The purpose of this bulletin is to reiterate the statutory and rule requirements regarding insurance carrier compliance with medical billing and payment data reporting.
TDI-DWC REVIEW OF MEDICAL BILLING AND PAYMENT DATA
TDI-DWC recently conducted a limited review of selected insurance carriers to determine compliance with medical billing data reporting requirements and found that all medical billing and payment data is not being submitted. So far, this review of selected insurance carriers has identified missing medical bills for calendar years 2006 and 2007. TDI-DWC is in the process of completing these reviews and is currently working with the affected insurance carriers to get this missing data reported in a timely fashion. Furthermore, a review of calendar year 2007 medical bill and payment data reported to TDI-DWC, indicates approximately 16% of the medical bills were not submitted within the 30 days required under 28 Tex. Admin. Code §134.802.
REQUIREMENTS FOR DATA SUBMISSION
Tex. Lab. Code Ann. §§413.007 and 401.024 require TDI-DWC to collect and maintain a statewide medical billing database and allows the commissioner to require electronic submission of information and prescribe the form, manner, and procedure for electronic submissions of information. 28 Tex. Admin. Code §134.802 requires insurance carriers to submit medical bill and medical payment data electronically to TDI-DWC within 30 days after the insurance carrier makes payment, denies payment, or receives a refund of overpayment on a medical bill.EXPECTATIONS OF MEDICAL BILL SUBMISSION
The TDI-DWC expects all medical billing and payment data to be submitted timely, accurately and completely in accordance with the statute and applicable rules. Further, the TDI-DWC reminds all insurance carriers that they are responsible for the actions of their third party administrators' and trading partners' data reporting activities. TDI-DWC will be initiating on-going monitoring reviews for selected insurance carriers to ensure that all medical billing and payment data is submitted timely, accurately and completely. All insurance carriers are encouraged to develop and implement a data monitoring strategy that tracks the volume of medical billing records being submitted to TDI-DWC, the percentage of these records that are rejected and corrected and the timeliness of these data submissions. Failure to comply with TDI-DWC data reporting requirements may result in administrative penalties up to $25,000 per day per occurrence.
INSURANCE CARRIER ACTION
TDI-DWC is requesting that each insurance carrier identify their current trading partners for Medical Electronic Data Interchange as well as identify the person in charge of monitoring data submissions, including that person's phone number and e-mail address and submit that information via e-mail to TDI-DWC. Please respond to TXComp.Help@tdi.state.tx.us by September 26, 2008 . Additionally, TDI-DWC expects insurance carriers and their trading partners to notify TDI-DWC on an ongoing basis if this information changes.
FURTHER INFORMATION
For further information on Medical EDI reporting, please see the EDI Guidelines at: http://www.tdi.state.tx.us/wc/edi/mededitoc.html. You may also contact the TXCOMP Help Desk at 888-489-2667.
Albert Betts
Commissioner of Workers' Compensation
Texas Department of Insurance