Division of Workers’ Compensation

Teresa Carney

OVERVIEW

Workers’ Compensation Complaints

Performance Based Oversight Dispute Resolution

Complaint Resolution

Complaints are received via mail, fax, e-mail, on-line complaint form

Complaints are entered in TDI Complaint Inquiry System (CIS)

Acknowledgement letter is sent to complainant

Complaint Resolution

Request letter is sent to insurance carrier requesting specific information: Resolution to complaint Evidence of compliance Correspondence exchanged Network status

Complaint Resolution

Carriers have 10 days to respond Response is reviewed by an insurance specialist

– is it sufficient? Can the complaint be resolved?

Unjustified complaints Violation not detected

Complaint is closed Closing correspondence sent to complainant with

copy of carrier response Copy of closing correspondence sent to parties

Complaint Resolution

Justified complaints Violation of statute or rule occurred Resolve complaint (compliance

achieved) Closed for monitoring or referred to

Audits & Investigations Monitoring/closure letter sent

Complaint Statistics – CY 2007

5,322 received through December 3, 2007

4,781 closed 1,716 – Medical Bill Processing 676 – Communication 473 – Fraud allegations 288 – Indemnity Benefit Delivery

Complaints Against Carriers

Timeliness of Medical Bill Payments Initial submission of the medical bill

45 days to pay or deny the medical bill Reconsiderations

21 days to pay or deny the medical bill Inappropriate denial of medical bills Late income benefit payments

TIBs, IIBs, SIBs Failure to comply with orders

Complaints Against HCPs Late filings

DWC-69, DWC-73, LOC Failure to comply with an order to

pay IRO fees for a retrospective medical necessity dispute review.

Private claims against the injured employee

Audits & Investigations Review complaint referrals Auditor reviews referral for accuracy and

complete documentation/evidence Violation determination

Violation confirmed Warning letter or penalty recommendation

meeting No violation

Closure letters

Audits & Investigations

Conduct audits on system participants

FY 08 – poor performers from PBO Other audits as necessary

Performance Based Oversight

Establishes performance objectives, measures and expectations

Encourages and rewards excellence and continuous improvement

Focuses on results rather than prescriptive requirements

1. Define Compliance Objectives (Key

Regulatory Goals)

2. Measure Overall Performance

(Assessments)

3. Report Performance Data

(Tiers)

4. Performance Data to Drive

Improvement (Incentives)

Accountability

PBO Steps

PBO – Key Regulatory Goals Provide timely and accurate income and

medical benefits Encourage safe and timely return of injured

employees to productive roles Promote safe and healthy workplaces Ensure each injured employee shall have

access to prompt, high-quality, cost-effective medical care

PBO – Key Regulatory Goals

Increase timely communications within the system

Limit disputes to those appropriate and necessary

Assessments

Conducted at least biennially on insurance carriers and health care providers

Conducted through analysis of data Maintained by Division Self-reported data

Specified measures

Assessment Measures

Insurance Carriers Timeliness of initiation of Temporary

Income Benefits Timely processing of medical bills Prevailing ratio at Contested Case Hearings

Health Care Providers Timeliness of filing Report of Medical

Evaluation – DWC 69

Regulatory Tiers

Poor performers Generally average performers Consistently high performers

Incentives

Developed by rule Publicly recognize high performers Allow high performer designation

as a marketing tool Modified penalties Self audits Tier flexibility

PBO Initial Assessment - Details

147 Insurance Carriers 89 Commercial carriers 3 State entities 43 self insureds 12 certified self insureds

Selected by volume of IP filings received in CY 2006

PBO Initial Assessment - Details

325 Health Care Providers 255 Designated Doctors 267 MDs 12 DC 46 Other

Selected based on volume of DWC 69 filings received in CY 2006

PBO Results – Insurance Carriers

21.8%

64.6%

13.6%

High

Average

Poor

PBO Results – Health Care Providers

20.0%

48.92%

31.08%

High

Average

Poor

PBO Results

Insurance Carriers 32 in High Tier 95 in Average Tier 20 in Poor Tier

Health Care Providers 101 in High Tier 159 in Average Tier 65 in Poor Tier

PBO Web Page

http://www.tdi.state.tx.us/wc/pbo/pbo.html

Dispute Resolution

Dispute Resolution Goal

To resolve the dispute at the lowest level without a proceeding.

Dispute Resolution Processes

Medical Dispute Resolution

Income Benefit Dispute Resolution

Medical Dispute Resolution

Preauthorization & Medical Necessity disputes Submitted on TDI form LHL009

Medical Fee disputes Submitted on DWC form DWC060

What is Reasonable and Necessary Medical care?

Reasonable Meets the standard of care generally

accepted by the medical community

Necessary Treatment to cure or relieve the

effects of the condition caused by the work-related injury

Income Benefit Dispute

A disputed issue regarding: • Compensability • Eligibility for, or entitlement to,

income or death benefits.

Common Types of Income Benefit Disputes

Compensability Extent of Injury Disability and Return to Work MMI/IR SIBs

Dispute Resolution Process

• Informal Dispute Resolution

• Benefit Review Conference

• Contested Case Hearing

• Review by Appeals Panel

• Judicial Review

Informal Dispute Resolution

• Dispute resolution begins once DWC learns a dispute exists.

• The party requesting a benefit review conference: must certify they have made a good faith

effort to resolve the dispute before requesting the conference; and

have supporting documentation.

Agreements

• Resolve disputed issues

• Secure the rights of all parties

• Are binding on both parties

• Prevent disputes from resurfacing

• Provide foundation for resolving other disputed issues

Benefit Review Conferences• Informal conferences designed to

mediate and resolve disputes

• Identify disputed issues or information needed to resolve disputes

• Benefit review officer is an impartial individual trained to help parties resolve disputes

• Two BRCs per disputed issue (max.)

Benefit Contested Case Hearings

• Formal hearings in which evidence is presented and testimony is taken

• Hearing officers issue written decisions, which are binding, on disputed issues

Appeals Panel• Three judges assigned to each panel to

review appeals of decisions

• Review is limited to the evidence admitted during the benefit contested case hearing

• The Hearing Officer’s decision is allowed to become final or reversed, remanded or a combination of these action

Judicial Review

Must be filed with appropriate court in county of injury or death

Must be filed simultaneously with the court, the Division and served on any opposing party

The court’s decision must take into account the appeals panel decision on each dispute issue