Workers’ Compensation  Medical Peer Review Data Call: Comprehensive Results Workers’ Compensation Research and Evaluation ...
Purpose of Division of WC’s Data Call <ul><li>To collect objective information regarding: </li></ul><ul><ul><li>The freque...
Summary of Data Call <ul><li>Division of Workers’ Compensation (Division) issued data call in late July 2006; </li></ul><u...
General Data Call Results <ul><li>A total of  11,437  peer reviews received during Sept/Oct 2006 by the 25 insurance carri...
Frequency, Cost and Type of WC Peer Reviews Requested
Percentage of Peer Reviews Conducted by Primary Reason Source: Texas Department of Insurance, Workers’ Compensation Resear...
Percentage of Peer Reviews Conducted by Cost Range Source: Texas Department of Insurance, Workers’ Compensation Research a...
Percentage of Peer Reviews Conducted by Cost Range and Primary Reason Source: Texas Department of Insurance, Workers’ Comp...
Type and Licensure of Doctors Performing Peer Reviews
Percentage of Peer Reviews Conducted by Texas/Non-Texas Licensed Doctors by Primary Reason   Source: Texas Department of I...
Percentage of Peer Reviews Conducted by Type of Doctor and Primary Reason Source: Texas Department of Insurance, Workers’ ...
Comparison of Peer Review Doctor Type with Type of Doctors Being Reviewed preauthorization/concurrent review of medical ne...
Comparison of Peer Review Doctor Type with Type of Doctors Being Reviewed retrospective review of medical necessity Source...
Specialties of MD/DO Peer Review Doctors Peer Reviews Requested With Primary Reason “Preauthorization/Concurrent Review of...
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Re...
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Re...
Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Re...
Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed 3% 4 unspecified administrative me...
Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 1% 1 unspecified aerospace...
Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 4% 12 unspecified anesthes...
Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 8% 2 physical med. & rehab...
Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 100% 1 anesthesiology gast...
Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 5% 1 physical med. & rehab...
Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 0% 1 unspecified general s...
Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 100% 1 family practice inf...
Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 100% 1 family practice neo...
Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 9% 2 pediatrics neurology ...
Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 1% 3 other specialty occup...
Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 20% 1 psychiatry ophthalmo...
Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 1% 15 other specialty orth...
Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 33% 1 urology pediatrics 3...
Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 2% 7 unspecified physical ...
Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d Source: Texas Department o...
Peer Review Opinions and Carrier Actions
Peer Review Opinions by Primary Reason Peer Review Was Requested Source: Texas Department of Insurance, Workers’ Compensat...
Peer Review Opinions by Primary Reason Peer Review Was Requested and Texas/Non-Texas Licensure Source: Texas Department of...
Peer Review Opinions by Primary Reason Peer Review Was Requested Cont’d Source: Texas Department of Insurance, Workers’ Co...
Carrier Actions as a Result of Peer Reviews Conducted <ul><li>Overall, approximately  45%  of all peer reviews reported in...
Percentage of Medical Necessity Peer Reviews that Resulted in an Adverse Carrier Action by Texas/Non-Texas Licensure Sourc...
Carrier Actions Compared to Peer Review Opinions on Preauthorization/Concurrent Review of Medical Necessity Source: Texas ...
Carrier Actions Compared to Peer Review Opinions on Retrospective Review of  Medical Necessity Source: Texas Department of...
Carrier Actions Compared to Peer Review Opinions on Extent of Injury/Compensability/Relatedness Source: Texas Department o...
Carrier Actions Compared to Peer Review Opinions on Extent of Injury/Compensability/Relatedness Source: Texas Department o...
<ul><li>Information on the Types of Claims Being Reviewed </li></ul>
Average Claim Maturity of Claims Being Reviewed During the Data Call Source: Texas Department of Insurance, Workers’ Compe...
Peer Review Volume Per Claim in the Data Call Period Source: Texas Department of Insurance, Workers’ Compensation Research...
<ul><li>Approved Doctor List (ADL) Status of Peer Review Doctors </li></ul>
<ul><li>Section 408.023 (b) (3), Labor Code, requires all doctors who perform medical peer review in the Texas workers’ co...
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Workers' Compensation Medical Peer Review Data Call ...

  1. 1. Workers’ Compensation Medical Peer Review Data Call: Comprehensive Results Workers’ Compensation Research and Evaluation Group June 2007
  2. 2. Purpose of Division of WC’s Data Call <ul><li>To collect objective information regarding: </li></ul><ul><ul><li>The frequency and cost of peer reviews requested by insurance carriers; </li></ul></ul><ul><ul><li>The reasons why peer reviews are requested; </li></ul></ul><ul><ul><li>The types (licensure) of doctors performing peer reviews; </li></ul></ul><ul><ul><li>The opinions of peer review doctors; and </li></ul></ul><ul><ul><li>The actions taken (or not) by insurance carriers as a result of the peer review. </li></ul></ul>
  3. 3. Summary of Data Call <ul><li>Division of Workers’ Compensation (Division) issued data call in late July 2006; </li></ul><ul><li>This is the first time this type of information has been collected on WC peer reviews; </li></ul><ul><li>25 insurance carriers were asked to submit data on every peer review they received during September and October 2006; </li></ul><ul><li>These 25 insurance carriers represented approximately 70% of the medical payments in 2003; and </li></ul><ul><li>Data was submitted to the Division at the end of December 2006. </li></ul>
  4. 4. General Data Call Results <ul><li>A total of 11,437 peer reviews received during Sept/Oct 2006 by the 25 insurance carriers included in the data call; </li></ul><ul><li>These peer reviews were conducted on approximately 8,583 WC claims; </li></ul><ul><li>Approximately 655 doctors (58% Texas licensed/42% non-Texas licensed) conducted these reviews. </li></ul>
  5. 5. Frequency, Cost and Type of WC Peer Reviews Requested
  6. 6. Percentage of Peer Reviews Conducted by Primary Reason Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note 1: Three peer reviews were missing information indicating the “primary reason” they were conducted. Note 2: “Other reasons” include reviews of impairment ratings, adjustment to reserves, etc. 2% 178 Other Reasons 3% 290 Treatment Planning/Appropriateness of Course of Care or Medications/Duration of Care Projections <1% 14 Ability to Return to Work 4% 462 Extent of Injury/Compensability/ Relatedness/Validation of Diagnosis 5% 575 Retrospective Review of Medical Necessity 87% 9,915 Preauthorization/Concurrent Review of Medical Necessity Percent Count Primary Reason Peer Review Was Requested
  7. 7. Percentage of Peer Reviews Conducted by Cost Range Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note: Forty-three peer reviews were missing information indicating “cost range”. 6% 723 >$500 5% 597 $251-500 82% 9,419 $100-250 6% 655 <$100 Percent Count Cost Range
  8. 8. Percentage of Peer Reviews Conducted by Cost Range and Primary Reason Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note 1: Forty-five peer reviews were missing information indicating the “primary reason” they were conducted or the cost of the review. Note 2: “Other reasons” include reviews of impairment ratings, adjustment to reserves, etc. 10% 19% 71% 0% Other Reasons 61% 27% 12% 0% Treatment Planning/Appropriateness of Course of Care or Medications /Duration of Care Projections 43% 7% 50% 0% Ability to Return to Work 52% 15% 32% <1% Extent of Injury/Compensability/ Relatedness/Validation of Diagnosis 34% 19% 8% 40% Retrospective Review of Medical Necessity 1% 3% 92% 4% Preauthorization/Concurrent Review of Medical Necessity >$500 $251-500 $100-250 <$100 Primary Reason Peer Review Was Requested
  9. 9. Type and Licensure of Doctors Performing Peer Reviews
  10. 10. Percentage of Peer Reviews Conducted by Texas/Non-Texas Licensed Doctors by Primary Reason Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note 1: Five peer reviews were missing information indicating the “primary reason” they were conducted or the licensure of the peer review doctor. Note 2: “Other reasons” include reviews of impairment ratings, adjustment to reserves, etc. 1% (2) 99% (175) Other Reasons 8% (23) 92% (267) Treatment Planning/Appropriateness of Course of Care or Medications/Duration of Care Projections 0% (0) 100% (14) Ability to Return to Work 4% (19) 96% (443) Extent of Injury/Compensability/ Relatedness/Validation of Diagnosis 15% (86) 85% (488) Retrospective Review of Medical Necessity 25% (2,523) 75% (7,392) Preauthorization/Concurrent Review of Medical Necessity Non-Texas Licensed Texas Licensed Primary Reason Peer Review Was Requested
  11. 11. Percentage of Peer Reviews Conducted by Type of Doctor and Primary Reason Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note 1: Ten peer reviews were missing information indicating the “primary reason” they were conducted or the type of peer review doctor conducting the review. Note 2: “Other reasons” include reviews of impairment ratings, adjustment to reserves, etc. “Other providers” include social workers, nurses, nurse practitioners, etc. <1% 0% 99% 1% Other Reasons <1% 0% 88% 12% Treatment Planning/Appropriateness of Course of Care or Medications/Duration of Care Projections 0% 0% 79% 21% Ability to Return to Work <1% <1% 97% 2% Extent of Injury/Compensability/ Relatedness/Validation of Diagnosis <1% <1% 91% 8% Retrospective Review of Medical Necessity <1% 5% 85% 10% Preauthorization/Concurrent Review of Medical Necessity Other PhD MD/DO DC Primary Reason Peer Review Was Requested
  12. 12. Comparison of Peer Review Doctor Type with Type of Doctors Being Reviewed preauthorization/concurrent review of medical necessity Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note : “Other providers” include social workers, nurses, nurse practitioners, etc. 34% 9% 37% 3% 18% PhD Type of Doctors Being Reviewed/Type of Treating Doctor 4% 62% 31% 4%   0% Other 2% 2% 80% 6% 11% MD 1% 1% 78% 11% 8% DO 0% 1% 21% 0% 78% DC PhD Other MD DO DC   Peer Review Doctor Type
  13. 13. Comparison of Peer Review Doctor Type with Type of Doctors Being Reviewed retrospective review of medical necessity Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note : “Other providers” include social workers, nurses, nurse practitioners, etc. Type of Doctors Being Reviewed/Type of Treating Doctor 0% 90% 3% 7% MD 0% 60% 20% 20% DO 2% 13% 0% 85% DC Other MD DO DC   Peer Review Doctor Type
  14. 14. Specialties of MD/DO Peer Review Doctors Peer Reviews Requested With Primary Reason “Preauthorization/Concurrent Review of Medical Necessity” Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note: “Other” include neurosurgery, pediatrics, emergency medicine, internal medicine, colon and rectal surgery, general practice, pathology, etc. 5% Other 2% Hand Surgery 2% Administrative Medicine 2% Psychiatry 5% Anesthesiology 7% Aerospace Medicine 9% General Surgery 14% Family Practice 15% Occupational Medicine 16% Physical Med. & Rehabilitation 24% Orthopedic Surgery PCT PR Primary Specialty
  15. 15. Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note: “Other” include neurosurgery, pediatrics, emergency medicine, internal medicine, colon and rectal surgery, general practice, pathology, etc. Specialties of MD/DO Peer Review Doctors Peer Reviews Requested With Primary Reason “Retrospective Review of Medical Necessity” PCT PR Primary Specialty 5% Other 1% General Surgery 1% Family Practice 2% Psychiatry 2% Anesthesiology 2% Occupational Medicine 6% Hand Surgery 28% Physical Med. & Rehabilitation 53% Orthopedic Surgery
  16. 16. Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note: “Other” include anesthesiology, neurosurgery, pediatrics, emergency medicine, internal medicine, colon and rectal surgery, general practice, pathology, etc. Specialties of MD/DO Peer Review Doctors Peer Reviews Requested With Primary Reason “ Extent of Injury/Compensability/Relatedness/Validation of Injured Employee’s Diagnosis” PCT PR Primary Specialty 16% Other 1% General Surgery 2% Family Practice 6% Psychiatry 7% Occupational Medicine 9% Administrative Medicine 10% Physical Med. & Rehabilitation 10% Hand Surgery 39% Orthopedic Surgery
  17. 17. Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note: “Other” include general surgery, anesthesiology, neurosurgery, pediatrics, emergency medicine, internal medicine, colon and rectal surgery, general practice, pathology, etc. Specialties of MD/DO Peer Review Doctors Peer Reviews Requested With Primary Reason “ Ability to Return to Work”, “Treatment Planning/Appropriateness of Course of Care or Medications/Duration of Care Projections”, or “Other Claim Management Actions” PCT PR Primary Specialty 18% Other 1% Anesthesiology 1% Hand Surgery 1% Family Practice 2% Psychiatry 5% Administrative Medicine 17% Physical Med. & Rehabilitation 22% Occupational Medicine 33% Orthopedic Surgery
  18. 18. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed 3% 4 unspecified administrative medicine 1% 2 psychiatry administrative medicine 1% 1 plastic surgery administrative medicine 3% 4 physical med. & rehabilitation administrative medicine 1% 1 pediatrics administrative medicine 1% 2 other specialty administrative medicine 54% 83 orthopedic surgery administrative medicine 1% 1 ophthalmology administrative medicine 1% 2 occupational medicine administrative medicine 1% 1 neurology administrative medicine 7% 11 neurological surgery administrative medicine 4% 6 internal medicine administrative medicine 1% 2 hand surgery administrative medicine 1% 1 general surgery administrative medicine 3% 5 general practice administrative medicine 11% 17 family practice administrative medicine 7% 11 anesthesiology administrative medicine Percentage Count HCP primary specialty PR primary specialty
  19. 19. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 1% 1 unspecified aerospace medicine 1% 2 psychiatry aerospace medicine 1% 2 plastic surgery aerospace medicine 6% 12 physical med. & rehabilitation aerospace medicine 2% 4 other specialty aerospace medicine 45% 88 orthopedic surgery aerospace medicine 5% 9 occupational medicine aerospace medicine 1% 1 obstetrics and gynecology aerospace medicine 2% 3 neurology aerospace medicine 3% 6 neurological surgery aerospace medicine 5% 10 internal medicine aerospace medicine 2% 3 hand surgery aerospace medicine 1% 2 general surgery aerospace medicine 5% 9 general practice aerospace medicine 13% 26 family practice aerospace medicine 1% 1 anesthesiology - pain management aerospace medicine 9% 18 anesthesiology aerospace medicine Percentage Count HCP primary specialty PR primary specialty
  20. 20. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 4% 12 unspecified anesthesiology 1% 2 public health anesthesiology 3% 7 psychiatry anesthesiology 0% 1 plastic surgery anesthesiology 11% 31 physical med. & rehabilitation anesthesiology 0% 1 pediatrics anesthesiology 0% 1 pediatric endocrinology anesthesiology 4% 10 other specialty anesthesiology 15% 42 orthopedic surgery anesthesiology 1% 4 occupational medicine anesthesiology 0% 1 obstetrics and gynecology anesthesiology 1% 4 neurology anesthesiology 2% 5 neurological surgery anesthesiology 0% 1 manipulative therapy anesthesiology 1% 3 internal medicine anesthesiology 1% 2 hand surgery anesthesiology 1% 4 general practice anesthesiology 6% 17 family practice anesthesiology 1% 2 emergency medicine anesthesiology 0% 1 dermatology anesthesiology 46% 127 anesthesiology anesthesiology Percentage Count HCP primary specialty PR primary specialty
  21. 21. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 8% 2 physical med. & rehabilitation emergency medicine 4% 1 pediatrics emergency medicine 4% 1 other specialty emergency medicine 42% 11 orthopedic surgery emergency medicine 8% 2 occupational medicine emergency medicine 4% 1 internal medicine emergency medicine 4% 1 hand surgery emergency medicine 8% 2 general surgery emergency medicine 19% 5 family practice emergency medicine 45% 5 orthopedic surgery diagnostic radiology 18% 2 occupational medicine diagnostic radiology 36% 4 family practice diagnostic radiology 17% 1 orthopedic surgery cardiovascular diseases 17% 1 family practice cardiovascular diseases 50% 3 cardiovascular diseases cardiovascular diseases 17% 1 anesthesiology cardiovascular diseases Percentage Count HCP primary specialty PR primary specialty
  22. 22. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 100% 1 anesthesiology gastroenterology 2% 1 psychiatry family practice 2% 1 plastic surgery family practice 4% 2 physical med. & rehabilitation family practice 40% 19 orthopedic surgery family practice 2% 1 occupational medicine family practice 2% 1 neurological surgery family practice 9% 4 internal medicine family practice 2% 1 general surgery family practice 2% 1 general practice family practice 26% 12 family practice family practice 2% 1 emergency medicine family practice 4% 2 anesthesiology family practice 2% 1 aerospace medicine family practice Percentage Count HCP primary specialty PR primary specialty
  23. 23. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 5% 1 physical med. & rehabilitation general practice 65% 13 orthopedic surgery general practice 5% 1 obstetrics and gynecology general practice 5% 1 neurological surgery general practice 20% 4 family practice general practice Percentage Count HCP primary specialty PR primary specialty
  24. 24. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 0% 1 unspecified general surgery 1% 2 psychiatry general surgery 1% 2 plastic surgery general surgery 9% 35 physical med. & rehabilitation general surgery 0% 1 pain management general surgery 1% 3 otolaryngology general surgery 1% 5 other specialty general surgery 38% 139 orthopedic surgery general surgery 1% 3 ophthalmology general surgery 4% 16 occupational medicine general surgery 0% 1 neurology general surgery 3% 10 neurological surgery general surgery 0% 1 manipulative therapy general surgery 2% 8 internal medicine general surgery 1% 2 hand surgery general surgery 1% 5 general surgery general surgery 5% 17 general practice general surgery 0% 1 gastroenterology general surgery 16% 58 family practice general surgery 0% 1 emergency medicine general surgery 0% 1 anesthesiology - pain management general surgery 16% 58 anesthesiology general surgery Percentage Count HCP primary specialty PR primary specialty
  25. 25. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 100% 1 family practice infectious diseases 1% 1 unspecified hand surgery 13% 12 plastic surgery hand surgery 39% 37 orthopedic surgery hand surgery 3% 3 occupational medicine hand surgery 1% 1 neurology hand surgery 1% 1 neurological surgery hand surgery 2% 2 internal medicine hand surgery 15% 14 hand surgery hand surgery 2% 2 general surgery hand surgery 3% 3 general practice hand surgery 16% 15 family practice hand surgery 3% 3 anesthesiology hand surgery 1% 1 aerospace medicine hand surgery Percentage Count HCP primary specialty PR primary specialty
  26. 26. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 100% 1 family practice neonatal-prenatal medicine 2% 1 psychiatry internal medicine 2% 1 plastic surgery internal medicine 10% 6 physical med. & rehabilitation internal medicine 13% 8 orthopedic surgery internal medicine 2% 1 ophthalmology internal medicine 6% 4 occupational medicine internal medicine 6% 4 neurological surgery internal medicine 19% 12 internal medicine internal medicine 3% 2 general surgery internal medicine 11% 7 general practice internal medicine 16% 10 family practice internal medicine 2% 1 emergency medicine internal medicine 6% 4 anesthesiology internal medicine 2% 1 allergy internal medicine Percentage Count HCP primary specialty PR primary specialty
  27. 27. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 9% 2 pediatrics neurology 9% 2 orthopedic surgery neurology 5% 1 oncology neurology 23% 5 neurology neurology 5% 1 neurological surgery neurology 9% 2 internal medicine neurology 5% 1 general practice neurology 32% 7 family practice neurology 5% 1 anesthesiology neurology 2% 1 vascular surgery neurological surgery 2% 1 plastic surgery neurological surgery 2% 1 physical med. & rehabilitation neurological surgery 26% 11 orthopedic surgery neurological surgery 2% 1 neurology neurological surgery 50% 21 neurological surgery neurological surgery 2% 1 internal medicine neurological surgery 5% 2 general practice neurological surgery 2% 1 family practice neurological surgery 5% 2 anesthesiology neurological surgery Percentage Count HCP primary specialty PR primary specialty
  28. 28. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 1% 3 other specialty occupational medicine 35% 120 orthopedic surgery occupational medicine 4% 13 occupational medicine occupational medicine 1% 3 neurology occupational medicine 4% 12 neurological surgery occupational medicine 4% 12 internal medicine occupational medicine 1% 3 hand surgery occupational medicine 2% 7 general surgery occupational medicine 4% 12 general practice occupational medicine 19% 64 family practice occupational medicine 1% 4 emergency medicine occupational medicine 0% 1 diagnostic radiology occupational medicine 0% 1 dermatology occupational medicine 0% 1 cardiovascular diseases occupational medicine 0% 1 anesthesiology - pain management occupational medicine 15% 50 anesthesiology occupational medicine Percentage Count HCP primary specialty PR primary specialty
  29. 29. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 20% 1 psychiatry ophthalmology 20% 1 ophthalmology ophthalmology 40% 2 occupational medicine ophthalmology 20% 1 family practice ophthalmology 1% 3 urology occupational medicine 1% 3 unspecified occupational medicine 1% 3 radiology occupational medicine 1% 3 psychiatry occupational medicine 0% 1 plastic surgery occupational medicine 5% 16 physical med. & rehabilitation occupational medicine 0% 1 pediatrics occupational medicine 1% 2 pathology occupational medicine Percentage Count HCP primary specialty PR primary specialty
  30. 30. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 1% 15 other specialty orthopedic surgery 59% 719 orthopedic surgery orthopedic surgery 0% 4 ophthalmology orthopedic surgery 2% 20 occupational medicine orthopedic surgery 0% 3 obstetrics and gynecology orthopedic surgery 1% 16 neurology orthopedic surgery 8% 93 neurological surgery orthopedic surgery 2% 30 internal medicine orthopedic surgery 0% 1 infectious diseases orthopedic surgery 1% 9 hand surgery orthopedic surgery 1% 11 general surgery orthopedic surgery 2% 27 general practice orthopedic surgery 0% 1 gastroenterology orthopedic surgery 8% 96 family practice orthopedic surgery 0% 1 family medicine orthopedic surgery 1% 8 emergency medicine orthopedic surgery 0% 1 diagnostic radiology orthopedic surgery 0% 3 dermatology orthopedic surgery 0% 6 cardiovascular surgery orthopedic surgery 5% 65 anesthesiology orthopedic surgery 0% 2 allergy and immunology orthopedic surgery Percentage Count HCP primary specialty PR primary specialty
  31. 31. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 33% 1 urology pediatrics 33% 1 orthopedic surgery pediatrics 33% 1 general surgery pediatrics 100% 1 orthopedic surgery pathology 100% 3 orthopedic surgery otolaryngology 0% 2 urology orthopedic surgery 1% 10 unspecified orthopedic surgery 0% 1 rheumatology orthopedic surgery 0% 2 radiology orthopedic surgery 0% 5 psychiatry orthopedic surgery 1% 15 plastic surgery orthopedic surgery 3% 41 physical med. & rehabilitation orthopedic surgery 0% 4 pediatrics orthopedic surgery Percentage Count HCP primary specialty PR primary specialty
  32. 32. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d 2% 7 unspecified physical med. & rehabilitation 0% 2 radiology physical med. & rehabilitation 1% 6 psychiatry physical med. & rehabilitation 1% 3 plastic surgery physical med. & rehabilitation 12% 49 physical med. & rehabilitation physical med. & rehabilitation 0% 1 pathology physical med. & rehabilitation 2% 10 other specialty physical med. & rehabilitation 24% 95 orthopedic surgery physical med. & rehabilitation 5% 21 occupational medicine physical med. & rehabilitation 1% 4 neurology physical med. & rehabilitation 5% 19 neurological surgery physical med. & rehabilitation 3% 14 internal medicine physical med. & rehabilitation 0% 1 hand surgery physical med. & rehabilitation 0% 1 gynecology physical med. & rehabilitation 1% 4 general surgery physical med. & rehabilitation 2% 7 general practice physical med. & rehabilitation 15% 61 family practice physical med. & rehabilitation 1% 4 emergency medicine physical med. & rehabilitation 23% 93 anesthesiology physical med. & rehabilitation 0% 1 aerospace medicine physical med. & rehabilitation Percentage Count HCP primary specialty PR primary specialty
  33. 33. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. 100% 1 occupational medicine urology 100% 1 internal medicine radiology 2% 1 vascular surgery psychiatry 9% 6 unspecified psychiatry 25% 16 psychiatry psychiatry 9% 6 physical med. & rehabilitation psychiatry 11% 7 orthopedic surgery psychiatry 3% 2 neurology psychiatry 2% 1 neurological surgery psychiatry 3% 2 internal medicine psychiatry 5% 3 general practice psychiatry 12% 8 family practice psychiatry 20% 13 anesthesiology psychiatry 33% 1 plastic surgery plastic surgery 33% 1 orthopedic surgery plastic surgery 33% 1 family practice plastic surgery Percentage Count HCP primary specialty PR primary specialty
  34. 34. Peer Review Opinions and Carrier Actions
  35. 35. Peer Review Opinions by Primary Reason Peer Review Was Requested Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. 3% 66% 7% 24% Retrospective Review of Medical Necessity 0% 46% 15% 39% Preauthorization/Concurrent Review of Medical Necessity Non conclusive Disagree Agree Partial Agree Primary Reason Peer Review Was Requested
  36. 36. Peer Review Opinions by Primary Reason Peer Review Was Requested and Texas/Non-Texas Licensure Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note: Non-TX cases for other reason types are not big enough Peer Review Opinion 0% 79% 7% 14% Non TX 4% 63% 7% 27% TX Retrospective Review of Medical Necessity 0% 50% 11% 39% Non TX 0% 45% 16% 39% TX Preauthorization/Concurrent Review of Medical Necessity Non conclusive Disagree Agree Partial Agree Peer Review Licensure Primary Reason Peer Review Was Requested
  37. 37. Peer Review Opinions by Primary Reason Peer Review Was Requested Cont’d Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note1: If “ability to return to work” was one of the reasons PR were requested, peer review doctors provided an opinion regarding return to work status for 62% of those cases. Note2: Peer review opinions for other primary reasons were not included because too few peer reviews reported on individual issues. 0% 69% 31% Treatment Planning/Appropriateness of Course of Care or Medications /Duration of Care Projections 4% 69% 27% Extent of Injury/Compensability /Relatedness/Validation of Injured Employee's Diagnosis Non conclusive Disagree Agree Primary Reason Peer Review Was Requested
  38. 38. Carrier Actions as a Result of Peer Reviews Conducted <ul><li>Overall, approximately 45% of all peer reviews reported in the data call resulted in some sort of adverse action taken by the insurance carrier (e.g., denial of medical necessity, denial of claim, denial of benefits). </li></ul><ul><li>Approximately 44% of all peer reviews conducted by Texas licensed doctors resulted in some sort of adverse action taken by the insurance carrier. </li></ul><ul><li>Approximately 47% of all peer reviews conducted by non-Texas licensed doctors resulted in some sort of adverse action taken by the insurance carrier. </li></ul>
  39. 39. Percentage of Medical Necessity Peer Reviews that Resulted in an Adverse Carrier Action by Texas/Non-Texas Licensure Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. 22% 78% Non TX 44% 56% TX Retrospective Review of Medical Necessity 54% 46% Non TX 56% 44% TX Preauthorization/Concurrent Review of Medical Necessity No Adverse Action Adverse Action Carrier Action Peer Review Licensure Primary Reason Peer Review Was Requested
  40. 40. Carrier Actions Compared to Peer Review Opinions on Preauthorization/Concurrent Review of Medical Necessity Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note: “Preauthorization/concurrent Review of Medical Necessity” was the primary reason why peer review is requested. Carrier Actions 2% 91% 7% Partially Agreed with Medical Necessity 97% 1% 2% Disagreed with Medical Necessity 1% 3% 96% Agreed with Medical Necessity Denied Preauth/ Concurrent Review Approved Modified Preauth/ Concurrent Review Approved Preauth/ Concurrent Review Peer Review Doctor’s Opinion
  41. 41. Carrier Actions Compared to Peer Review Opinions on Retrospective Review of Medical Necessity Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note: “Retrospective Review of Medical Necessity” was the primary reason why peer review is requested. Carrier Actions 26% 70% 4% Partially Agreed with Medical Necessity 97% 1% 2% Disagreed with Medical Necessity 24% 7% 69% Agreed with Medical Necessity Carrier Denied Payment Carrier Approved Partial Payment Carrier Approved Payment Peer Review Opinions 
  42. 42. Carrier Actions Compared to Peer Review Opinions on Extent of Injury/Compensability/Relatedness Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note: “Extent of Injury/compensability/relatedness/validation of injured employee’s diagnosis” was the primary reason why peer review is requested. Analysis for other primary reasons were excluded because too few peer reviews reported on individual issues. Carrier Actions 57% 43% Disagreed that Injury or Diagnosis Was Related to the Compensable Injury 92% 8% Opinion Non-Conclusive 87% 13% Agreed that Injury or Diagnosis Was Related to the Compensable Injury Carrier Did Not Dispute Extent of Injury/Compensability/ Relatedness Carrier Disputed Extent of Injury/Compensability/ Relatedness Peer Review Opinions  
  43. 43. Carrier Actions Compared to Peer Review Opinions on Extent of Injury/Compensability/Relatedness Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note: “Extent of Injury/compensability/relatedness/validation of injured employee’s diagnosis” was the primary reason why peer review is requested. Carrier Actions 79% 21% Disagreed that Injury or Diagnosis Was Related to the Compensable Injury 96% 4% Opinion Non-Conclusive 98% 2% Agreed that Injury or Diagnosis Was Related to the Compensable Injury Carrier Did Not Deny Claim Carrier Denied claim   Peer Review Opinions 
  44. 44. <ul><li>Information on the Types of Claims Being Reviewed </li></ul>
  45. 45. Average Claim Maturity of Claims Being Reviewed During the Data Call Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. 25% 2,168 24+ months 19% 1,605 12 to 24 months 18% 1,534 6 to 12 months 17% 1,445 3 to 6 months 7% 569 2 to 3 months 9% 729 1 to 2 months 6% 533 Less than 1 month Percentage Count Timeframe from the injury date to the date being reviewed
  46. 46. Peer Review Volume Per Claim in the Data Call Period Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. <1% 33 >= 5 2% 135 4 5% 382 3 18% 1529 2 76% 6504 1 Percent Count # of Peer Reviews Per claim
  47. 47. <ul><li>Approved Doctor List (ADL) Status of Peer Review Doctors </li></ul>
  48. 48. <ul><li>Section 408.023 (b) (3), Labor Code, requires all doctors who perform medical peer review in the Texas workers’ compensation system to be on the Division’s Approved Doctor List (ADL). </li></ul><ul><li>359 (55 percent) of the 655 peer review doctors were on the Approved Doctor List (ADL) as of July 2006. </li></ul><ul><li>About 20 (6 percent) of the 359 peer review doctors practicing with a temporary ADL Exception as of July 2006. </li></ul><ul><li>8,600 (75 percent) of the 11,437 peer reviews were conducted by the ADL doctors. </li></ul><ul><li>516 of the 8,600 peer reviews were conducted by doctors practicing with a temporary ADL exception as of July 2006. </li></ul>Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Peer Review Doctor ADL Status as of July 2006

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