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System Monitoring and Oversight

Helpful Links:
EDI-Home Page
DWC Fraud-Home Page
PBO-Home Page
WC Complaint-Home Page

System Monitoring and Oversight consist of three sections (Compliance Review, Audits & Investigations and Monitoring & Analysis).  Each section works together to promote compliance in the Texas workers’ compensation system by:

  • Promptly detecting and appropriately addressing acts or practices of noncompliance
  • Promoting compliance with the Texas Workers’ Compensation Act and rules adopted under the Act through performance-based incentives
  • Promoting communication between system participants
  • Educating system participants of compliance requirements

Program Areas

Compliance Review

The Compliance Review section investigates allegations of noncompliance in the Texas workers' compensation system. The Compliance Review section investigates more than 3,000 allegations of non-compliance a year.

Click Here to file a complaint.

Audits & Investigations

The Audits & Investigations section conducts compliance audits of workers' compensation system participants and prepares confirmed complaints for potential enforcement action. The Audits & Investigations section conducts more than 60 compliance audits a year and handles more than 500 confirmed complaints a year.

 Monitoring & Analysis

Monitoring & Analysis section monitors compliance trends in the workers’ compensation system. Monitoring & Analysis' primary objectives are achieved through monitoring electronic data submitted to the Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) and communicating with system participants of potential compliance issues.

Some of the compliance trends monitored are:

  • Claims and Medical Electronic Data Interchange (EDI) transmissions
  • Ongoing claims benefits
  • Accuracy of certain Medical State Reporting fields (see FY2017 audit plan for a list of data elements)
  • Accuracy of certain Claims Data Reporting (see FY2017 audit plan for a list of data elements)
  • Underpayment of Death Benefits and Lifetime Income Benefits
  • Plain Language Notices

The following are standard monitoring reports available:

      Click here to read more on EDI in Texas.

Performance Based Oversight (PBO)

      Click here for the main PBO web page.
 

 Insurance Carrier Quarterly Meetings

Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) holds quarterly insurance carrier meetings to discuss complaints and other compliance issues in the workers' compensation system.

The purpose of these meeting are to provide insurance carriers with early notice of complaint issues currently impacting the system and to solicit feedback that will assist the TDI-DWC in resolving these issues. Our goal will be to provide system complaint information and to problem-solve through focused, open communication in an informal atmosphere.


System Monitoring Reports


Insurance Performance Score Card

Insurance Performance Score Card contain information related to a specific insurance carrier regarding complaints, timeliness of initial payment and reporting of TIBs, and timeliness of medical bill processing and reporting.

To request a Carrier Performance Score Card, you will need to send your request by email to System Monitoring and Oversight (SMO@tdi.texas.gov). Please include the insurance carrier name/FEIN in your request and how you would like the data set delivered (email, disc, etc.).

Detailed Insurance Carrier Initial Payment Data

Detailed Insurance Carrier Initial Payment Data (Standard Report) contains initial payment data submitted by an insurance carrier.

To request an Insurance Carrier Initial Payment Data report, you will need to request through Open Records Request to the ATTENTION of System Monitoring and Oversight. Please include the insurance carrier name/FEIN in your request and how you would like the data set delivered (email, disc, etc.).

Detailed Medical Bill Monitoring Data

Detailed Medical Bill Monitoring Data (Standard Report) contains each type of medical bill (SV1, SV2, SV3, & SV4) with the most recent quarter of refresh MB data. 

To request a Medical Bill Processing Monitoring Data Report, you will need to request through Open Records Request to the ATTENTION of System Monitoring and Oversight. Please include the insurance carrier name/FEIN in your request and how you would like the data set delivered (email, disc, etc.).

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Last updated: 11/14/2017

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