’s work status;of the worker’s work status;

Upon request by the insurance carrier or the employer (through the Upon request by the insurance carrier or the employer (through the insurance carrier), not more than once every 2 weeks;insurance carrier), not more than once every 2 weeks;

If the employee experiences a change in work status or a If the employee experiences a change in work status or a substantial change in activity restrictions substantial change in activity restrictions

Form identifies worker’s current work status and any Form identifies worker’s current work status and any physical restrictions/abilitiesphysical restrictions/abilities

These reports are utilized by the carrier and the These reports are utilized by the carrier and the employer in making bona fide offers of employment employer in making bona fide offers of employment and income benefit entitlement decisionsand income benefit entitlement decisions

ResourcesResources

For health care providers:For health care providers: See frequently asked questions See frequently asked questions

http://http://www.tdi.state.tx.us/wc/information/providerresources.htmlwww.tdi.state.tx.us/wc/information/providerresources.html and and

http://www.tdi.state.tx.us/wc/information/hb7providerfaq.htmlhttp://www.tdi.state.tx.us/wc/information/hb7providerfaq.html

For workers:For workers: See frequently asked questions See frequently asked questions

http://www.tdi.state.tx.us/wc/information/workerresources_enhttp://www.tdi.state.tx.us/wc/information/workerresources_english.htmlglish.html

and andhttp://www.tdi.state.tx.us/wc/information/hb7employeesfaq.hthttp://www.tdi.state.tx.us/wc/information/hb7employeesfaq.htmlml

For employers:For employers: See frequently asked questions See frequently asked questionshttp://www.tdi.state.tx.us/wc/information/employerresources.htmlhttp://www.tdi.state.tx.us/wc/information/employerresources.html and andhttp://www.tdi.state.tx.us/wc/information/hb7employercarrierfaq.htmlhttp://www.tdi.state.tx.us/wc/information/hb7employercarrierfaq.html

Other ResourcesOther Resources

For general WC customer service: 1-800-252-For general WC customer service: 1-800-252-7031 7031

For WC medical questions: For WC medical questions: MedicalBenefits@tdi.state.tx.usMedicalBenefits@tdi.state.tx.us

For network questions: For network questions: WCNet@tdi.state.tx.usWCNet@tdi.state.tx.us

For questions about OIEC’s ombudsmen For questions about OIEC’s ombudsmen program: program: OIECInbox@oiec.state.tx.usOIECInbox@oiec.state.tx.us