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Workers' Compensation Networks Informal Working Group (October 11, 2006)

October 11, 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' health care provider.

Agenda - October 11, 2006

Agenda Items Presenter
  • Antitrust statement
  • Review of ground rules

Albert Betts
Division of Workers´ Compensation

  • Update on networks
    • Applications
    • Process update
    • Complaints
    • Alternatives for counties with no certified networks

Margaret Lazaretti
Deputy Commissioner, Health and Workers´ Compensation Network Certification and Quality Assurance

  • Medical disability management
    • Overview - what is medical disability management?
    • Update on status of rule proposal
    • Training for providers to follow rule guidelines

Allen McDonald
Deputy Commissioner
Workplace and Medical Services

  • Overview of Medical Quality Review Process (MQRP) and activities

Allen McDonald
Deputy Commissioner
Workplace and Medical Services

  • Status report on performance-based oversight system

Teresa Carney
Monitoring and Analysis

  • Discussion - Return-to-work

Allen McDonald
Deputy Commissioner
Workplace and Medical Services

  • Discussion - How to identify whether a patient is in a certified WC network or an informal WC network, or a WC injury

Brent Hatch
Deputy Commissioner
Field Services

  • Wrap up and thank you to WCWG members

Meeting Minutes - October 11, 2006

Albert Betts, Commissioner of Workers' Compensation, welcomed the group and reviewed the antitrust statement and ground rules.

Update on networks

Margaret Lazaretti reported there are 15 certified workers' compensation (WC) networks: five are only available through certain carriers, and ten are available to any carrier to use. In addition there have been three requests for modifications to service areas. There are 15 pending WC network applications and nine pending requests for modifications to service areas. She also provided an updated report regarding WC network complaints.

Margaret reviewed two memoranda to interested parties, one regarding an informal, draft rule about amendments to network coverage in metropolitan divisions and the other requesting comments about "rural" and "nonrural" mileage requirements for workers' compensation healthcare network service areas.

The informal draft rule is posted on TDI's website at http://www.tdi.texas.gov/rules/drules.html. She encouraged the members to submit comments on the draft rule and/or memorandum by October 20, 2006, to margaret.lazaretti@tdi.texas.gov.

Margaret explained that it has come to TDI's attention that there is confusion regarding what is not considered initial selection of a treating doctor in a WC network. These situations do not constitute an initial selection of a treating doctor: a doctor providing emergency care; a doctor salaried by the employer; and any doctor who provides care before the employee is notified of the network, except for a doctor selected under Insurance Code Section 1305.105 (HMO PCP). She emphasized that if an injured worker in a network sees a doctor salaried by the employer, this does not count as the initial selection of a treating doctor.

Medical disability management

Allen McDonald explained there are three proposed rules regarding medical disability management: treatment, disability, and return-to-work guidelines. The comment period has closed on these rules and staff is preparing the final adoption orders. Currently staff is drafting the case management rule. He reiterated that guidelines are intended to be just that - guidelines, not hard and fast rules - to be considered along with a patient's needs. As a result, DWC is attempting to balance carriers' concerns that the guidelines may be too broad with providers' concerns that guidelines may be overly prescriptive and create administrative burdens. The proposed effective date is January 1, 2007. He asked the members to comment on "when" the guidelines should be effective, and the best way to train all parties. Creg Parks suggested a pilot test in a small region with a phase-in plan. Bruce Singleton said moving back the effective date would allow more lead time for training and education. Dr. Norwood suggested a phase-in plan over a two-three month period, with voluntary participation, and a training plan that allows providers to learn "real time" while treating patients. Brian White suggested that, because injured workers may cross regions, the implementation date be pushed back and that rural areas be included. Lee Ann Alexander expressed concern about the short timeframe. Nick Huestis observed it is important the guidelines be understood, and that if the rules are adopted in December 2006, then the effective date should be in April 2007. Lindsey Johnson suggested pushing the effective date back three to six months to May 1, 2007, allowing time to provide training for all parties. Judy Roach said a phase-in approach would be a problem for employers who may have injured employees located all over Texas.

Medical Quality Review Process (MQRP)

Allen McDonald provided a copy of information posted on DWC's website regarding the purpose and background of the MQRP. He explained that DWC will monitor complaints to identify trends. DWC staff will also use information available from the Texas Medical Board. He reviewed key features of the MQRP including the role of the Quality Monitoring and Enforcement Team composed of DWC Deputy Commissioners and the steps in the process. Nick Huestis asked, what if a doctor goes to an elected official and exerts political pressure on DWC? Commissioner Betts replied that the MQRP is an open process with clear opportunities for a doctor to present information and discuss it face-to-face or via teleconference, and that the process will withstand challenges. Dr. Norwood asked, what about network doctors? Margaret explained that the reviews would apply to network doctors, and that networks also should be aware of the issues because of their quality monitoring programs . Robert Saenz noted that not all WC networks say that the disability management standards apply to ancillary providers. Allen explained that, as part of HB 7, a report on pain management is due in December 2006. Amy Lee added that the network report card will provide an overall look at injured workers' satisfaction with care. Rick Levy asked if the process will be able to detect under-utilization, and that it is important to look at utilization. Allen said yes, but that complaints could likely be a better indicator. Brian White asked, when the Approved Doctor List (ADL) is gone, how will DWC keep doctors who are "off" the list out of the system? The statute says that such doctors may not receive direct or indirect remuneration, and that carriers have programmed their systems not to pay such doctors. Also, recall that such doctors may also apply to be reinstated on the ADL. In addition, doctors may continue to file financial disclosures even after the ADL goes away. Allen explained that DWC will not take action based solely on "numbers" - rather, the statistical analysis may lead to a review of a particular doctor. A review includes the participation of the doctor who is the subject of the review as well as two Medical Quality Review Panel reviewers, doctors who are experienced in the type of care being examined. It also includes an informal resolution conference. The MQRP will make recommendations to the Commissioner who will issue sanctions, if warranted. Dr. Gude asked, can the ADL be continued? Commissioner Betts replied that he had heard such a recommendation will be made to the Legislature.

Performance-based Oversight (PBO)

Teresa Carney reminded the members about the PBO web resource page at http://www.tdi.texas.gov/wc/dwc/divisions/pbo.html. She explained that staff considered the idea of doing a PBO pilot project and developed a model. In doing so, they noted certain limitations to this approach, for example, how to decide who would be included, what measures would be used, and how to group carriers into tiers if a pilot included only a subset. Staff reviewed the HB 7 PBO provisions and noted the first assessment must be completed before September 1, 2007. As a result, the decision was made to complete a full PBO assessment in the summer of 2007 rather than do a pilot project now. Next steps include focusing on measures for providers and facilities, and continuing to meet with the PBO working group and post meeting notes and other information on the PBO web page. Lee Ann Alexander said she agreed that delaying the assessment was the best way to go, and added that it would have been a mistake to move forward without doing a full assessment.

Discussion on return-to-work

Allen McDonald reported there have been many inquiries but no takers for the small employer return-to-work pilot project. He has learned that because the pilot is set up to reimburse small employers on the back end, after they have made accommodations for the injured employee, employers may fear that they will not be reimbursed. Commissioner Betts said a statutory change would be needed to allow payment up-front. Allen asked the members to offer suggestions for how they can help make return-to-work work. Jaelene Fayhee suggested that DWC partner with the Texas Workforce Commission to help injured employees find other jobs. This effort may be occurring now via PCs located in the lobbies of the DWC field offices; Brent Hatch will follow-up. Dr. Norwood said the determination that an injured employee can go back to his or her previous job should be made as soon as possible, and the employer should be encouraged to make modified duty available. Dr. Bill Nemeth suggested that doctors should be encouraged to talk directly with employers; for example, some injured employees may not understand the treating doctor's recommendation, so direct communication with the employer would be helpful. Nick Huestis pointed to studies that show it will make a difference long-term if an injured employee who has a chronic case can be identified early and placed in a special treatment program. Robert Saenz observed that some injured employees may be ready to return to work but wait weeks to see their treating doctor in order to be released. Or they may become convinced they have a problem and cannot work, and they are fired. He agreed, the solution is to intervene earlier. Rick Levy added that return-to-work requires employers to make a monetary investment and cannot be fixed on the cheap. Lindsey Johnson said that getting injured employees back to work requires the carrier, provider, and employer to work together. Commissioner Betts said there is no easy answer, reiterated that to be successful return-to-work needs help from all stakeholders, and that DWC will look at what more it can do.

Discussion on how to identify whether a patient is in a WC network, etc.

Brent Hatch explained the issues that make it difficult to identify whether an injured employee is in a WC network include: not all carriers use WC networks; if an employer has coverage with a carrier who offers a WC network, the employer may not opt to use it; not all injured employees whose employers have selected a network are "in" the network; TPAs are not aware of WC networks; and carriers' customer assistance line staff may not be fully informed about "who" is in a WC network. Possible solutions include: using the current list of carriers' 800 numbers on DWC's website; collecting information from the 837 medical claim form, which has a flag for WC network claims; ID cards issued to injured employees; creating a new web resource page; and allowing carriers to notify DWC about WC networks via a form. Bruce Singleton said his network has provided a form that employers give to an injured employee that tells a doctor the patient is in a WC network. Members noted that ID cards cost money to produce and are easily lost or overlooked, etc. One audience member suggested DWC convene a subgroup to look at solutions. Creg Parks said the network should be responsible for informing its members and treating doctors. Jim Baker suggested holding carriers responsible to improve the information given via their 800 numbers. Commissioner Betts asked Margaret Lazaretti to convene a subgroup to make recommendations about how to address this issue. Margaret said she will contact the stakeholder groups over the next month and request one representative from each group to participate in the new subgroup.

Commissioner Betts thanked the WCWG members for their participation over the past several months.

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Last updated: 9/6/2014