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Workers’ Compensation Medical Peer Review Data Call: Comprehensive Results

Workers’ Compensation Medical Peer Review Data Call: Comprehensive Results. Workers’ Compensation Research and Evaluation Group July 2008. Purpose of Division of WC’s Data Call. To collect objective information regarding:

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Workers’ Compensation Medical Peer Review Data Call: Comprehensive Results

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  1. Workers’ Compensation Medical Peer Review Data Call: Comprehensive Results Workers’ Compensation Research and Evaluation Group July 2008

  2. Purpose of Division of WC’s Data Call To collect objective information regarding: • The frequency and cost of peer reviews requested by insurance carriers; • The reasons why peer reviews are requested; • The types (licensure) of doctors performing peer reviews; • The opinions of peer review doctors; and • The actions taken (or not) by insurance carriers as a result of the peer review.

  3. Recent Statutory Changes to WC Medical Peer Reviews • HB 1006 (80th Legislature) required all doctors performing medical reviews, including peer reviews to be Texas licensed – effective September 1, 2007. • HB 2004 (80th Legislature) required all doctors performing medical reviews, including peer reviews be certified in a professional specialty appropriate to the care received by the injured employee – effective September 1, 2007.

  4. Summary of Data Call • Division of Workers’ Compensation (Division) issued a second peer review data call to update the results from the 2006 analysis and to monitor insurance carrier compliance with HB 1003 and HB 1006 Texas licensure requirements for doctors performing peer review and other types of medical reviews; • The same 25 insurance carriers that participated in the 2006 data call were asked to submit data on every peer review they received from November 1, 2007-January 31, 2008; • These 25 insurance carriers represented approximately 70% of the medical payments in 2003.

  5. General Data Call Results • A total of 17,732 peer reviews received by the 25 insurance carriers included in the data call; • These peer reviews were conducted on approximately 12,060 claims; • Approximately 680 Texas licensed doctors (80% Texas Resident/20% Non-Texas Resident) conducted these reviews; • Approximately 4 percent of the peer reviews collected during this data call were conducted by “non doctors,” including PhDs, psychologists, physical therapists; • Approximately 1 percent of the peer reviews collected during this data call were conducted by doctors whose Texas licensure needs verification;

  6. General Data Call Results • Overall, the results from this second peer review data call were similar to the results from the first data call issued by the Division in 2006; • The vast majority of peer reviews are requested by insurance carriers for medical necessity determinations (81% for preauthorization and 8% for retrospective review); • Most of these peer reviews cost between $100-$150 each, with the exception of reviews involving an entire course of care which generally cost more $250 each; • For medical necessity peer reviews, MD/DO/DC peer review doctors generally reviewed the care requested/conducted by other MDs/DOs/DCs; however, there were several preauthorization peer reviews where the provider type match may need further review to determine whether these peer review doctors had the appropriate education and training to conduct the review;

  7. General Data Call Results • The three most frequent medical specialties for MD and DO peer reviewers included occupational medicine, physical medicine and rehabilitation and orthopedic surgery; • Case-level reviews will be necessary to determine whether the professional specialties of peer review doctors are appropriate for the treatment being reviewed in accordance with HB 2004; however, this data call identified the following issues that need to be addressed: • Education is needed regarding the definition of “peer review” and the requirements for doctors performing peer review; • Insurance carriers who have delegated peer review and utilization review functions to multiple entities should institute monitoring programs to ensure that those entities are complying with peer review statutes and regulations; and • The Division may need to examine current preauthorization rules to determine if additional information is needed regarding the type/specialty of the provider requesting preauthorization and/or the worker’s treating doctor in order to assist the carrier in selecting an appropriate type of peer review doctor.

  8. General Data Call Results • Peer review opinions and resulting carrier actions did not vary significantly from the 2006 data call: • Generally half of preauthorization peer reviews resulted in the peer review doctor agreeing that the proposed care was necessary; • Generally a lower percentage (34-39%) of retrospective medical necessity, extent of injury and treatment planning peer reviews resulted in the peer review doctor agreeing that the rendered care was necessary or the injury was work-related; • Approximately 46% of all peer reviews conducted resulted in some sort of adverse action taken by the insurance carrier (e.g., denial of medical necessity, denial of claim, etc.); • Generally insurance carriers followed the opinions of their peer review doctors on medical necessity issues, but did not always follow the opinions of their peer review doctors on compensability/extent of injury and treatment planning issues;

  9. General Data Call Results • Peer review doctor opinions and resulting carrier actions did not vary significantly based on whether the peer review doctor was a Texas resident or not; • Almost half of the peer reviews conducted during the data call focused on older claims (i.e., claims more than one year old); and • The vast majority of the claims (76%) that were reviewed during the data period had only 1 or 2 peer reviews, although a small percentage (4%) had 5 or more peer reviews during the 3 month data call period.

  10. Frequency, Cost and Type of WC Peer Reviews Requested

  11. Percentage of Peer Reviews Conducted by Primary Reason Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2008. Note: “Other reasons” include reviews of impairment ratings, adjustment to reserves, etc.

  12. Percentage of Peer Reviews Conducted by Cost Range Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2008. Note: Ten peer reviews were missing information indicating “cost range.”.

  13. Percentage of Peer Reviews Conducted by Cost Range and Primary Reason Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2008. Note 1: Ten peer reviews were missing information indicating the “primary reason” they were conducted or the cost of the review. Note 2: “Other reasons” include reviews of impairment ratings, adjustment to reserves, etc.

  14. Type and Licensure of Doctors Performing Peer Reviews

  15. Percentage of Peer Reviews Conducted by Type of Doctor and Primary Reason Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2008. Note: “Other reasons” include reviews of impairment ratings, adjustment to reserves, etc. “Other providers” include dentists, podiatrists, PhDs, psychologists, physical therapists, nurse practitioners, etc.

  16. Comparison of Peer Review Doctor Type with Type of Doctors Being Reviewedpreauthorization/concurrent review of medical necessity Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2008. Note : “Other providers” include dentists, podiatrists, PhDs, psychologists, physical therapists, nurse practitioners, etc.

  17. Comparison of Peer Review Doctor Type with Type of Doctors Being Reviewedretrospective review of medical necessity Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2008. Note : “Other providers” include dentists, podiatrists, PhDs, psychologists, physical therapists, nurse practitioners, etc.

  18. Specialties of MD/DO Peer Review DoctorsPeer Reviews Requested With Primary Reason “Preauthorization/Concurrent Review of Medical Necessity” Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2008. Note: “Other” include neurosurgery, pediatrics, emergency medicine, psychiatry, colon and rectal surgery, pain management, pathology, etc.

  19. Specialties of MD/DO Peer Review DoctorsPeer Reviews Requested With Primary Reason “Retrospective Review of Medical Necessity” Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2008. Note: “Other” include neurosurgery, pediatrics, emergency medicine, psychiatry, colon and rectal surgery, pain management, pathology, etc.

  20. Specialties of MD/DO Peer Review DoctorsPeer Reviews Requested With Primary Reason “Extent of Injury/Compensability/Relatedness/Validation of Injured Employee’s Diagnosis” Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2008. Note: “Other” include neurosurgery, pediatrics, emergency medicine, internal medicine, colon and rectal surgery, general practice, pathology, etc.

  21. Specialties of MD/DO Peer Review DoctorsPeer Reviews Requested With Primary Reason “Treatment Planning/Ability to Return to Work/Other reason” Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2008. Note: “Other” include neurosurgery, pediatrics, emergency medicine, internal medicine, colon and rectal surgery, general practice, pathology, etc.

  22. Peer Review Opinions and Carrier Actions

  23. Peer Review Opinions by Primary Reason Peer Review Was Requested Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2008. Note 1: 154 peer review records were missing information indicating the peer review doctor’s “primary opinion.” Note 2: “Other opinions” include requesting a designated doctor opinion, initiating dispute resolution, etc. Note 3: “Ability to return to work” and “other reason” peer reviews were excluded from this analysis due to the low frequency of these types of reviews.

  24. Peer Review Opinions by Primary Reason Peer Review Was Requested and Texas Residency of the Peer Review Doctor Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note 1: “Other opinion” include reviews of impairment ratings, stop loss eligibility, etc.

  25. Carrier Actions as a Result of Peer Reviews Conducted • Overall, approximately 46% of all peer reviews reported in the data call resulted in some sort of adverse action taken by the insurance carrier (e.g., denial of medical necessity, denial of claim, denial of benefits). • Overall, peer review doctor opinions and resulting carrier actions for medical necessity peer reviews did not vary significantly based on the residency of the peer review doctor (i.e., whether the peer review doctor is a Texas resident or not).

  26. Carrier Actions Compared to Peer Review Opinions Peer Reviews Requested With Primary Reason “Preauthorization/Concurrent Review of Medical Necessity” Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2008. Note: “Other Actions” included contact treating doctors, etc.

  27. Carrier Actions Compared to Peer Review Opinions Peer Reviews Requested With Primary Reason “Retrospective Review of Medical Necessity” Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2008. Note: “Other Actions” included contact treating doctors, etc.

  28. Carrier Actions Compared to Peer Review Opinions Peer Reviews Requested With Primary Reason “Extent of Injury/Compensability/Relatedness” Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2008. Note: “Other Actions” included contact treating doctors, etc.

  29. Carrier Actions Compared to Peer Review Opinions on Peer Reviews Requested With Primary Reason “Treatment Planning/Appropriateness of Course of Care or Medications/Duration of Care Projections” Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2008. Note: “Other Actions” included contact treating doctors, etc.

  30. Information on the Types of Claims Being Reviewed

  31. Average Claim Maturity of Claims Being Reviewed During the Data Call Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2008.

  32. Peer Review Volume Per Claim in the Data Call Period (Nov, 2007-Jan, 2008) Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2008.

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