1

Health Care Provider Quarterly Meeting

August 26, 2020

9:30 a.m. to 10:30 a.m.

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Agenda Items

• Welcome

• Office of Medical Advisor Update

• DD and Business Process Update

• Compliance and Investigations Update

• Telemedicine Update

• MFDR Update

• Q&A

• Closing

3

WelcomeCassie Brown, Commissioner

Division of Workers’ Compensation

4

Office of Medical Advisor Update

Mary Landrum, DirectorHealth Care Business Management

5

Quality of Care Complaints

Calendar Year 2020• 59 complaints forwarded to OMA

(includes external complaints & internal referrals)

• 91 complaints investigated by OMA

54% closed with no action 34% issued letters of education5% initiated a medical quality review7% referred to Enforcement

Source: Texas Department of Insurance, Division of Workers’ Compensation, data as of 07/27/20

6

Medical Quality Reviews

Calendar Year 2020• 2 reviews initiated

• includes complaint, audit, or monitoring based reviews

• assigned to MQRP members for review

• 6 reviews concluded67% referred to Enforcement

33% recommended other actions(includes letters of education, referrals to medical licensing boards, and closures with no action)

Source: Texas Department of Insurance, Division of Workers’ Compensation, data as of 07/30/20

7

OMA Enforcement Cases

Calendar Year 2020• 13 OMA referrals received in Enforcement

• 9 OMA cases concluded by Enforcement• 2 consent orders/final orders • 5 warning letters• 2 other action

• 33 OMA cases pending in Enforcement

• 2 OMA cases pending at SOAHSource: Texas Department of Insurance, Division of Workers’ Compensation, data as of 07/27/20

8

DD and Business Process Update

Joe McElrath, Deputy Commissioner

Business Process

9

Compliance and Investigations Update

Debra Knight, Deputy Commissioner

Compliance and Investigations

10

CY2020 Complaints

11

*Based on complaint data as of 8/3/2020

1,053 Complaints Received72 attendance

307 communications0 fraud

269 indemnity benefit delivery254 medical benefit delivery

84 other67 quality of care

1,408 Complaints Closed318 confirmed448 DWC education complaint642 not confirmed

CY2020 - Complaints

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2020 Complaint Volume by Month

13

System Performance

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Category Jan ’20 Feb ’20 Mar ’20 Apr ’20 May ’20 Jun ’20 Jul ’20 Aug ’20 Sep ’20 Oct ’20 Nov ’20 Dec ’20Medical Bill Processing 98.94% 99.06% 99.18% 99.47% 99.01% 99.37% 99.14%

Reconsideration MB Processing 90.48% 96.27% 96.62% 93.84% 95.72% 94.91% 94.52%Initial TIBs Payment 79.37% 84.36% 83.81% 82.01% 86.05% 84.11% 85.09%

* Based on data as of 4/1/2020

75%

80%

85%

90%

95%

100%

Jan ’20 Feb ’20 Mar ’20 Apr ’20 May ’20 Jun ’20 Jul ’20 Aug ’20 Sep ’20 Oct ’20 Nov ’20 Dec ’20

Monthly Payment/Processing Performance

MB

RECON

Initial TIBs

CY2020 – Payment of Initial Temporary Income Benefits ( TIBs) and Processing of Medical & Reconsideration Bills

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Payment of Initial TIBs and Processingof Medical & Reconsideration Bills

CY2019

CY2020

16

Category Jan ’20 Feb ’20 Mar ’20 Apr ’20 May ’20 Jun ’20 Jul ’20 Aug ’20 Sep ’20 Oct ’20 Nov ’20 Dec ’20RECON EDI Reporting 99.17% 99.69% 99.57% 98.67% 99.23% 99.61% 98.38%

MB EDI Reporting 98.60% 98.68% 98.40% 98.24% 98.73% 99.23% 98.08%

IP EDI Reporting 93.75% 95.69% 96.47% 92.83% 94.97% 94.89% 96.38%

* Based on data as of 4/1/2020

CY2020 – EDI Reporting of Initial TIBs Payment, Medical Bill and Reconsideration

90%

92%

94%

96%

98%

100%

Jan ’20 Feb ’20 Mar ’20 Apr ’20 May ’20 Jun ’20 Jul ’20 Aug ’20 Sep ’20 Oct ’20 Nov ’20 Dec ’20

Monthly EDI Performance Per Category

RECON EDI

MB EDI

IP EDI

17

2021 Performance Based Oversight (PBO)

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2020 Performance Based Oversight

Assessment Selection

121 insurance carriers with 20+ initial payment of TIBs between January-June

Assessment Timeline

August 28, 2020 distribute preliminary findings

October 5, 2020 management response due

January 2021 distribute results

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Performance Based Oversight (PBO)

2021 HCP PBO Assessment Timeline• April 2021 Data call for DWC-73s• July 2021 Distribute initial findings for all measures• November 2021 DWC distributes results

• December 2021 Publish results

Assessment Period

• DWC-73’s identified through medical billing data received between June 1, 2020, and February 28, 2021.

• DWC-69’s with exam dates between January 1, 2021, and April 30, 2021.

20

Performance Based Oversight (PBO)

2021 Methodology Changes

• No pre-selection – selection is based on volume of assessment period data.

• DWC73 measures combined into one category: • 70% weight – off work measure

• 30% weight – completeness measure

2021 PBO Methodology Paper • Located on website

(https://www.tdi.texas.gov/wc/pbo/hcppbo.html)

21

DWC Fraud

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Fraud Definition

Per Black’s Law Dictionary:

“Fraud includes any intentional or deliberate act to deprive another of property or money by guile, deception, or other unfair means.”

https://www.acfe.com/fraud-101.aspx

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Fraud Schemes

Examples of fraud the DWC Fraud and Prosecution teams investigate:

• Billing for services not performed by attorneys and healthcare providers.

• Under reporting employees or misclassifying high risk employees in order to obtain lower premium rates.

• Working and drawing.

• Falsifying documents to keep from having to pay benefits.

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*Based on data received as of 6/30/2020

889 fraud referrals received

137 fraud cases open *

781 fraud cases closed

2 fraud referrals for prosecution

CY2020 – DWC Fraud Stats

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*Based on data received as of 6/30/2020

4 Indictments • 3 healthcare provider

• 1 injured employee

CY2020 – DWC Prosecution Stats

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2 Convictions• 1 employer

• 1 injured employee

CY2020 – DWC Prosecution Stats

*Based on data received as of 6/30/2020

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Enforcement Update

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Enforcement Key Initiatives

Strategies DWC Enforcement uses to improve efficiencies in market compliance and case processing:

• Using clear, express statutory authority for all enforcement cases.

• Informing workers’ compensation stakeholders about compliance goals.

• Partnering with DWC program areas to foster compliance.

• Assisting the Office of the Medical Advisor.

• Providing swift, appropriate actions for statutory and rule violations.

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Examples of Administrative Violations• Billing injured employee;

• Quality of care;

• Failure to pay timely indemnity benefits;

• Failure to initiate TIBS;

• Failure to accurately pay TIBS;

• Attorney fee billing violations; and

• Failure to comply with medical fee dispute resolution (MFDR) or decision and order (D&O) order.

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2020 Closed Cases Pending Cases

Cases 367 298

367

298

0

100

200

300

400

Closed Pending

CY 2020 Case Status

Enforcement Case Status for CY2020

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2020 Health Care Provider Insurance Carrier Other

Cases 71 184 43

71

184

43

0

20

40

60

80

100

120

140

160

180

200

Health Care Provider Insurance Carrier Other

CY 2020 Cases Pending by Subject Type

Cases Pending by Subject Type as of July 31, 2020

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Cases Closed by Disposition Type for CY2020

10

66

7

74

155

51

43

60

20

40

60

80

100

120

140

160

180

DWC Order Warning Letter Other

CY 2020 Cases Closed by Disposition TypeHealth Care Provider Insurance Carrier Other

2020 Health Care Provider Insurance Carrier Other

DWC Order 10 74 1

Warning Letter 66 155 43

Other 7 5 6

33

83

234

50

0

50

100

150

200

250

Health Care Provider Insurance Carrier Other

CY 2020 Case Status

Cases Closed by Subject Type for CY2020

2020 Health Care Provider Insurance Carrier Other

Cases 83 234 50

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Matt Zurek, Deputy Commissioner

Health and Safety

Telemedicine Update

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11 53 80 50 46 84 113 129 104 75 87 88 143 105 132 136 169 207

1805

8705

5577

3242

1222

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

Bills by Date of Service

Bills

Telemedicine Activity

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10 31 68 40 40 80 99 114 76 61 60 67 120 94 111 115 152 184

1545

7422

4691

2604

960

0

1000

2000

3000

4000

5000

6000

7000

8000

Office Visits

Office Visits

Telemedicine Activity

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Types of Telemedicine Providers

MD, 1549, 64%DO, 169, 7%

DC, 33, 1%

PA , 162, 7%

Other, 522, 21%

Provider Count

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Types of Telemedicine Providers

MD, 1549

DO, 169

PT, 199

APN, 148

PA , 162

DC, 33

PSY, 37

LPC, 24

RN, 46

OT, 26 DP, 18 CSW, 9

LVN, 8

DME, 2

AU, 2PTA, 1

OD, 1

DS, 1

Provider Count

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TelemedicineMost frequently reported diagnosis codes

Diagnosis code Description

Times

Reported

M54.5 Low back pain 1217

S33.5XXD Sprain of ligaments of lumbar spine, subsequent encounter 978

S39.012A Strain of muscle, fascia and tendon of lower back, initial encounte 883

G89.4 Chronic pain syndrome 813

S33.5XXA Sprain of ligaments of lumbar spine, initial encounter 682

M54.16 Radiculopathy, lumbar region 678

M96.1 Post laminectomy syndrome, not elsewhere classified 663

M51.26 Other intervertebral disc displacement, lumbar region 485

S13.4XXD Sprain of ligaments of cervical spine, subsequent encounter 371

S13.4XXA Sprain of ligaments of cervical spine, initial encounter 370

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Extension of Telemedicine Emergency Rule 167.1

• On April 13, 2020, DWC adopted this rule on an emergency basis.

• DWC has extended Rule 167.1, relating to telemedicine and telehealth.

• Under the authority of Government Code §2001.034(c), the rule will be effective for 60 more days, through October 8, 2020.

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Greg Arendt, Director

Medical Fee Dispute

MFDR Update

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MFDR Reminder

• Medical fee dispute resolution is for non-networkhealth care rendered to an injured employee that has been determined to be medically necessaryand appropriate for treatment of the injured employee’s compensable injury.

• Examine your Explanation of Benefits carefully. Medical fee dispute resolution is not always the appropriate dispute path.

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2,939 Disputes Received Fiscal Year 2020

0

100

200

300

400

500

600

Division Specific Facility Non-MFDR Pharmacy Professional Air Ambulance All Other

FY 2020

Division Specific

Facility Non-MFDR Issues

Pharmacy Professional Air Ambulance

All Other Total

554 401 369 461 350 324 480 2,939

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2,990 Disputes Closed Fiscal Year 2020

0

100

200

300

400

500

600

700

Pharmacy Division Specific Facility Non-MFDR Professional All Other

Disputes Closed FY 2020

Pharmacy Division Specific

Facility Non-MFDR Issues

Professional Services

All Other Total

649 554 448 433 400 506 2990

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Types of Closures in Fiscal Year 2020

0

200

400

600

800

1000

1200

Withdrawal Zero Order Decision Decision with Order to Pay Dismissal

FY 2020 Closure Types

Withdrawal Zero Order Decision

Decision with Order to Pay

Dismissal

Number of Disputes 1104 837 643 406

Percentage 37% 28% 22% 13%

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Average Days to Adjudicate a Dispute

0

200

400

600

800

1000

1200

2013 2014 2015 2016 2017 2018 2019 2020

Average Days

2013 2014 2015 2016 2017 2018 2019 2020

1023 554 289 358 174 68 81 102

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Q&A

48

ClosingCassie Brown, Commissioner

Division of Workers’ Compensation