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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 June 2007. 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 June 2007

  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. Summary of Data Call • Division of Workers’ Compensation (Division) issued data call in late July 2006; • This is the first time this type of information has been collected on WC peer reviews; • 25 insurance carriers were asked to submit data on every peer review they received during September and October 2006; • These 25 insurance carriers represented approximately 70% of the medical payments in 2003; and • Data was submitted to the Division at the end of December 2006.

  4. General Data Call Results • A total of 11,437 peer reviews received during Sept/Oct 2006 by the 25 insurance carriers included in the data call; • These peer reviews were conducted on approximately 8,583 WC claims; • Approximately 655 doctors (58% Texas licensed/42% non-Texas licensed) conducted these reviews.

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

  6. 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, 2007. Note 1: Three peer reviews were missing information indicating the “primary reason” they were conducted. Note 2: “Other reasons” include reviews of impairment ratings, adjustment to reserves, etc.

  7. 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, 2007. Note: Forty-three peer reviews were missing information indicating “cost range”.

  8. 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, 2007. Note 1: Forty-five 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.

  9. Type and Licensure of Doctors Performing Peer Reviews

  10. Percentage of Peer Reviews Conducted by Texas/Non-Texas Licensed Doctors by Primary Reason Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note 1: Five peer reviews were missing information indicating the “primary reason” they were conducted or the licensure of the peer review doctor. Note 2: “Other reasons” include reviews of impairment ratings, adjustment to reserves, etc.

  11. 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, 2007. Note 1: Ten peer reviews were missing information indicating the “primary reason” they were conducted or the type of peer review doctor conducting the review. Note 2: “Other reasons” include reviews of impairment ratings, adjustment to reserves, etc. “Other providers” include social workers, nurses, nurse practitioners, etc.

  12. 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, 2007. Note : “Other providers” include social workers, nurses, nurse practitioners, etc.

  13. 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, 2007. Note : “Other providers” include social workers, nurses, nurse practitioners, etc.

  14. Specialties of MD/DO Peer Review Doctors 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, 2007. Note: “Other” include neurosurgery, pediatrics, emergency medicine, internal medicine, colon and rectal surgery, general practice, pathology, etc.

  15. Specialties of MD/DO Peer Review Doctors 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, 2007. Note: “Other” include neurosurgery, pediatrics, emergency medicine, internal medicine, colon and rectal surgery, general practice, pathology, etc.

  16. Specialties of MD/DO Peer Review Doctors Peer 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, 2007. Note: “Other” include anesthesiology, neurosurgery, pediatrics, emergency medicine, internal medicine, colon and rectal surgery, general practice, pathology, etc.

  17. Specialties of MD/DO Peer Review Doctors Peer Reviews Requested With Primary Reason “Ability to Return to Work”, “Treatment Planning/Appropriateness of Course of Care or Medications/Duration of Care Projections”, or “Other Claim Management Actions” Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note: “Other” include general surgery, anesthesiology, neurosurgery, pediatrics, emergency medicine, internal medicine, colon and rectal surgery, general practice, pathology, etc.

  18. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed

  19. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d

  20. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d

  21. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d

  22. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d

  23. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d

  24. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d

  25. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d

  26. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d

  27. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d

  28. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d

  29. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d

  30. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d

  31. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d

  32. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d

  33. Comparison of Peer Review Doctor Specialties with Specialties of Doctors Being Reviewed, Cont’d Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.

  34. Peer Review Opinions and Carrier Actions

  35. 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, 2007.

  36. Peer Review Opinions by Primary Reason Peer Review Was Requested and Texas/Non-Texas Licensure Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note: Non-TX cases for other reason types are not big enough

  37. Peer Review Opinions by Primary Reason Peer Review Was Requested Cont’d Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note1: If “ability to return to work” was one of the reasons PR were requested, peer review doctors provided an opinion regarding return to work status for 62% of those cases. Note2: Peer review opinions for other primary reasons were not included because too few peer reviews reported on individual issues.

  38. Carrier Actions as a Result of Peer Reviews Conducted • Overall, approximately 45% 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). • Approximately 44% of all peer reviews conducted by Texas licensed doctors resulted in some sort of adverse action taken by the insurance carrier. • Approximately 47% of all peer reviews conducted by non-Texas licensed doctors resulted in some sort of adverse action taken by the insurance carrier.

  39. Percentage of Medical Necessity Peer Reviews that Resulted in an Adverse Carrier Action by Texas/Non-Texas Licensure Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.

  40. Carrier Actions Compared to Peer Review Opinions on 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, 2007. Note: “Preauthorization/concurrent Review of Medical Necessity” was the primary reason why peer review is requested.

  41. Carrier Actions Compared to Peer Review Opinions on Retrospective Review of Medical Necessity Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note: “Retrospective Review of Medical Necessity” was the primary reason why peer review is requested.

  42. Carrier Actions Compared to Peer Review Opinions on Extent of Injury/Compensability/Relatedness Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note: “Extent of Injury/compensability/relatedness/validation of injured employee’s diagnosis” was the primary reason why peer review is requested. Analysis for other primary reasons were excluded because too few peer reviews reported on individual issues.

  43. Carrier Actions Compared to Peer Review Opinions on Extent of Injury/Compensability/Relatedness Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007. Note: “Extent of Injury/compensability/relatedness/validation of injured employee’s diagnosis” was the primary reason why peer review is requested.

  44. Information on the Types of Claims Being Reviewed

  45. 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, 2007.

  46. Peer Review Volume Per Claim in the Data Call Period Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.

  47. Approved Doctor List (ADL) Status of Peer Review Doctors

  48. Peer Review Doctor ADL Statusas of July 2006 • Section 408.023 (b) (3), Labor Code, requires all doctors who perform medical peer review in the Texas workers’ compensation system to be on the Division’s Approved Doctor List (ADL). • 359 (55 percent) of the 655 peer review doctors were on the Approved Doctor List (ADL) as of July 2006. • About 20 (6 percent) of the 359 peer review doctors practicing with a temporary ADL Exception as of July 2006. • 8,600 (75 percent) of the 11,437 peer reviews were conducted by the ADL doctors. • 516 of the 8,600 peer reviews were conducted by doctors practicing with a temporary ADL exception as of July 2006. Source: Texas Department of Insurance, Workers’ Compensation Research and Evaluation Group, Analysis of Division’s Peer Review Data Call, 2007.

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