Workers' Compensation Health Care Networks
(En Español) (PDF)
(February 2012)
Some Texas employers provide workers’ compensation benefits through health care networks. Workers' compensation health care networks are groups of doctors and hospitals that work together to treat injured workers.
Overview
Insurance companies, certified self-insured employers, groups of certified self-insured employers, and political subdivisions can run their own networks or contract with an independent network.
Insurance companies with networks pay the cost of health care and any income benefits owed to the worker for lost wages or permanent physical impairment. The network provides the health care injured workers need for work-related injuries and illnesses.
The Texas Department of Insurance (TDI) certifies and regulates workers’ compensation health care networks. TDI sets financial standards and requirements for access and availability of care. TDI also issues an annual report card that compares a variety of factors, such as satisfaction of care, health outcomes, and health care costs. You can view the report card on the TDI Workers' Compensation web page at www.tdi.texas.gov/wc/indexwc.html.
Visiting a Doctor or Hospital
Workers’ compensation networks are similar to managed care plans, such as health maintenance organizations (HMOs) and preferred provider plans. Managed care plans control costs by contracting with networks of doctors and hospitals and by closely supervising patient care and treatment.
Workers who live in the network’s service area must use doctors and hospitals in the network. Insurance companies may deny payment if workers don’t use doctors in the service area, expect in emergencies or if they received approval to go to a doctor outside the network.
Injured workers must choose a treating doctor from the network’s list. The treating doctor oversees the workers’ compensation-related care, provides treatment, and makes referrals to specialists.
The equivalent of the treating doctor in an HMO is called a primary care physician. A primary care physician may also be a treating doctor if doctor agrees to the network’s terms.
Workers are generally not allowed to see specialists without their treating doctor’s approval. For certain types of care, a network may require the treating doctor to obtain preauthorization for proposed treatments and referrals to determine if they are medically necessary. A similar process – called concurrent review or retrospective review – decides whether treatment is medically necessary.
In most cases, an insurance company will only pay for health care that is medically necessary. Networks are required to have a process to allow patients and doctors to appeal decisions.
Information for Workers
If you have a work-related injury or illness, you must do the following:
- report your injury to your employer
- file a claim with TDI’s Division of Workers’ Compensation by calling the Injured Worker Hotline at 1-800-252-7031
- choose a treating doctor from the network’s list.
If you live within a network’s service area, you must select a treating doctor who will supervise your treatment and make referrals to other doctors if needed. The insurance company will give your employer a list of participating treating doctors every quarter.
Your treating doctor must follow the network’s rules, treatment guidelines, and return-to-work guidelines. You may also have to get prior approval from the network if you require expensive or nonroutine medical care to ensure the care is medically necessary.
Workers’ compensation insurance companies are generally responsible for 100 percent of the treatment cost of work-related injuries and illnesses. An insurance company, doctor, or hospital may not bill you for any treatment or services that are related to your work-related injury or illness.
An insurance company may deny payment if you use a doctor or hospital outside the network without approval, except for in an emergency or certain other situations.
Network Requirements
Networks operate in geographic service areas and must provide sufficient medical services in the area. Networks are required to contract with enough doctors and hospitals to
- treat workers 24 hours a day, seven days a week
- provide all necessary hospital, psychiatric, and physical therapy services
- treat workers in urban areas within 30 miles of their homes (the area is expanded to 75 miles for specialty services)
- treat workers in rural areas within 60 miles of their homes (the area is expanded to 75 miles for specialty services).
TDI may give a network an exception if it can’t meet these requirements but can in the future. The network must have a plan to provide services to all workers currently in the service area.
Workers who live outside the service area are usually exempt from the network’s rules and requirements. Workers in a network’s service area may also be exempted from some or all of the requirements if
- you require emergency care. The network must cover the cost of treatment from any health care provider, regardless of network status. However, you will be required to change to a network-approved provider once your condition has stabilized.
- there is no network provider qualified to deliver the care you need, the network must approve your use of a nonnetwork provider.
- you have been receiving your care from an HMO primary care doctor through your personal health plan. You may ask that the network allow this provider to serve as your treating doctor for your workers’ compensation claim. However, to be approved, your HMO doctor must agree to abide by the network’s rules, treatment guidelines, and return-to-work guidelines.
Notification Requirements
Your employer must give you the network notice and rules when it joins a network. Employers must also give the network notice and rules to new workers within three days of their date of hire and to any worker who reports a work-related injury. The notice of rules must include information about the network’s service area and procedures for complaints and appeals of the network’s treatment decisions.
You’ll be asked to sign and return a form acknowledging that you received the notice. Failure to return the form will not exempt you from the provider network’s rules if you have a future claim
If you don’t live in the network’s service area, you must tell the insurance company immediately or the company will assume that you live at the address you gave your employer.
Workers for the same company who live outside the service area may have different requirements for their workers’ compensation claims. Never lie about where you live to avoid a network’s rules or to transfer to another network. If the insurer learns about the lie, it may deny coverage for the cost of any treatment associated with your workers’ compensation claim.
Your Rights
If you or your treating doctor disagrees with any medical necessity decision made by the network or the insurance company, you or your doctor has 30 days to file an appeal to have the decision considered by another doctor. The entity that issued the medical necessity denial must complete your review as soon as reasonably possible, and generally not more than 30 days after receiving your appeal.
If it is not a life-threatening condition and you or your doctor disagrees with the decision, you or your doctor may file for an independent review by an independent review organization. In the case of a life-threatening condition, you have the right to request immediate review by an independent review organization.
Employees who receive medical care through a network have the following additional rights:
- You may select another doctor from the network’s list of treating doctors if you are not satisfied with your treating doctor. You must notify the network and the network may not deny your request. If you are not satisfied with the other doctor, you may have to receive network approval for another change.
- A network must arrange for medical services, including referrals to specialists, within 21 days after the request for services.
- An employer or network may never retaliate for appeals or complaints. If you believe your employer or the network has acted improperly, you should file a complaint with TDI.
You have the right to file a complaint if you believe a network has acted improperly. The network must provide written acknowledgment of your complaint within seven days of receipt, and must resolve your complaint within 30 days.
You have the right to file a complaint with TDI. Complaints may be filed online through the TDI website or by calling the Consumer Help Line
1-800-252-3439
463-3515 in Austin
www.tdi.texas.gov
Information for Employers
When deciding whether to participate in a certified network, an employer should consider where its workers live. If they live in different areas of the state or even in several adjacent counties, some may reside outside the service area of any available network. Out-of-area employees are not required to use the network.
To legally operate in Texas, a workers’ compensation health care network must be approved by TDI as meeting the minimum coverage and service standards required by law. A list of approved certified networks is available on the TDI Workers' Compensation web page.
Required Notice
If you decide to participate in a network, you must provide your employees with written notice of the network’s rules and requirements. Your insurer will give you the notice. The notice must include
- a list of any health care services that require preauthorization or utilization review
- descriptions of all network processes
- information on the network’s service area
- a complete list of network providers.
You must provide the notice in English, Spanish, and any language common to 10 percent or more of your employees. You are required to provide this notice to existing employees at the time coverage takes effect and to all new employees no later than the third day of hire. You must also provide the notice again when an employee reports a work-related injury or illness.
If you don’t provide notice to an employee, the employee is not required to follow the network’s treatment rules. Employees must sign a form acknowledging receipt of the network rules, but an employee’s failure to sign and submit the form will not exempt the employee from the network rules.
You are required to keep a record of all acknowledgment forms and document the method of delivery. This is important because it can help support your case if an employee disputes whether you provided the notice.
Employers are also required to keep a list of the network’s doctors and hospitals. You must also provide a copy when an employee requests it. Your insurance company must update the list quarterly. You are also required to post notices about network coverage prominently in the workplace.
Information for Doctors and Hospitals
Any licensed health care professional may apply to become a participating provider within one or more networks. Each network has its own credentialing process and may set its own minimum standards for participating providers.
Texas is not an “any willing provider” state. This means a network may decline your application if it has already contracted with a sufficient number of doctors and hospitals to meet the needs of injured workers. It may also decline your application if it does not credential doctors and hospitals in your particular medical specialty.
Your Requirements and Rights
As a network provider, you will be required to follow to its policies, procedures, treatment guidelines, and return-to-work guidelines for all patients.
Doctors and hospitals may not bill an injured worker for any costs related to treatment of work-related injuries or illnesses, including copays or balance billing amounts for additional payment beyond the network’s contract rate. All payment for services must come either from the insurance company or a third party acting on behalf of the insurance company.
If you are accepted as a participating provider, the network may not offer you any financial incentives to limit medically necessary services. You are also required to post the toll-free number prominently in your office for anyone who wants to file a complaint about a network’s operations.
You have the following additional rights and protections under state law:
- You may appeal any adverse determination for pre-authorization, concurrent review, retrospective review, or other network coverage decisions, on behalf of a patient. A certified network may never terminate or nonrenew your contract or otherwise retaliate against you for filing an appeal or a complaint.
- The network must give you written notice before conducting any economic profiling or utilization review studies comparing your history of care to that of any other provider.
- It is your right to review any information used in the network’s credentialing process, correct any errors, and learn the status of any pending application.
Leaving the Network
Except in cases of fraud, suspension of a medical license, or possible imminent harm to a patient, the certified network must provide 90 days’ notice of termination of your network contract. You may appeal the termination within 30 days of receiving notice.
You may leave the network for any reason after providing 90 days’ advance written notice. If you request to leave the network, the network must continue to reimburse you for care your provide to patients with an acute or life-threatening condition for up to 90 days, but you must show that disruption of care could potentially harm the patient.
For More Information or Assistance
If you have a dispute involving workers’ compensation benefits, call the Injured Worker Hotline
1-800-252-7031
933-1899 in Austin
You may file a complaint about workers’ compensation claims, benefits, and workplace safety by contacting any Division of Workers’ Compensation field office or the main office in Austin
1-800-372-7713
804-4000 in Austin
For answers to general insurance questions, for information on filing an insurance-related complaint, or to report suspected insurance fraud, call the Consumer Help Line between 8 a.m. and 5 p.m., Central time, Monday-Friday, or visit our website
1-800-252-3439
463-6515 in Austin
www.tdi.texas.gov
You can also visit HelpInsure.com to help you shop for automobile, homeowners, condo, and renters insurance, and TexasHealthOptions.com to learn more about health care coverage and your options.
For printed copies of consumer publications, call the 24-hour Publications Order Line
1-800-599-SHOP (7467)
305-7211 in Austin
To report suspected arson or suspicious activity involving fires, call the State Fire Marshal’s 24-hour Arson Hotline
1-877-4FIRE45 (434-7345)
The information in this publication is current as of the revision date. Changes in laws and agency administrative rules made after the revision date may affect the content. View current information on our website. TDI distributes this publication for educational purposes only. This publication is not an endorsement by TDI of any service, product, or company.
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