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You are here: www.tdi.texas.gov . hprovider . cpmchiropractors
Archived File - for Reference Use

This file is historical in nature. Links and contact information may be outdated and no longer valid.


Chiropractors Resource Page

Purpose

This page serves as a resource for doctors of chiropractic and their staff. It contains information and links reflecting how TDI can assist chiropractors in understanding insurance and HMO coverages, workers' compensation, workers' compensation networks, and claims processing and payment requirements.

TDI can help chiropractors with complaints regarding prompt and correct payment of health care claims. For example, a chiropractic clinic complained to TDI that they had not been paid for services provided to an accident victim who had medical coverage through an auto insurance policy. TDI staff wrote to the insurance carrier, reviewed the carrier's response, then called the carrier to discuss the response. As a result of TDI's intervention, the carrier paid the clinic more than $4,900 for the services performed. Send complaints to TDI:

Links to Chiropractors Quarterly Meeting Notes

TDI 2007 Mini-Conference for Chiropractors

Assistance to Chiropractors Agenda
Presentation Time Title / Links Presenter(s)
2:30 - 2:45 p.m. Welcome and Introductions
Antitrust Statement
TDI Key Regulatory Functions
Presentation (PPS)
Audrey Selden
Senior Associate Commissioner
Consumer Protection
2:45 - 3 p.m. TDI Complaint Process
Presentation (PPS)
Valerie Brown
Director, Complaints Resolution
Consumer Protection
3 - 3:20 p.m. Division of Workers´ Compensation (DWC) - Complaints, Performance-Based Oversight, and Dispute Resolution
Presentation (PPS)
Teresa Carney
Director, System Monitoring & Oversight, DWC
3:20 - 3:30 p.m. The Enforcement Process
Presentation (PPS)
Catherine Reyer
Associate Commissioner
Enforcement
3:30 - 3:40 p.m. TDI Fraud Unit
Presentation (PPS)
Dennis Pompa
Associate Commissioner
Fraud
3:40 - 3:50 p.m. TDI Resources for Chiropractors
Presentation (PPS)
Katrina Daniel
Policy Advisor
Life, Health & Licensing
3:50 - 4 p.m. Questions and Answers Group

FAQs

(June 2012)

Q: Can carriers determine the number of chiropractors in a WC network?

A: Insurance carriers do not determine the number of chiropractors in a certified workers compensation network. The networks make this decision but must contract with sufficient numbers and types of health care providers to ensure choice, access and quality of care to injured employees. The access standards differ based on whether chiropractors are allowed by the network to serve as treating doctors or whether they participate as specialists. The statute requires that the distance from any point in the service area to a treating doctor not exceed 30 miles in non-rural areas and 60 miles in rural areas while the distance from any point in the service area to a specialist cannot exceed 75 miles in both rural and non-rural areas. Except for emergencies, networks must arrange for services and specialty referrals on a timely basis upon request but not later than the last day of the third week following the request. If a network meets these standards in the service area, the network is considered to be in compliance with the statutory requirements.

Q: Can an insurance carrier make an on-site visit to a provider's office and review/copy patient records? Is such an audit permitted without a Commissioner of Workers' Compensation order?

A: Yes, according to Texas Labor Code §408.027 which in part states: If the insurance carrier elects to audit the claim, the carrier must complete the audit not later than the 160th day after the date of receipt by the carrier of the health care provider's claim..... If the insurance carrier chooses to audit the claim, the insurance carrier must pay to the health care provider not later than the 45th day after the date of receipt by the carrier of the provider's claim 85 percent of: (1) the amount for the health care service established under the fee guidelines authorized under this subtitle...... (2) the amount of the contracted rate ........

There is nothing in the Labor Code nor the rules that states the audit must be approved by the division.

Q: Is the chiropractor entitled to notice prior to an on-site visit by an insurance carrier's auditor? What provisions of the Texas Insurance Code or Labor Code permit this?

A:Yes. Division of Workers' Compensation rule 28 TAC §133.230 provides the specific requirements for an audit by the insurance carrier which includes providing notification of the audit and a proposed date of the audit, subject to mutual agreement.

Q: Is release of information by a chiropractor to a health plan's auditor a HIPAA violation?

A: No. Please see the attached for information regarding HIPAA and medical records www.tdi.texas.gov/wc/hcprovider/documents/releasemedinfo.pdf. Further, 28 TAC §133.230(d) states that the health care provider shall make available to the insurance carrier: all notes, reports, test results, narratives and other document the health care provider has relating to the billing(s) subject to the audit.

Q: Is all the information submitted to TDI considered public information or is confidentiality maintained?

A: In general, all information collected, assembled, or maintained by a state agency is deemed public information and is open to the public unless it falls within a specific exception to disclosure under the Texas Public Information Act, found in Texas Government Code Chapter 551. For example, private medical information and medical records are made confidential by the law and TDI is prohibited from releasing such information. Further information concerning confidentiality of information can also be found at the page on the Texas Attorney General's website addressing open government.

Q: Can a provider be forced to sign a workers' compensation network contract without notice of the fee structure?

A: The certified network rules, at 28 TAC §10.42(11), require that each provider contract must contain the schedule of fees that will be paid to the contracting provider. The Texas Labor Code provision addressing informal and voluntary networks, at §413.011(d-1)(2), requires a contract for fees that differs from Division fee guidelines to include a specific fee schedule. If you are offered a contract that does not contain a fee schedule and are not comfortable signing it, you are free to refuse to do so.

Q: Can a network contract provision supersede Texas insurance law? Will/does TDI mandate carriers make benefits information available online. This would include current deductible (met amount), etc.

A: Certified network contract provisions cannot supersede Texas insurance law and may not be enforceable if they do so. Many managed care contracts contain a clause concerning conformity with state and federal law that clarify that any provision in the contract that is not in conformity with the laws is not valid. Currently, state law does not mandate that carriers make benefits information available online. HB 522, which was passed in 2007, requires a pilot project to be conducted to explore methods of making real-time eligibility information available to providers concerning insurance benefits. The pilot project will be started in 2008. Voluntary and informal network contract provisions must comply with Labor Code §§413.011 and 413.0115.

Q: Regarding fraud, can you offer suggestions on how to reassure our patients/society not to commit fraud when a pre-existing or past condition prevents a person from getting coverage or have their claims paid, leading the consumer to want to omit details on an application.

A: Patients should be made aware that insurance fraud costs consumers nationally an estimated $150 billion annually - on average, this is nearly $1,800 per family. As such, insurance fraud is a crime that is taken very seriously. Texas law requires individuals who become aware of insurance fraud to report it within 30 days. TDI has a Fraud Unit consisting of peace officers, non-commissioned investigators, prosecutors, and criminal analysts. The Fraud Unit works with other law enforcement agencies to investigate allegations of insurance fraud, and if an investigation indicates that a crime has occurred, the Fraud Unit will refer the case to State or Federal prosecuting attorneys for indictment and prosecution.

Resources



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Last updated: 11/10/2014

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