Texas Department of Insurance (TDI)
Workers’ Compensation Working Group
 August 9, 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.

Workers' Compensation Working Group (WCWG)
August 9, 2006 Agenda

Workers' Compensation Working Group (WCWG)
August 9, 2006 Meeting Notes

Audrey Selden welcomed the members and reviewed the antitrust statement. Members introduced themselves.

Update on networks

Margaret Lazaretti reported that a new workers' compensation (WC) network, Corvel Healthcare Corporation, was certified on July 18. Several others are close to being certified. Also TDI has received some WC network area expansions, and will add a column to the report to indicate whether a new network or an expansion of an existing one was approved. Regarding number of covered lives, this information is not collected during the application process.

Margaret explained the new format of the complaint summary. Members had additional questions about some of the complaints. Upon reexamination, staff found a data entry error. Please see revised report attached. At a future WCWG meeting, TDI staff will provide an overview of the complaint process, including the definition of a justified complaint, how a complaint is determined to be justified, and complaint information provided to the public.

TDI will conduct a self-evaluation of the WC network certification process. Please submit suggestions to wcnet@tdi.state.tx.us. TDI will not consider rule changes at this time. Margaret reported that the open conference calls with applicants and interested parties are going well, and open calls with providers will be scheduled soon.

Regarding balance billing, a Commissioner's Bulletin is under review to clarify that an injured employee in a WC network will not be balance billed by any provider, including a non-network, hospital-based provider. During the network certification process, TDI staff checks to see if the hospital-based providers in the proposed WC network are under contract. If they are not, then the applicant must provide an access plan explaining how the hospital-based provider will be paid so that the injured employee is not billed. For example, the hospital-based provider could receive the fee guideline rate, another rate specified in the Labor Code, or the contract rate. Audrey added that TDI would like to partner with provider members to get the word out to providers about "how" they will be paid. Michael Reed agreed to include this information in the upcoming TMA seminars.

Audrey noted that TDI is planning a compliance conference for October 30 - November 1 at the Double Tree Hotel in Austin. Also the Division of Workers' Compensation is holding its annual conference on December 4 and 5. The complaints process, WC networks, and other topics of interest will be covered at the conferences.

WC rule updates

Designated Doctor/Required Medical Examinations: Brent Hatch provided an overview of the adopted rules regarding designated doctor (DD) and required medical exams (RME), see summary attached. Regarding whether these rules apply to WC network patients, RMEs regarding appropriateness of healthcare cannot be requested for network patients. There is a new requirement that a treating doctor provide notice to the employee at the time of exam of the doctor's certification of Maximum Medical Improvement and Evaluation of Permanent Impairment or MMI/IR and the employees' ability to dispute the certification by requesting a benefit review conference (BRC). This notice can be an attachment to the DWC - 69 form and the rule includes language the doctor can use on the form.

Dr. Wilson explained that a recent study by the Texas Orthopedic Association revealed a "political bias" in how designated doctors are selected and asked what TDI has in place to counter this bias. Brent explained that DDs are selected randomly by using a computerized process that matches an employee's injuries to the doctor's experience based on matrices completed by the employee and the doctor. He added that DWC has received some complaints from certain geographic areas within Texas, and he would like to discuss the study and its findings further with Dr. Wilson. TDI will provide a further update on this matter at the next meeting.

Peer review rule and data call: Allen McDonald explained the rule defines peer review, and establishes qualifications for the peer reviewer and requirements for peer review reports and record keeping. Please see attached summary. The peer review data call was sent to the top 25 WC carriers, representing 75 percent of the WC claims. The data call is designed to collect basic information regarding "how many" peer reviews are conducted, and how the information from the peer reviews is used by the carriers. The data call is an Excel spreadsheet designed so that a WC adjuster can enter manually basic information about a review. Carriers will collect data for September and October; the September data is due 11/30. When the peer review data is compiled and analyzed, it will be a great resource to help all parties understand more about the peer review process. DWC will prepare a report on the data, share the report with WCWG and post it on the website.

Hospital fee guidelines: Allen explained that a pre-proposal draft is being developed by a sub-group including all stakeholders. A stakeholder meeting to review the proposed draft will be scheduled in August. TDI hired Ingenix to provide commercial plan data compared to Medicare. TDI has 2004 hospital payment data and is in the process of collecting the 2005 and 2006 data. TDI will update the WCWG when the data is  available. DWC plans to propose the rule in October. Members asked for an analysis of the impact of a fee change on the system before the rule is proposed.

Electronic medical billing: Patricia Gilbert provided information that the rule defines the standard electronic format for medical billing transactions including flexibility for participants to exchange data in non-prescribed formats providing such formats contain all the required elements and code sets defined in the standard formats. Also providers and carriers must exchange medical bill data electronically by January 1, 2008. Please see attached summary.

Status report on performance-based oversight (PBO) system

Teresa Carney thanked the members for their increased participation in the PBO subgroup. Meeting notes and other information about the PBO sub-group are available on a special web resource page at http://www.tdi.state.tx.us/wc/dwc/divisions/pbo.html. To date, they have discussed tiers, placement strategies, and incentives, and whether proposed measures were viable, easy and cost-effective to collect, and provided useful information. The PBO subgroup's next and last scheduled meeting is August 18. All information gathered by the group will be summarized in a paper that will be shared with the WCWG and posted on the website. Next steps include a pre-proposal draft rule. Bonnie Bruce asked whether the PBO project could go forward without the EDI data. Lee Ann Alexander noted that the subgroup felt it was important to include this data and that the PBO process be all-inclusive. An update on the Business Process Improvement (BPI) project will be included at the next WCWG meeting.

Access to care

Allen McDonald said the policy issue is: Does the Approved Doctor List (ADL) increase or hinder access to WC health care?  In order to determine if there is a problem with access to care, TDI is conducting a telephone survey of providers on the ADL list to find out if they are accepting WC patients. A report is due to Commissioner Betts in August. Allen encouraged the members to express their views also. When WC networks and treatment guidelines are in place, then the ADL can be eliminated. Members asked, when the ADL goes away, how will we determine if there is an access problem? Allen explained that complaints information, medical billing data, and physician association surveys will provide this information.

Presentation on Return-to-Work (RTW)

Sam McMurry, Lockheed-Martin, gave a presentation on the company's return-to-work program. Please see PowerPoint slide show attached. Highlights include:

• The company has had a program in place for many years in an effort to reduce WC costs and take care of employees. It has 16,000 employees, and 400 - 700 WC claims.
• Because only an employer can return an employee to work, a successful return-to-work program depends on the employer's commitment.
• The company's current program includes a medical facility, a modified duty program, reasonable accommodations, an emphasis on medical provider relations, and union involvement. Not every employer can provide these resources "in house" though all are key to the success of RTW.
• Statistics compiled by the company over a period of several years showed that, at 40 percent productivity, it is cheaper to have an employee at work (performing modified duty, for example), than to pay temporary income benefits and lose the employee's productivity.
• If the employer gives the employee the expectation that the employee will be coming back to work, then it will happen.

Next meetings: The August 30 and September 20 meetings are canceled. The next WCWG meetings will be held on September 11 and October 11 from 1 p.m. to 4:30 p.m. in Hobby Room 100.

FYI TDI's Compliance Conference will be held in Austin at the Doubletree Hotel on October 30, 31, and November 1, 2006. The Division of Workers' Compensation Compliance Conference will be held at the same location on December 4 and 5, 2006. For more information, please visit the TDI website at http://www.tdi.state.tx.us/company/index.html#compliance. The TDI Compliance Conference online registration form will be posted at that link by the third week in September.

For more information contact: ConsumerProtection@tdi.state.tx.us