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workers compensation latest trends:

TOPICS FOR DISCUSSION. HB7

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workers compensation latest trends:

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    1. WORKERS COMPENSATION LATEST TRENDS: A DISCUSSION ABOUT NEW RULES, THE ALLIANCE AND EXPOSURES

    3. HB7 MAJOR REFORM Intense scrutiny of workers compensation system during 2004 Sunset Review Sunset Committee recommended to abolish the Texas Workers Compensation Commission (TWCC) Passage of House Bill 7 (79th Legislature) effective 9/1/05

    4. HB7 MAJOR REFORM Significant Changes TWCC is abolished - Authority is transferred to the Division of Workers Compensation within the Texas Department of Insurance (TDI-DWC) Creation of the Office of Injured Employee Counsel (OIEC) - New state agency whose mission is to represent the interest of injured employees Changes State Average Weekly Wage (AWW), increased from $540 to $674 Changes waiting period for first benefit check, decreased from 4 weeks to 2 weeks

    5. HB7 MAJOR REFORM Significant Changes Establishes a means to manage disabilities (Disability Management) Official Disability Guidelines (ODG) Medical Disability Advisor (MDA) Allows participation in networks or direct contracting with service providers

    6. COMPLIANCE IN THE WORKERS COMPENSATION SYSTEM Performance Based Oversight Goals Provide timely & accurate income & medical benefits Safe & timely return of injured workers to productive roles Promote save & healthy workplaces Ensure each injured employee shall have access to prompt, high quality, cost-effective medical care Increase timely communications with the system

    7. COMPLIANCE IN THE WORKERS COMPENSATION SYSTEM Performance Based Oversight Assessments Conducted every 2 years Conducted through analysis of data Maintained by the Division Self-Reported data from Carriers Tiers Poor Performers Average Performers High Performers

    8. COMPLIANCE IN THE WORKERS COMPENSATION SYSTEM Performance Based Oversight Incentives Publicly recognize high performers Modified penalties Limited audits System Monitoring & Oversight Monitor the workers compensation system for compliance in 3 Sections Monitoring & Analysis Complaint Resolution Audits & Investigations

    9. COMPLIANCE IN THE WORKERS COMPENSATION SYSTEM Performance Based Oversight Violations Carrier/TPA Violations Employer Violations Employee Violations Health Care Provider Violations

    10. COMPLIANCE IN THE WORKERS COMPENSATION SYSTEM Performance Based Oversight Carrier/TPA Violations Timeliness of Medical Bill Payments 45 days to pay or deny the medical bill 21 days to pay or deny the medical bill on reconsiderations Inappropriate Denial of Medical Bills Late Income Benefit Payments TIBs IIBs SIBs Failure to Comply with Orders

    11. COMPLIANCE IN THE WORKERS COMPENSATION SYSTEM Performance Based Oversight Employer Violations Late Filings DWC-1 DWC-3 DWC-6 Posting/Coverage Failure to post coverage Rights & Responsibilities to employee

    12. COMPLIANCE IN THE WORKERS COMPENSATION SYSTEM Performance Based Oversight Employee Violations Fraud Cases Working & Drawing TIBs Failure to Attend Benefit Review Conference (BRC) Contested Case Hearing (CCH) Required Medical Exam/Designated Doctor Exam (RME/DDE)

    13. COMPLIANCE IN THE WORKERS COMPENSATION SYSTEM Performance Based Oversight Health Care Provider Violations Late Filings DWC-69 DWC-73 Failure to comply with an order to pay IRO fees Private claims against the injured employee

    14. COMPLIANCE IN THE WORKERS COMPENSATION SYSTEM Performance Based Oversight Penalty Assessment Violations occurring after September 1, 2005 may receive a penalty up to $25,000.00 per day per occurrence. Factors Considered Seriousness of violation History & extent of previous violations Demonstrated good faith of the violator Penalty necessary to deter future violations Performance Based Oversight Tiering

    15. NETWORKS VS. DIRECT CONTRACTING Under Chapter 1305 of the insurance Code, an employer may elect to contract with a network provider Under Chapter 504 of the Labor Code, a political subdivision may elect to participate in a direct contracting arrangement Carve out due to the fact that political subdivisions cant opt out of the Workers Compensation Act

    16. NETWORKS VS. DIRECT CONTRACTING Major Differences Chapter 1305 Chapter 504 Regulated by TDI Regulated by Alliance No Non-Network Coverage Local Control Non-Network Network chooses Fee Guides Alliance chooses Fee Guides Subject to WC Act & TDI Exempt from WC Act & TDI Limited coverage in rural areas Statewide coverage including rural Approximate rate of $8 per bill Approximate rate of $2 per bill

    17. POLITICAL SUBDIVISION WORKERS COMPENSATION ALLIANCE TAC has participated in a work group composed of representative of 5 public entity pools Considered the feasibility of developing a direct contracting arrangement between the pools and health care networks under the new law Assessed proposals from potential networks for costs and availability

    18. POLITICAL SUBDIVISION WORKERS COMPENSATION ALLIANCE Decision To Direct Contract Assessed network participation and concluded the high cost of networks and the unavailability of network services except in major metropolitan areas were significant areas for concern Determined that a certified workers compensation healthcare network is not available or practical for TAC and its members

    19. POLITICAL SUBDIVISION WORKERS COMPENSATION ALLIANCE Power in Numbers Alliance is comprised of: 3,000 Public Employers 500,00+ Public Employees Collectively experience about 30,000 on the job injuries per year $80,000,00.00 in Medical Benefits paid annually Approximately 400,000 bills processed annually

    20. POLITICAL SUBDIVISION WORKERS COMPENSATION ALLIANCE Contacting the Alliance Alliance Website www.pswca.org Provider look up & printable directories By Name, Specialty, Zip Code Mile Radius, County & City Website updated weekly Nominations Online Toll Free Alliance Access (866) 997-7922 E-Mail Info@pswca.org

    21. POLITICAL SUBDIVISION WORKERS COMPENSATION ALLIANCE The Direct Contracting Process Recruiting Provider Lists Contracting Consultants Adjusters Credentialing Board Certification Education/Training, Board Specialization Verification of DEA Certification Sanctions

    22. THE DIRECT CONTRACTING PROCESS Provider Monitoring Disability Management Official Disability Guidelines (ODG) Nationally recognized Mandatory adherence per signed contract Medical Disability Advisor (MDA) Nationally recognized Official Return to Work Guidelines Mandatory adherence per signed contract Treatment Planning When treatment exceeds ODG, providers are required to submit a treatment plan for approval for continued treatment

    23. THE DIRECT CONTRACTING PROCESS Provider Monitoring Physician Advisory Panel (PAP) 5 Doctor Panel Monthly Meetings Review ODG, MDA & Treatment Planning Compliance Ongoing Training of contracted providers Dispute Resolution

    24. THE DIRECT CONTRACTING PROCESS What Does This Mean to You? Quality Medical Treatment ODG MDA Better RTW Outcomes Discouragement of Unnecessary Medical Treatment Treatment Planning Easy Alliance Accessibility Long Term Savings Goal

    25. (FAQs)Frequently Asked Questions

    26. Question 1: Why was the Alliance formed?

    27. Answer: The Alliance was formed as a result of Texas Labor Code 504.053 to directly contract with medical providers for three main reasons: To control utilization To reduce medical costs, and To encourage better return to work outcomes

    28. Question 2: Can anyone join the Alliance?

    29. Answer: No. The Alliance was formed solely as a benefit for members of TASB RMF, TML IRP, TAC, TWCARMF, and TCRMF.

    30. Question 3: Are we required to notify our employees about the Alliance contracted provider panel?

    31. Answer: Yes. If an employee is not notified that they must select an Alliance Contracted Provider, then we are not able to dispute payment for treatment.

    32. Question 4: As an employer, do I have to do anything different when filing a First Report of Injury?

    33. Answer: No.

    34. Question 5: How do I know which doctors have been contracted by the Alliance to treat injured employees?

    35. Answer: Provider search is available on the Alliance Web Site for all treating doctors and specialists with corresponding service areas that have been implemented. Providers can be located by specialty or location on the Alliance website, www.pswca.org. If you need assistance, a representative of the Alliance can be reached at 866-99-PSWCA to assist you.

    36. Question 6: Can an injured worker opt out of the Alliance and treat with any doctor he or she chooses for a work-related injury?

    37. Answer: No. Once an injured worker has been notified of the Alliance requirements by his or her pool, he or she must choose a doctor designated as Treating on the Alliance service area provider list. If the injured worker chooses to treat with a non-Alliance doctor, he or she assumes risk of payment for the medical treatment and potential loss of income benefits. There are some very specific case-by-case exceptions that can only be arranged with the individual respective pool. To discuss the possibility of an exception, please contact your adjuster.

    38. Question 7: What should an injured employee do in an emergency situation?

    39. Answer: The injured employee should seek care from the nearest emergency room. Following the emergency treatment, the injured employee will be required to seek treatment with an Alliance contracted provider.

    40. Question 8: How does an injured worker change treating doctors within the Alliance?

    41. Answer: An injured worker is allowed an initial choice of treating doctor and one change within the Alliance without approval. After the change, approval must be sought from the adjuster.

    42. Question 9: What should an injured employee do if an Alliance contracted provider is not available to treat that employee?

    43. Answer: Aside from emergency situations the injured employee should: Contact his or her employer or the claims adjuster Go to TDI-DWC website to locate a TXCOMP (formerly ADL) doctor

    44. Question 10: How do I get a provider on the contracted provider panel who is currently not on the list?

    45. Answer: Visit the Alliance website at www.pswca.org to nominate a provider for the Alliance contracted provider panel. A nomination will not necessarily guarantee the provider will be contracted with the Alliance.

    46. Question 11: What is the process if there is a dispute regarding compensability issues?

    47. Answer: There will be no change to the dispute resolution process of compensability issues. The injured employees adjuster will continue to coordinate the resolution of these issues through the Division of Workers Compensation.

    48. Question 12: Recognizing that we are in a transitional environment, what are some concrete ways that members can help make this effort successful?

    49. Answer: Call and encourage reputable occupational providers with whom you have a rapport to contact the Alliance and fill out the nomination form If they express interest, nominate the provider using the Provider Nomination form on the PSWCA website Encourage hesitant providers (primarily in smaller rural areas) to contact the Alliance

    50. Thank You

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