Workers' Compensation Health Care Networks
Workers' compensation health care networks are groups of doctors and hospitals that treat injured employees. Employees whose employers are part of a network must use the network to receive care for a work-related injury.
The Texas Department of Insurance 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 satisfaction of care, health outcomes, and health care costs. You can look at the report card on the TDI Workers' Compensation web page at www.tdi.texas.gov/wc/indexwc.html.
Insurance companies, certified self-insured employers, groups of certified self-insured employers, and political subdivisions can set up and 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 employee for lost wages or permanent physical impairment.
Visiting a Doctor or Hospital
Workers' compensation networks are similar to managed care plans, such as health maintenance organizations (HMOs) and preferred provider plans (PPOs). Managed care plans control costs by contracting with networks of doctors and hospitals and by supervising patient care and treatment.
Employees who live in the network's service area must use doctors and hospitals in the network. Insurance companies may deny payment if employees don't use doctors in the service area. There are exceptions for emergencies or for employees who have approval to go to a doctor outside the network.
Injured employees must choose a treating doctor from the network's list. A treating doctor in an HMO is called a primary care physician. Employees can use their primary care physician as their treating doctor if the doctor agrees to the network's terms.
The treating doctor provides employees' workers' compensation-related care and makes referrals to specialists. Employees must usually get a treating doctor's approval before seeing a specialist. For certain types of care, a network may require the treating doctor to get preauthorization for treatments and referrals so the network can decide if the treatments are medically necessary. Insurance companies use a similar process - called concurrent review or retrospective review - to decide whether treatment is medically necessary.
In most cases, an insurance company will only pay for health care that is medically necessary. Networks must have a process to allow patients and doctors to appeal these decisions.
Information for Employees
If you're injured on the job and your employer is part of a workers' compensation health care network, 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 Employee 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 choose a treating doctor who will supervise your treatment and make referrals to specialists if needed. The insurance company will give your employer a list of participating treating doctors every three months.
Your treating doctor must follow the network's rules, treatment guidelines, and return-to-work guidelines. If you need expensive or non-routine medical care, the network may require you to get prior approval so they can decide if the care is medically necessary.
The insurance company usually pays 100 percent of the cost to treat your work-related injury and illness. 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.
Note: Be aware that if you use a doctor or hospital outside the network without approval, the insurance company may deny payment and you might be charged. There are exceptions for emergencies and other situations.
Networks operate in geographic service areas and must provide enough medical services in the area. Networks are required to contract with enough doctors and hospitals to:
- treat employees 24 hours a day, seven days a week
- provide all necessary hospital, psychiatric, and physical therapy services
- treat employees in urban areas within 30 miles of their homes (the area is expanded to 75 miles for specialty services)
- treat employees 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 has plans to in the future. The network must have a plan to provide services to all employees currently in the service area.
Employees who live outside the service area are usually exempt from the network's rules and requirements. If you live in a network's service area, you may also be exempted from the requirements if:
- you require emergency care. The network must cover the cost of treatment from any doctor or hospital, regardless of network status, in an emergency. You must change to a network-approved doctor or hospital when your condition stabilizes.
- there isn't a network doctor that is qualified to deliver the care you need. The network must approve your use of a non-network doctor.
- you have been receiving your care from an HMO primary care doctor through your health plan. You may ask the network to allow your primary care doctor to serve as your treating doctor for your workers' compensation claim. To be approved, your HMO doctor must agree to the network's rules, treatment guidelines, and return-to-work guidelines.
Employers must give employees the network notice and rules when
- they join a network
- they hire new workers
- workers report work-related injuries.
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 saying that you received the notice. If you don't return the form, it doesn't mean you're exempt from the network's rules if you have a 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. Employees who live outside the service area may have different requirements than employees who live in the service area. Never lie about where you live to avoid a network's rules or to transfer to another network. If the insurance company learns about the lie, it may refuse to pay for your treatment.
If your network makes a medical necessity decision you or your doctor disagrees with, you or your doctor have 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 usually not more than 30 days after receiving your appeal.
You also have the right to ask for an independent review by an independent review organization. If your condition is life-threatening, you have the right to request an immediate review by an independent review organization.
If you receive medical care through a network, you have the following additional rights:
- You may choose another doctor from the network's list of treating doctors if you aren't happy with your treating doctor. You must tell the network, but the network may not deny your request. If you aren't happy with the second doctor you choose, 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 you request the services.
• An employer or network may not retaliate against you if you file an appeal or complaint. If you think 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 and must resolve your complaint within 30 days.
You may file a complaint with TDI through our website at www.tdi.texas.gov or by calling the Consumer Help Line at 1-800-252-3439 or 512-463-3515 in Austin.
Information for Employers
Employers should consider where its employees live when deciding whether to participate in a certified network. Employees living in different areas of the state or in neighboring counties may not be in a network's service area. Employees who don't live in the service area aren't required to use the network.
To legally operate in Texas, TDI must approve a workers' compensation health care network 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.
If you decide to participate in a network, you must give your employees written notice of the network's rules and requirements. Your insurance company 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 give notice to an employee, the employee isn't required to follow the network's treatment rules. Employees must sign a form saying that they received the network rules, but an employee is not exempt from the network rules if they don't sign it.
You are required to keep a record of all acknowledgment forms and how you delivered them. 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 give employees a copy if they ask for it. Your insurance company must update the list quarterly. You are also required to post notices about network coverage in the workplace where they can be seen.
Information for Doctors and Hospitals
Any licensed health care professional may apply to become a participating provider in 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 employees. It may also decline your application if it doesn't credential doctors and hospitals in your particular medical specialty.
Your Requirements and Rights
As a network provider, you will be required to follow the plan's 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 non-renew 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 you 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 at 1-800-252-7031 or 512-933-1899 in Austin.
You may file a complaint about workers' compensation claims, benefits, and workplace safety by calling any Division of Workers' Compensation field office at 1-800-372-7713 or the main office in Austin at 512-804-4000.
For answers to general insurance questions, for information about filing an insurance-related complaint, or to report suspected insurance fraud, call the Consumer Help Line at 1-800-252-3439 or 512-463-6515 in Austin between 8 a.m. and 5 p.m., Central time, Monday-Friday, or visit our website at www.tdi.texas.gov.
For printed copies of consumer publications, call the 24-hour Publications Order Line at 1-800-599-SHOP (7467) or 512-305-7211 in Austin.
To report suspected arson or suspicious activity involving fires, call the State Fire Marshal's 24-hour Arson Hotline at 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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Last updated: 09/08/2014