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Advisory 92-03

Submission of Medical Bills

The Texas Workers' Compensation Commission is changing its policy regarding the submission of medical bills. It has been the policy of the Commission that in accordance with Rule 134.801 "health care practitioners (as defined in the Act, Section 1.03(22)) shall submit to the carrier a properly completed bill within 15 days after the initial service or treatment date." However, there has been no method of enforcement established to ensure "properly completed bills" are submitted to the carriers. The number of improperly completed bills being submitted, not only to the carriers but to the Commission, has developed into an unmanageable quality assurance issue.

It is the intent and policy of the Commission that healthcare providers be reimbursed as expeditiously as possible for services provided and deemed to be medically necessary to injured workers. The quality of reimbursement to the provider is directly related to the quality of billing/documentation submitted to the carrier for services rendered during treatment. The submission of improperly completed bills causes the system to slow down due to increased audits, administrative processing, and the return and re-submission of corrected bills. The quality of billing also impacts the establishment of our statewide medical billing database, which is the first of its type nationally. The information contained in the database is essential and instrumental in the development and revision of all treatment and reimbursement guidelines. It also identifies treatment trends and patterns used in the workers' compensation industry. The quality of this database, liked directly to the quality of health care provider billing, is essential to the Commission's efforts in developing and implementing a state-of-the-art workers' compensation system, benefitting injured workers, employers, carriers, and health care providers alike.

In order to enforce quality control in provider billing, the Commission will be implementing the following changes:

Effective September 1, 1992 carriers are instructed to begin enforcing the return of all improperly completed bills submitted for reimbursement to the provider in accordance with Rule 133.300(c).

The time periods described in Article 8308-4.68 for reimbursement do not begin until a properly completed bill is received by the carrier.

The carrier will be held accountable for any improperly completed bills submitted to the Commission. A carrier who submits improperly completed bills to the Commission will be in violation of Rule 134.802 and may be subject to an administrative violation. Should electronically submitted bills require to be returned to the carrier, the entire tape will be returned. The 15 days starts upon "final payment" according to Rule 134.802(a).

Your immediate attention and cooperation in the implementation of this advisory is appreciated as these changes will benefit all parties in the workers' compensation system. Should you require further assistance or have questions contact the Medical Review Division at (512) 440-3513.

Signed this 25 th day of June, 1992.

Todd K. Brown
Acting Executive Director


Austin Carrier Representatives
Professional Medical Associations
County Medical Societies
Medical Advisory Committee Members
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