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

September 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´s health care provider.

Agenda - September 11, 2006

Agenda Items Presenter
  • Antitrust statement
  • Review of ground rules

Albert Betts
Division of Workers´ Compensation

Audrey Selden
Senior Associate Commissioner
Consumer Protection

  • Update on networks
    • Applications
    • Process update

Jennifer Ahrens
Associate Commissioner
Life, Health & Licensing

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

  • Overview of TDI Complaint Process
    • Definition of a justified complaint
    • How a complaint is determined to be justified
    • Complaint information provided to the public

Margaret Lazaretti

  • WC rule status

Stan Strickland
Deputy Commissioner
Legal & Compliance

  • TXCOMP update

Patricia Gilbert
Executive Deputy Commissioner

  • Status report on performance-based oversight system

Teresa Carney
Director, DWC Monitoring and Analysis

  • FY 2007 Research Agenda for the Workers' Compensation Research and Evaluation Group

Amy Lee
Director, Workers´ Compensation Research and Evaluation Group

  • Discussion topics for next meeting
  • Next meeting: October 11, 2006

Meeting Notes - September 11, 2006

Audrey Selden welcomed the group and reminded them of the antitrust statement and groups rules. Members introduced themselves.

Update on networks

Margaret Lazaretti reported that 11 workers' compensation (WC) networks have been certified and two modifications to service areas have been approved. Twenty WC network applications are pending. She distributed copies of a Texas map showing the counties that have at least one network; copies of the map are available on request by sending a note to wcnet@tdi.texas.gov. Margaret asked that problems with provider listings on carrier or WC network webpages be reported to her as soon as possible. Regarding improvements to the application process, she explained that TDI is monitoring the process daily and constantly looking for ways to improve the process. Once an issue is identified, it is addressed. Also, the review process depends on how quickly the applicant provides responsive information to TDI.

Margaret provided an overview of the TDI complaint process. Three TDI sections handle different types of complaints:

  • The Health and WC Network (HWCN) staff in the Life, Health & Licensing program handle complaints about WC networks and HMOs.
  • The WC Classification and Premium Calculations staff in the Property & Casualty program handle complaints about WC rates and classifications.
  • The Division of Workers' Compensation - Complaint Resolution and Customer Services (DWC-CRCS) staff handle complaints regarding WC claims.

DWC-CRCS recently relocated from the Metro Building to the Hobby Building and has begun using the same automated systems used by other TDI divisions that handle complaints. All TDI complaints are tracked in a database called CIS (Complaint Inquiry System), and three divisions including HWCN, CP, and now DWC-CRCS, use a scanning and imaging software called VisiFlow so the complaint handling process is "paperless." When a complaint is received, it is entered in CIS and assigned a unique six-digit number called a document ID number. Then an acknowledgment letter is sent to the complainant, and a copy of the complaint along with a letter requesting information is sent to the carrier, network, or other licensed entity involved in the complaint. Depending on the issue, the letter may go to the carrier or network or both. TDI requests a response within ten days under Section 38.001 of the Texas Insurance Code; the carrier or network may request an extension. For more information about requesting an extension, please view the Commissioner's Bulletin B-0040-00 at http://www.tdi.texas.gov/bulletins/2000/b-0040-0.html. TDI staff review the carrier's response and may request more information. If no violation is detected, then the complaint is closed. If a violation is detected, then the complaint is referred to TDI Enforcement. Enforcement staff evaluate complaints taking into account various factors and criteria, and may or may not decide to open an enforcement case. On all complaints, TDI sends the complainant a copy of the carrier's response and a closing letter.

In reviewing the summary of WC network complaints provided, WCWG members asked for more specific information about "who" the complainant is and why/not a complaint may be justified. Regarding complaint #16, Margaret will provide more information about why it was coded as justified. Joe Woods asked for more information about the complaint shown on the August report regarding contract negotiation, was it justified or unjustified. After further investigation, complaint #16 on the September report and the contract negotiation issue from the August report were both incorrectly coded due to a data entry error on both reports. HWCN apologizes for the errors, please see the corrected September report attached.

Margaret also reviewed the complaint information available on TDI's website at www.tdi.texas.gov/consumer/cpportal.html. TDI provides a company profile about every licensed carrier. Lists of complaint indices for the licensed auto, home, life, health, and WC carriers are also available. She noted that the WC list reflects very few complaints and explained this will change as DWC-CRCS complaints are starting to be tracked in CIS. Audrey added that only the number of justified complaints appears on these lists and in the company profiles, not "all" complaints received. She emphasized that TDI uses many different types of data to monitor companies, not just justified complaints. Margaret added that TDI can use its examination authority to address communication issues between a WC network and providers or other issues, for example.

Regarding complaints about providers, Stan Strickland, DWC Legal & Compliance, explained that all complaints regarding WC claims will be entered in CIS. He has a team of auditors who will review complaints referred to DWC-Legal for possible enforcement action. Brent Hatch said that quality-of-care issues will be reviewed by the Medical Advisor's staff. Commissioner Betts noted that Medical Quality Review Panel (MQRP) actions will be posted on the website. He added that TDI is charged with identifying high performers and is wrestling with the best way to do this. Jaylene Fayhee asked if, in the future, TDI could list justified complaints, number of patients, and a complaint ratio for providers. Commissioner Betts said yes, possibly TDI could do this in the future.

As a reminder, TDI hosts weekly conference calls about WC networks for providers and administrators on Tuesday at 2 p.m. To dial in, please call 888-387-8235, enter 5751967, then press the # key.

WC rule status

Stan Strickland reviewed the revised list of proposed rules available on TDI's website at www.tdi.texas.gov/wc/rules/tableofcontents/rulesoptions.html - scroll down to view DWC Rule-making Timeline (updated daily). Please note the new October 5 hearing date for treatment planning rules. Staff is reviewing comments received on the medical dispute resolution rules now. Commissioner Betts thanked the members for their assistance with the rules.

TXCOMP update

Joe McElrath, DWC Business Analyst, provided an update on stabilization of TXCOMP. In April 2006, a stabilization assessment was completed including a review of hardware/software infrastructure issues. As a result, TDI purchased over $300,000 of hardware, software, and consulting services to stabilize TXCOMP. Problems identified with the document management applications are now being addressed. Regarding collection of medical billing data, a database outside of TXCOMP was created to hold this data. In June, carriers began submitting data, and corrections to 2005 data are due October 15, and corrections to 2006 data are due December 30. The backlog of A49 Subsequent Report of Injury (Income Benefit Information) data from October 2005 to present will be processed within three to four weeks. Regarding the proof of coverage/EDI data, TDI also has held onto it for processing and is currently evaluating how best to process the data. TDI will issue a request for information (RFI) to take COMPASS data from its current mainframe platform to a web-based platform.

Creg Parks asked if providers could have access to TXCOMP in order to identify"who" is in a network. Allen McDonald said TXCOMP is designed for claims data only, not customer service uses. Amy Lee reminded the group that carriers were asked to provide a single point of contact that providers can call to find out if a patient is in a network. The list is available on TDI's WC network web resource page, http://www.tdi.texas.gov/wc/wcnet/documents/nwcarrierphones.pdf. Commissioner Betts said TDI needs to do more regarding information about "who" is in/not in a WC network. Regarding whether proof of coverage data could be used, Joe added that staff is reviewing this now. Amy said that, for HB 7 a required report to the Legislature is due in December 2006, TDI issued a data call during the first week of September to collect data about how many people are currently in WC networks and other information.

Status report on performance-based oversight (PBO)

Teresa Carney explained that staff is looking at measures and possible data sources, and discussing all with Commissioner Betts. A revised project timeline is coming. The next subgroup meeting is set for September 27 from 9:30 - 11:30 a.m. in the Tippy Foster Room at Metro. Regarding a pilot to test the PBO model, Teresa said yes, TDI will do a pilot and staff is working on an approach. For additional information, please see the materials on the PBO web resource page at www.tdi.texas.gov/wc/dwc/divisions/pbo.html.

FY 2007 Research agenda for the WC Research and Evaluation Group (WCREG)

Amy Lee explained that, each year, the research agenda is adopted by the Commissioner of Insurance. Regarding the 837 medical data, she recently met with TDI's trading partners to discuss "how much" and "what kind" of data will be provided. She asked the trading partners and some carriers to complete a spreadsheet listing the data elements. This information will help her shape the WC research agenda. The FY 2006 agenda is on the WCREG web resource page on TDI's website at www.tdi.texas.gov/wc/regulation/roc/index.html. Summary PowerPoint presentations for those reports will be posted on the website soon including non-subscription estimates, medical bill and claim denial rates, and calculating return-to-work outcomes. For the FY 2007 agenda, please send an e-mail to wcresearch@tdi.texas.gov by September 27 with your suggestions. Criteria for selecting projects include: is data available? does the WCREG have the expertise? will the study be valuable to many stakeholders? The FY 2007 agenda will be posted, and if there are no comments then it will be adopted without a hearing. Regarding WC premium, the Property & Casualty program actuaries prepare those analyses.

Discussion topics for next meeting

Commissioner Betts said the WCWG will have one last meeting on October 11 before the legislative session starts and will not meet during the session. Regarding topics for the next meeting, members suggested the following:

  • How to identify whether a patient is in a certified WC network or an informal WC network or a WC injury
  • Medical disability management - how to train providers to follow guidelines that TDI adopts and update on status of rule proposal
  • Return-to-work - further input on system participant involvement
  • Results of DWC's telephone survey regarding access to medical care
  • Update on MQRP activities and overview of MQRP process
  • Alternatives for counties with no certified WC networks
  • DWC's efforts to reduce paperwork and administrative hassles for providers
  • Update on PBO
  • What will happen when the Approved Doctor List goes away as required by HB 7

Regarding issues for a legislative agenda, Bonnie Bruce from Representative Solomons' office invited the WCWG members to discuss their ideas with her. Please contact her directly at bonnie.bruce@house.state.tx.us.

Next meeting: October 11, Hobby Room 100, 1 p.m. to 4:30 p.m.

For more information, contact:

Last updated: 7/30/2018