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Workers' Compensation Networks Informal Working Group (April 19, 2006)
April 19, 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.
Agenda - April 19, 2006
Meeting Notes - April 19, 2006
Audrey Selden welcomed the Workers' Compensation Working Group (WCWG) and invited observers, and reviewed the antitrust statement and ground rules. Members introduced themselves. Following each meeting, TDI will send meeting summaries to the members and invited observers, and post the summaries on the WCWG web page at http://www.tdi.state.tx.us/consumer/wcnetiwg.html. TDI will send meeting agendas about one week before each WCWG meeting; future meeting dates are 5/1, 5/24, 6/14, 7/12, 8/9, 8/30, 9/20, and 10/11. During each meeting, there will always be time for questions and comments from invited observers and audience members. TDI very much appreciates the participation of all stakeholders.
Update on networks
Margaret Lazaretti noted there are 20 pending network applications. Two networks have been certified: Concentra HCN and Texas Star Network/Concentra; for more details please go to http://www.tdi.state.tx.us/wc/wcnet/wcnetworks.html.
Regarding Form 22 - Required Medical Examination Notice or Request for Order and Form 32 - Request for Designated Doctor, Brent Hatch explained that TDI is in the process of updating them to include a check box for "network" and "non-network." Until the updated forms are available, please write NON to indicate the injured worker is not in a network, or NET to indicate the injured worker is in a network, on the top of the form when faxing or mailing it to DWC. The forms are available on the website at http://www.tdi.state.tx.us/wc/forms/index.html.
Regarding the carriers' 800 numbers to call in order to verify if an injured worker is "network" or ''non-network," TDI requests that carriers provide both the 800 number and instructions about how to navigate the automated telephone system to reach the person who will provide the information.
Quality Improvement (QI) Program
Margaret reviewed the elements of the quality improvement program that networks are required to have. Please see attached PowerPoint presentation. Key points include:
- The network's governing body is responsible for the QI program. The purpose of a QI program is to assure the quality, accessibility, and appropriateness of network services.
- TDI's Health and Workers' Compensation Network Certification and Quality Assurance (HWCN) staff will monitor the network to make sure that the QI program described in the network's application is put into operation.
- A network must have both a medical case management and return-to-work program. Again, HWCN staff will be monitoring the networks to make sure these programs are put into operation.
- A network must develop an annual quality improvement work plan with goals, timeframes, and an evaluation methodology.
- A network must file an annual report with TDI; the report for each year is due in the first quarter of the following calendar year along with the network's financial report.
- A network must report to TDI any change that affects access to care. For example, if network membership suddenly increases and results in an access to care issue, then this change should be reported to TDI.
- If a network delegates oversight of a utilization review, retrospective review, and complaints handling, then that must be reported to TDI. If these functions are delegated, TDI will check to make sure that the network has done due diligence and is providing appropriate oversight.
- A network must have medical case management with certified case managers. Until 1/1/2007, a non-certified case manager may provide case management under the direct supervision of a certified case manager. See PowerPoint slides for examples of case manager certifications. Please note that an error was noted in the slide regarding non-accredited networks. The designation COHN is an accredited certification. A corrected page is included with the PowerPoint presentation attached to these notes.
Margaret explained that the network must have a procedure for resolving oral and written complaints that includes both a notice and appeal process (see attached PowerPoint presentation). Networks may have a 90-day deadline to file a complaint. TDI does not have a deadline for filing a complaint. Networks must follow the specific requirements for complaint records and coding.
Regarding TDI's complaints process, key points include:
- TDI receives complaints via phone, e-mail or in writing.
- TDI sends a copy of the complaint to the entity involved and asks for information.
- TDI evaluates the information and responds to the complainant.
- Complaints are tracked in a database and coded as "justified" or "unjustified." The number of justified complaints against a regulated entity is made available to the public via TDI's 800 number and also on TDI's website as part of the company profile information.
- TDI reviews complaint data for trends, and uses it to inform educational efforts and enforcement actions.
- TDI may also request to examine the network's complaint record.
- If TDI sees a negative trend in complaints regarding a network, possible actions could include management conferences, enforcement actions, and possible loss of certification and license.
- TDI expects all regulated entities to use complaints as a mechanism to identify areas of improvement and to "self-correct."
Margaret asked the members to review the draft WC network complaint report (copy attached) and provide comments. At a future meeting, TDI will provide a list of complaint codes and sample complaints to illustrate how complaints are coded. Given that the implementation of WC networks is a big change, TDI expects to receive many complaints and so should carriers.
TDI has received questions regarding "tailored" networks. A "tailored" network is a smaller part of a large network. For example, an applicant files two applications, and one network is a subset of the other. In this example, both networks would get a full review by TDI staff. Another example is that a certified network may establish a "preferred" network, demonstrated to be more efficient and effective in treating injured workers, for a specific employer; or an employer whose employees live in the Houston area only wants Houston providers in the network rather than a statewide network. In this example, the tailored network would also be evaluated separately and must meet all the requirements for services and network adequacy. An annual report will be submitted for both networks.
The WC network "report card" being developed will reflect data for certified networks because the certification number will appear in billing data. However, requirements for the report card and annual reports can be aligned so that TDI is receiving information on tailored networks separately. In addition, TDI can issue data calls to networks and tailored networks if necessary to obtain appropriate information.
TDI has received no applications that include a "tailored" network. TDI is mindful of stakeholders' concerns that tailored networks may dilute the performance of networks. TDI will monitor the proliferation of tailored networks and come back to the WCWG regarding the need for more detailed reporting.
Regarding a WC network and self-insured employer, a WC network that contracts with a self-insured employer must go through the certification process, like any other WC network that would contract with an insurance carrier.
Regarding how providers will know which network they are in, this information will be included in the providers' contracts and provider listings. Networks and tailored networks must have different names. Members expressed concern that there is the potential for confusion among providers and injured workers about "who is in what network," and that more education and guidance is needed. While no applicant has requested a tailored network, TDI will continue to monitor this issue.
Update on bulletins and rules
Allen McDonald provided updates on the medical billing and reimbursement rules, and preauthorization rule. For the medical billing and reimbursement rules, staff is preparing a crosswalk between the old and new rules that will be published on the website in May. The peer review and Required Medical Examination (RME) rules will likely be drafted in June.
Discuss draft proposal of performance-based oversight (PBO) system
Teresa Carney presented an overview of the requirement to adopt a performance-based oversight system included in HB 7 (see PowerPoint presentation attached). HB 7 requires the department to develop and use key regulatory goals to assess insurance carriers and health care providers; at least biennially, assess the performance of insurance carriers and health care providers; and, based on the assessment, develop regulatory tiers. Senior staff members working on a cross-agency team have completed research on performance-based oversight systems used at other agencies and developed preliminary thoughts about a PBO system for workers' compensation. Input from stakeholders is requested regarding how to identify the key regulatory goals, define the assessment mechanism, define the tiers and place carriers and providers into tiers, and develop incentives for each tier. Timeframes for this project are aggressive, with a target date for completing the initial assessment of 9/30/2006.
Members' comments on PBO are summarized below:
- Expand the definition of performance incentives to include monitoring all WC system participants. PBO should recognize all parts tie together.
- Suggest annual review - a biennial review cycle is too long.
- Check implementation timeline against logical order of steps to develop a PBO system.
- How will PBO tie into the Report Card?
- Is there a "double jeopardy" for a provider - for example, complaints to TDI and to the Medical Board?
- Develop PBO in relation to federal pay for performance and similar initiatives.
- Be cautious about picking too many variables.
- Be cautious about using variables that would put providers in certain parts of Texas at a disadvantage - for example, no return to work services available to employees in _____ so providers in those areas would not score well on that variable.
- Don't reinvent, use existing performance and quality measurement tools that are already available, for example, URAC and Medical Quality Review Panel (MQRP).
- Have a pilot test and use it to get input from all system stakeholders; include different part of the state/different industries in the pilot.
- Keep in mind that, because employers are not required to take an injured worker back, the return-to-work model is "missing" an important partnership - employers.
- Consider measuring separately 1) date a doctor releases an injured worker and 2) date when the injured worker returns to work.
- Use "frequency" measures, for example, how often a provider talks to an injured worker about return-to-work.
- Start "small" and use data TDI has already collected. Consider using data sampling methodologies. Use complaint data. Use medical reports. Use cost data report from a few years ago, and compare to today.
- Look at outliers - what puts a doctor outside "good medicine"?
- Be cautious about using "distribution" models, for example, BCBS had problems with this.
PBO will be an agenda topic for the May 1 WCWG meeting.
Silent and rental PPOs
Jennifer Ahrens stated that the WCWG and Technical Advisory Committee on Claims Processing will hear a panel presentation on PPOs on May 1 from 1 p.m. to 3 p.m. In particular, TDI would like to know what issues stakeholders have with PPOs. Creg Parks recommended that, in addition to PPO representatives, the panel should include a provider representative who understands the reimbursement issues that providers face regarding silent PPOs. He explained that a network may try to fill a gap in a particular provider panel by leasing a second network that has contracts with those providers. Not all networks disclose when these arrangements have been made. As a result, providers do not know "which" network they are in and what they will be paid.
Regarding EPOs, they will be added to the list of topics for discussion at a future meeting.
Jaelene Fayhee requested that the group look at outreach as a whole, and discuss outreach activities at a future meeting. She also suggested that the Texas Medical Board be invited to give a presentation on how it monitors providers and quality of care; other licensing boards will also be invited to explain how they monitor their licensees. Dr. Steve Norwood asked that the group discuss the benefits of the Approved Doctors List. Creg Parks noted that some providers have cited the administrative hassles and paperwork associated with networks as the reason why they are not going back into the WC system. Also providers are asking about the medical fee guidelines for non-network providers. Albert Betts said the department is looking at how technology can help reduce paperwork. Discussions with stakeholders on the non-network medical fee guidelines will begin in June; there will likely be no adoption before the legislative session. Regarding having certified networks represented on the WCWG, TDI will invite those networks who are not already represented to participate as invited observers.
Next meeting: May 1, 1 p.m. to 4:30 p.m., Hobby Building Room 100
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Last updated: 10/16/2015