What Has Not Changed In Workers’ Compensation


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What Has Not Changed In Workers’ Compensation

  1. 1. LIFE, HEALTH & LICENSING 2007 Workers’ Compensation Health Care Network Workshop Texas Department of Insurance What Has Not Changed In Workers’ Compensation? Amy Lee Workers’ Compensation Research and Evaluation Group (REG)
  2. 2. Focus of This Presentation <ul><li>To highlight the key provisions of the WC statute and rules that apply to all claims, regardless of network participation </li></ul>
  3. 3. Key WC Provisions Covered in This Presentation <ul><li>Injury notification and WC claim filing; </li></ul><ul><li>Determinations of compensability/extent of injury; </li></ul><ul><li>Payment of income benefits/disputes over entitlement and amount of benefits; </li></ul><ul><li>Impairment ratings, MMI determinations, and use of Designated Doctors; </li></ul>
  4. 4. Key WC Provisions Covered in This Presentation <ul><li>Medical bill submission and prompt payment; </li></ul><ul><li>Medications; and </li></ul><ul><li>Work status reports </li></ul>
  5. 5. Injury Notification and Claim Filing Requirements
  6. 6. How does the process work? (Workers’ responsibilities) <ul><li>Within 30 days from the date of the injury or 30 days from the date the worker should have known an occupational disease was work-related, the worker must report the injury to the employer. </li></ul><ul><li>Within one year, the injured worker must also file a claim for compensation with the DWC. </li></ul><ul><li>If the worker does not report the injury to the employer or file a claim with the DWC in a timely fashion, then the worker may lose eligibility to benefits. </li></ul>
  7. 7. How does the process work? (Employers’ responsibilities) <ul><li>Employers must report any work-related injury that results in more than one-day of lost time, or any occupational disease claim, to the insurance carrier. </li></ul><ul><li>Employers must report any work-related injury or occupational disease within 8 days from the date the injured worker began to lose time away from work or within 8 days from the date that the employer received notice that the worker contracted an occupational disease. </li></ul><ul><li>The employer must provide a copy of the injury report to the injured worker along with a copy of the employee’s rights and responsibilities under the Act. </li></ul>
  8. 8. Determinations of Compensability/ Extent of Injury
  9. 9. Compensability Determinations <ul><li>Regardless of whether a claim is part of a network or not, insurance carriers still have a responsibility to review whether the injury is “work-related” or compensable under the WC Act; </li></ul><ul><li>Insurance carriers, by statute, may investigate and contest the compensability of an injury within 60 days from the date the carrier received notice of the injury; </li></ul><ul><li>Additionally, insurance carriers may contest the “extent” of the compensable injury (e.g., whether a worker’s new shoulder injury is related to the worker’s compensable neck injury) at any point during the claim; </li></ul>
  10. 10. Compensability Determinations <ul><li>***Note: In accordance with Section 1305.153(e), network doctors receive written notice when an insurance carrier contests the compensability of a network claim (doctors treating non-network claims are not required to receive such a notice). Payment for services rendered prior to this notice cannot be denied based on compensability; however, they may be denied based on medical necessity. </li></ul><ul><li>If an insurance carrier successfully contests compensability of a network claim, the carrier’s liability for payment of medical care is capped at $7,000 </li></ul>
  11. 11. Treating Doctor Exam to Define the Compensable Injury <ul><li>Carriers may request that the worker’s treating doctor perform an examination to define the compensable injury (see DWC Rule 126.14); </li></ul><ul><li>Once an examination is performed by the treating doctor, the insurance carrier will review the results and either “accept” or “deny” the injury or diagnoses documented in the doctor’s report; </li></ul><ul><li>If the carrier denies all or part of the injury documented in the doctor’s report, then any care related to the specific injury or diagnosis denied, must be preauthorized by the carrier until the compensability or extent of injury dispute can be resolved through dispute resolution or mutual agreement of the parties </li></ul>
  12. 12. <ul><li>Payment of Income Benefits </li></ul><ul><li>and Benefit Disputes </li></ul>
  13. 13. Income Benefits <ul><li>Replace a portion of wages lost due to work-related injury or illness </li></ul><ul><li>Except for Lifetime Income Benefits, entitlement to all income benefits ends 401 weeks (7 yrs., 9 mos. and 1 week) from the date of injury </li></ul>
  14. 14. Five Types of Income Benefits <ul><li>Income benefits are paid by insurance carrier directly to injured employee </li></ul><ul><ul><li>Temporary Income Benefits (TIBS) </li></ul></ul><ul><ul><li>Impairment Income Benefits (IIBS) </li></ul></ul><ul><ul><li>Supplemental Income Benefits (SIBS) </li></ul></ul><ul><ul><li>Lifetime Income Benefits (LIBS) </li></ul></ul><ul><ul><li>Death & Burial Benefits </li></ul></ul>
  15. 15. How are Income Benefit Disputes Resolved in Texas? <ul><li>Benefit Review Conference (BRC) – an informal mediation between the parties and a DWC benefit review officer; </li></ul><ul><li>Contested Case Hearing (CCH) – a formal hearing between the parties that is presided over by a Contested Case Hearing officer; a formal decision is typically rendered at this level. </li></ul><ul><li>Appeals Panel review (AP) – a paper review of the CCH decision by a panel of three administrative law judges at DWC; the AP may agree, reverse or remand the CCH decision (this is the end of DWC’s administrative dispute process). </li></ul><ul><li>Judicial review of DWC decision – if a party is still not satisfied with the AP decision, then a party may appeal the decision to a district court. </li></ul>
  16. 16. Most Common Income Benefit Disputes <ul><li>Existence/duration/extent of disability </li></ul><ul><li>Compensability </li></ul><ul><li>Amount of Average Weekly Wage </li></ul><ul><li>Extent of Injury </li></ul><ul><li>Impairment rating assigned by a Division Designated Doctor </li></ul>
  17. 17. Ombudsmen Program <ul><li>Operated by the Office of Injured Employee Counsel (OIEC) </li></ul><ul><li>An Ombudsman primarily assists unrepresented injured employees or their beneficiaries </li></ul><ul><li>An Ombudsman meets with injured employees that have a dispute to explain the dispute resolution process and prepare them for the upcoming dispute proceeding </li></ul><ul><li>An Ombudsman assists injured employees at administrative hearings only </li></ul>
  18. 18. Impairment Ratings, MMI Determinations, and Use of Designated Doctors
  19. 19. Maximum Medical Improvement (MMI) <ul><li>Maximum Medical Improvement means the earlier of: </li></ul><ul><ul><li>the earliest date after which, based on reasonable medical probability, further material recovery from or lasting improvement to an injury can no longer reasonably be anticipated; </li></ul></ul><ul><ul><li>the expiration of 104 weeks from the date on which income benefits begin to accrue; or </li></ul></ul><ul><ul><li>the date determined by the Division if spinal surgery is performed within 12 weeks of the 104 week date </li></ul></ul>
  20. 20. Impairment Ratings <ul><li>An impairment rating is given after a physical exam to determine the existence and degree of an employee's total body impairment. </li></ul><ul><li>Impairment is based upon the AMA's fourth edition of &quot;Guides to the Evaluation of Permanent Impairment”; </li></ul><ul><li>Doctors who perform MMI determinations/impairment rating evaluations must fill out the DWC-69 form; </li></ul><ul><li>Network and non-network doctors must complete DWC-approved training and testing on the use of the AMA Guides in order to assign impairment ratings </li></ul>
  21. 21. Designated Doctors <ul><li>At the request of a carrier, an employee or at Division order, a medical exam by a Designated Doctor may be ordered. </li></ul><ul><li>The Designated Doctor is not the employee's doctor, nor is it one of the employer's choosing. </li></ul><ul><li>The Division keeps a list of Designated Doctors and randomly assigns cases based on geography, licensure appropriateness and any conflicts of interest. </li></ul>
  22. 22. Issues a Designated Doctor May Review <ul><li>Impairment Ratings </li></ul><ul><li>Maximum Medical Improvement </li></ul><ul><li>Extent of Injury </li></ul><ul><li>Compensability of Injury </li></ul><ul><li>Ability to Return to Work </li></ul><ul><li>Issues similar to those described above </li></ul><ul><li>*****Note: Network doctors cannot serve as a Designated Doctor for claims in the same network </li></ul>
  23. 23. Medical Bill Submission and Prompt Payment
  24. 24. Medical Bill Submission and Prompt Payment Requirements <ul><li>Health care providers must submit medical bills within 95 days after the date of service; </li></ul><ul><li>Network and non-network health care providers must use the same billing forms and follow the billing and coding requirements set out in DWC rules; </li></ul>
  25. 25. Medical Bill Submission and Prompt Payment Requirements <ul><li>Insurance carriers must pay, reduce, deny, or determine to audit not later than the 45 th day after date of receipt of the bill; </li></ul><ul><li>Audits must be completed not later than the 160 th day after receipt of the bill; </li></ul><ul><li>Carrier must pay 85% of the contracted rate (network) or of the fee guideline rate (non-network) no later than the 45 th day after date of receipt if it elects to audit the bill </li></ul>
  26. 26. Medications
  27. 27. Pharmacy Provisions <ul><li>Pharmacy services are statutorily excluded from WC networks so these services will be rendered and paid the same way for network and non-network claims; </li></ul><ul><li>Insurance carriers must pay for the first seven days of medications regardless of claim status; </li></ul><ul><li>Doctors must prescribe over-the-counter medications and generic prescription drugs whenever clinically appropriate; </li></ul><ul><li>Carrier may request a statement of medical necessity from the prescribing doctor before denying reimbursement; </li></ul>
  28. 28. Pharmacy Provisions <ul><li>Pharmacy services may be reimbursed in accordance with the DWC rules or by carrier/provider contracts; </li></ul><ul><li>Once the DWC has established its closed pharmaceutical formulary and fee guideline, those rules will apply to both network and non-network claims </li></ul>
  29. 29. Work Status Reports
  30. 30. Work Status Reports <ul><li>Regardless of network participation, doctors are supposed to fill out the Work Status Reports (DWC -73 form) in the following situations (see DWC Rule 129.5): </li></ul><ul><ul><li>Upon the initial examination of the worker by the doctor, regardless of the worker’s work status; </li></ul></ul><ul><ul><li>Upon request by the insurance carrier or the employer (through the insurance carrier), not more than once every 2 weeks; </li></ul></ul><ul><ul><li>If the employee experiences a change in work status or a substantial change in activity restrictions </li></ul></ul><ul><li>Form identifies worker’s current work status and any physical restrictions/abilities </li></ul><ul><li>These reports are utilized by the carrier and the employer in making bona fide offers of employment and income benefit entitlement decisions </li></ul>
  31. 31. Resources <ul><li>For health care providers: See frequently asked questions </li></ul><ul><li>http:// www.tdi.state.tx.us/wc/information/providerresources.html and </li></ul><ul><li>http://www.tdi.state.tx.us/wc/information/hb7providerfaq.html </li></ul><ul><li>For workers: See frequently asked questions </li></ul><ul><li>http://www.tdi.state.tx.us/wc/information/workerresources_english.html and </li></ul><ul><li>http://www.tdi.state.tx.us/wc/information/hb7employeesfaq.html </li></ul><ul><li>For employers: See frequently asked questions </li></ul><ul><li>http://www.tdi.state.tx.us/wc/information/employerresources.html and </li></ul><ul><li>http://www.tdi.state.tx.us/wc/information/hb7employercarrierfaq.html </li></ul>
  32. 32. Other Resources <ul><li>For general WC customer service: 1-800-252-7031 </li></ul><ul><li>For WC medical questions: [email_address] </li></ul><ul><li>For network questions: [email_address] </li></ul><ul><li>For questions about OIEC’s ombudsmen program: [email_address] </li></ul>