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Workers' Compensation Networks Informal Working Group (March 22, 2006)
March 22, 2006
1 p.m. to 4:30 p.m.
Hobby Building - Room 100
Goals of the workers' compensation system of Texas
- Each employee shall be treated with dignity and respect when injured on the job;
- Each injured employee shall have access to a fair and accessible dispute resolution process;
- Each injured employee shall have access to prompt, high-quality medical care within the framework established by the Texas Workers' Compensation Act;
- Each injured employee shall receive services to facilitate the employee's return to employment as soon as it is considered safe and appropriate by the employee's health care provider.
Purpose of the Workers' Compensation Health Care Network Act
- Authorize the establishment of workers' compensation health care networks for the provision of workers' compensation medical benefits;
- Provide standards for the certification, administration, evaluation, and enforcement of the delivery of health care services to injured employees by networks.
Agenda - March 22, 2006
Jeannie Ricketts, Staff Attorney
Meeting Notes - March 22, 2006
April 19 and May 1, 1 p.m. to 4:30 p.m., Hobby Building - Room 100
Audrey Selden welcomed the group, and reviewed the antitrust statement and ground rules.
Update on network applications and rules
Margaret Lazaretti reported TDI has received 18 WC network applications, all are moving through the process and some are close to being approved. Members can follow the rules process via the WC rules web page at www.tdi.texas.gov/wc/rules/planning/ruleschart.html.
Margaret provided an overview of the credentialing process. Key points included:
- The network checks the background and history of providers in WC networks.
- HB 7 specifies the network will review providers under national standards and according to adopted rules.
- TDI wrote a rule and adopted the NCQA standards, which are very similar to URAC standards. Reviews may include checking providers' licenses against their role in the network, and checking for malpractice lawsuits and medical board sanctions. Staff check at least 50 credentialing files as part of the application process.
- Network applicants must provide information about their credentialing process. A provider who has a sanction may still be accepted into the network if the network decides to do so, but generally is not accepted.
- No providers who are located outside of Texas have been proposed as part of a network.
TDI will research these questions and provide answers at the next meeting:
- Are all WC network doctors licensed in Texas?
- How would a Durable Medical Equipment (DME) provider be credentialed?
Referral procedures, preauthorization
Jeannie Ricketts (Staff Attorney, Legal & Compliance) provided an overview of WC networks referral and preauthorization requirements (see PowerPoint presentation attached). Key points included:
- Networks either approve or deny referral requests, within the appropriate timeframe but not later than seven days after the date the referral is requested.
- An injured employee may appeal an adverse decision to the network or file a complaint with TDI. A network may require the appeal be filed within a certain timeframe.
- Denials made because the treatment is considered not medically necessary may be appealed to an independent review organization.
- Pre-authorization is the process required to request approval from the carrier or network to provide a specific treatment or service before the treatment or service is provided. It is a prospective review by the carrier of treatments and services for medical necessity. WC networks are not required to use preauthorization; if they do, then they must comply with specific statutes and rules.
- WC networks are required to adopt and update a list of services requiring preauthorization.
- There is no preauthorization for emergencies, medical or mental health.
- If a WC network uses preauthorization, it may be performed by the carrier or a utilization review (UR) agent.
- Carriers or UR agents are required to respond to preauthorization requests within certain time periods.
Regarding whether a WC network could respond to a referral request to see Dr. Smith by stating the injured worker could see Dr. Jones not Dr. Smith, the answer is yes. In such a case, typically the two doctors would discuss the referral and the treating doctor would withdraw the referral. Regarding whether a network may require that "notice" of certain procedures be provided to the network, yes this is permissible. This network may want to address in the provider contract what would happen if the provider did not give notice of the procedure to the network (not get paid? another consequence?). Regarding whether the pre-authorization list may be "provider-specific", that is, low-performing doctors have more requirements and high-performing doctors have less, the answer is yes. The network should explain clearly how this will work in the provider contract so that all providers will know the process.
Regarding "sub-networks," Margaret explained that some employers want certain providers in network, for example, only Houston area providers. They are being proposed two ways: as a separate WC network application, and as a DBA under a WC network application. "Sub-networks" or "customized networks" must still meet all network access and quality requirements. Carriers must be clear to providers "what" network they are in, whether this is done via a contract amendment or another means; carriers must provide provider directories for both networks and sub-networks. Regarding whether sub-networks would be included in the WC network report card, Amy Lee explained that, if a sub-network is a DBA then it cannot be identified "separately" via a certification number that will appear on medical bills, so it cannot be tracked separately and will not be included in the report card. Rick Levy expressed concerns about sub-networks as they may be "employer-driven" and will diminish the choice afforded by a WC network. Sub-networks will be the topic for the next WCNIWG meeting agenda including a staff presentation on what is a sub-network and how it can be identified, how it will be monitored, notice requirements, report card considerations, etc., and full discussion by members. So that staff may prepare thorough responses to members' questions, please send questions about sub-networks to email@example.com. None of the current applications include sub-networks. Audrey thanked the members for openly expressing their concerns.
Review outreach plan
Members received an updated outreach plan and two draft/proposed web pages about WC networks, one for stakeholders and one for injured workers. The WC network publications for injured workers will be available in Chinese, English, Korean, Spanish, and Vietnamese. TDI contacted the independent agents association and the National Federation of Independent Businesses. Both organizations were enthusiastic about partnering with TDI to get information about WC networks to their members by inviting TDI to speak at various events, including information in their newsletters, fax blasts, and linking to TDI's website. WCNIWG members are encouraged to link to TDI's webpages also. Chuck Whitacre (DWC) noted that the next technical healthcare update will include extensive information about WC networks. TDI will add a glossary to the web pages. Audrey invited the members to continue to provide helpful comments and suggest additional activities. TDI will track activities and provide regular reports to the WCNIWG. The Office of Injured Employee Counsel (OIEC) is involved with TDI staff in developing publications and outreach activities for injured workers.
TDI complaint process
Members also received a one page description of the TDI complaints process. Complaints data will be used to tailor education and outreach activities. A TDI team is developing a uniform complaint-handling process, including best practices, for the agency that will be shared with the staff who draft the WC complaint rule. Complaints regarding WC networks may be submitted now using the online complaint form at http://www.tdi.texas.gov/consumer/complfrm.html. Providers may also use the TMA hassle factor process; many of these complaints are referred by TMA to TDI.
- TDI will provide a summary report to the WCNIWG about WC network complaints and their resolution, and other issues regarding WC networks that come to light during the complaint process.
- Regarding return-to-work and treatment guidelines, will there be a difference between network and non-network guidelines? This topic will be on the agenda for a future meeting.
- Regarding a WC network access plan, do providers sign a contract with the carrier? The answer is no. How will injured workers know if the doctor is taking patients? The access plan must include details about why the network does not have certain providers, how it will get them, and how they will be paid.
- Regarding lease network arrangements, TDI is not aware of any. This topic will be discussed at the next meeting.
- Regarding whether pre-authorization is a guarantee of payment, the answer is that if the service has been pre-authorized, then payment cannot be denied for medical necessity; however, it may be denied for another reason.
Next meetings: April 19 and May 1, 1 p.m. to 4:30 p.m., Hobby Building - Room 100
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Last updated: 10/16/2015