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You are here: Home . wc . news . advisories . ad2000-02

Advisory 2000-02

Commission to Change Medical Dispute Resolution Process

As part of its ongoing Process Improvement Program Reviews, the TWCC has identified improvements to the Medical Dispute Resolution (MDR) process as a top priority.

Broadly speaking, medical disputes can be categorized into three groups: fee related; preauthorization; and medical necessity. Currently, all medical disputes are processed in the Austin Central Office. Some cycle times have been too long, leading to some customer dissatisfaction.

FEE DISPUTES

Approximately 60% of all medical disputes are fee related. Using its cadre of experienced dispute resolution personnel located in field offices throughout the state to resolve these disputes will enable the Central Office Medical Dispute Resolution officers to concentrate on preauthorization and medical necessity disputes.

This change will begin with a pilot program being implemented in two field offices on May 1st. A number of process changes will be implemented through the pilot:

TWCC will begin handling these disputes on a scheduled basis in two field offices. Beginning mid-April, the parties will be notified by fax or e-mail of the time when the dispute will be considered, approximately 2 weeks prior to the scheduled consideration date. Parties who wish to participate will do so by telephone.

Participation by the parties will be voluntary. Mediated resolutions will be encouraged. If no agreement is reached, TWCC will make decisions based on the information available to the MDR officer at that time and place. If parties reach an agreement, the fee for dispute resolution will be waived.

TWCC reminds the parties of the procedural requirements under Rule 133.305, particularly regarding the time requirements. To expedite fair resolution of fee disputes, procedural requirements will be enforced.

As TWCC adjusts the process based on lessons learned in the pilot program, this program may be fanned out to other field locations. It is TWCC's goal to deal with these disputes by phone and fax, and therefore, not to assign these to field offices based on dispute locations. Rather, it is the our goal to establish a few Centers of Excellence throughout the state based on staff experience, workload, available facilities, etc.

System participants are alerted to the likelihood that the mailing address for fee-only disputes will change.

PRE-AUTHORIZATION DISPUTES

A recent change to Rule 133.305 reduced the time a carrier has to respond to a pre-authorization dispute.

New preauthorization rules were proposed at the TWCC April 18th public meeting. Interested parties are encouraged to check TWCC's website for details on the proposed rules and to submit comments through our e-comment process..

Resolving pre-authorization disputes will remain the top priority for the Central Office MDR officers.

MEDICAL NECESSITY DISPUTES

These disputes typically involve more in-depth review as medical necessity is determined based on the compensable injury and medical documentation submitted.

These disputes will continue to be processed by the Central Office MDR officers.

OTHER CHANGES

To better coordinate the changes listed above and concurrent medical and compensation benefit disputes, the Manager of Medical Dispute Resolution will report jointly to the Director of Hearings and the Director of Medical Review. These two divisions have a shared responsibility for medical dispute resolution.

Signed this 28th day of April, 2000

Leonard W. Riley, Jr., Executive Director

Distribution: TWCC Staff | Carrier Representatives | Public Information List | TWCC Website | Medical Professional Associations



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