Present:  Debra Diaz-Lara, Charles Reyna, Becky Nichols, Olga Escobedo, Dina Bonugli represented HWCN

TOPIC

DISCUSSION/ACTION

FOLLOW-UP

Antitrust Statement

Charles Reyna read the antitrust plan.

Exhibit 11 and Maps

Olga Escobedo was presenter.

We have had inquiries relating to the treating doctor maps, in relation to individual maps of those specialties that have been selected as treating doctors.  We are requiring one map for all treating doctors and we are requiring one map per each specialty that has been selected as a treating doctor.  We have had the question “why do we need to have individual maps for those specialties?”  The answer is the same, we have to assess the configuration for all providers, including individual providers as well as treating doctors.

Q:  I understand that you want a map for each specialty group. 

A:  That is correct.

Q:  Basically what you are saying is ‘I want a map for all treating doctors; I want a map for each specialty designated as a treating doctor, and I want a map for each specialty group such as chiropractors, hand specialists, etc.’

A:  That is correct.  Very well put.

Any other questions on this topic?

We want some input from all of you on discussion topics so that we might have some exciting conference calls.  We really want your suggestions for topics related to any of the exhibits, specifically exhibits 10 and 11 for my group.  If you have topics, please help us out.

Provider Contracts

Charles Reyna was presenter.

Provider contracts are subject to the requirements of Section 10.42.  What we review for are elements laid out in 10.42(b).  There are 14 sub-paragraphs that follow under 10.42(b).   I’ll mention a few of those required provisions that might be interesting.

There is, required under paragraph 1, “hold harmless” except as provided in TIC 1305.451(b)(6) stating the provider contract must include a hold harmless clause stating the provider and provider network will not bill or attempt to collect any amounts of payment from an employee for health care services for a compensable injury under any circumstances, including the insolvency of the insurance carrier or the network.

We also look for a provision relating to the fact there will not be any retaliatory action against a provider or an employee because they have reasonably filed a complaint.

Another provision of interest is the network agrees to furnish the provider and the provider agrees to abide by the list of any treatments or any services that require the network’s pre-authorization, and any procedures to obtain pre-authorization.

Another provision under 10.42(b) relates to Olga’s discussion on the designation as a treating doctor.  A provider contract, if there are requirements that apply to the designation as a treating doctor, must explain and describe what those requirements are.  If there are none, it would be nice to say there are none that go with that designation.

The final provision I’ll mention under 10.42(b)(14) is a statement that the provider specifically agrees to provide treatment for injured employees who obtain workers compensation health care services through the network that is specifically identified in the contract as a contracting party.

If there are any questions, I would be happy to address those at this time.

Q:  Would you expand on that last section, where you say there is a provision about the contracting party and clarification as to what you are actually looking for?

A:  What we are looking for is language that pretty much tracks what I just read, 10.42(b)(14), as follows:  “a statement that the provider specifically agrees to provide treatment for injured employees who obtain workers compensation health care services through the network that is specifically identified in the contract as the contracting party.”  This is what we are looking for in as much as that is what the TAC lays out as required language. 

Q:  Would you give us an example of what TDI would accept as a statement for that provision?

A:  The contract must very clearly state or provide that the provider knows that he or she is providing care to an injured employee that belongs in a network.  So the contract must be specific to that particular requirement.  You can very well use the statutory language for that.  We would accept that. 

Do we have any other questions for Charles?

We have had a couple of very busy weeks here at the Department.  We have certified quite a few new networks in the past ten days.  We would like to welcome the First Health Care Network that was certified on August 15th.  We certified the Genex Services Network on August 18th.  The First Health/Travelers HCN went in as certified on August 18th.  Also on the 18th we certified the network modification service area expansion for the Concentra HCN and Texas Star Network.  On the 21st we certified the Intracorp. Network; on the 22nd the Liberty HCN, and yesterday we certified the First Health/AIGCS Network, so welcome.  We still have quite a few networks in our system that are pending.  We have quite a few that are very close, so we are looking forward to welcoming some new members next week as well. 

At this point I would like to open it up for questions.  Does anyone have any questions for us? 

Audience Questions

Q:  Do you anticipate certifying anyone else this week?

A:  I’m not sure about this week.  We have a couple that are very close but it is depending on what kind of responses we get.  And since it is late on Thursday it probably will not happen until next week.  But we will do our best to get anyone who is in our system and that close, out this week.

Q:  In regards to the material modification, is there a document on line we can refer to?

A:  To submit a modification?

Q:  Yes

A:  Yes.  You must go back to the application itself.  Print out the application and there are some boxes that need to be checked for the network modification, as well as the instructions for what needs to be submitted with that. 

Please keep in mind that in network modifications we will be looking at your proposed expanded service areas, list of providers and we will be doing another credentialing file review for those providers you have added.  We will also require the maps in the same fashion that we did for the initial application, for all the service areas you are proposing to move into.

Also keep in mind in the credentialing file review, we will be looking at contracts.  We want to see that contract in the file review so we can ensure that they have indeed signed on and agreed to participate in a workers compensation health care network, much like Charles talked about earlier this afternoon.

Q:  And that is for every provider?

A:  We expect you to have it for every provider.  In every credentialing file we request, we expect to find that in that file.

Q:  Do you know how many providers you will be asking for, or how many provider files you will be asking for?
A:  It depends on the network size and how extensive it is.

Q:  I got the bulletin on balance billing and hospital providers.  It is helpful and I appreciate it.  I’m trying to think of a policy to ensure (and I don’t think we can ensure) that non-contracted doctors don’t balance bill.  Do you have any guidance there you could help me with, as far as the policy?  Should we put a reminder not to balance bill on the EOB?  I don’t know how else to ensure that they don’t, or help them.  How can we best help you ensure that non-contracted providers don’t balance bill?

A:  For clarification, a non-contracted provider would only be used if, and only if, the services were not available in the network.  So this is not an “EOB” situation, but an access plan situation.  You must have a plan that when an employee must be referred, an approved referral, to non-network providers, you should have a plan that gets you involved from the beginning, where the provider is educated and told about the balance billing position, and how you are going to pay that provider so that balance billing does not occur.  You have to have a plan ready for that.  That’s what we are looking for.

Q:  The non-contracted provider – really the contract that the network provides is paying that provider, right?

A:  If it is a non-network provider who is seeing your injured employee because you don’t have that service within the network, we would expect that you would be proactive in getting with that provider because you know that you are referring outside the network, and discuss that sort of business arrangement early on.

Q:  Once the employee goes to see the non-network provider, then you are saying the network should either call or write a letter to that provider and point out the law is that they cannot balance bill the injured employee, and that the network will be paying according to TDI fee schedule and rules?  Does that work?

A:  I think we need to be a little more proactive.  Before you get to that point, before the member sees them, if they are seeing a non-contracted provider because the service is not available within the network, then you need to be looking at that, at the time that referral is approved and sent out.  I think we should be doing this on the front end, rather than waiting for EOB’s to come out.

Q:  So at the time of referral, then it would be appropriate to contact them either by phone or letter and say you are going to be seeing one of our patients, here is how we are going to pay you.  We will pay you and, by the way, the law says you cannot balance bill.  Is that what you are talking about?

A:  The process that you adopt is your decision, so long as it is exactly that.  Yes, the answer is yes to that.  That is the kind of policy and procedures that we look for or that type of summary that we look for in an access plan.

Let’s quickly talk about the fact that in an emergency situation you may not be able to get involved until you get a claim.  The carrier is liable for it.  But there has to be compensation as well between the carrier and network in situations like that.  So you need to have a plan about how you are going to deal with that situation as well.

Q:  The only thing I can think of is that as soon as the network learns that employee has seen an ER doctor in the emergency room, I guess they could send out the same type of notice.  Is this what you are talking about?

A:  Yes.

Q:  I’m sure you know there is no way for the network to absolutely prevent a non-contracted doctor from billing if that is in the doctor’s head.  Of course it would be a violation of the law, though.  The kind of procedure you are talking about would be very helpful to the system.  I will do everything I can to spread the word to the people I am working with.    

Any other questions, comments, concerns?

I want to encourage everyone to send your comments and questions and topics to us on the WCNet@tdi.state.tx.us email box.  We monitor that on a daily basis, and read it so please feel free to communicate with us there. 

Q: Is everyone finding these calls to still be beneficial?

A:  Yes.

Please send us your suggested topics.  We will be glad to continue the calls.  We will work on next week’s agenda.  We will get the minutes of this call up on our website as quickly as we can.  We are a little behind on our meeting minutes.  We are trying to get those out.  We will get the agenda out for next week as soon as we can.

Q:  Are you going to go over the bulletin?

A:  No, not at this time.  We had not planned to.  Do we need to put that on for next week?

Q:  Yes, that would be good.

A:  OK.  We will put that on for next week.  We do not have the bulletin in front of us at this time. 

Q:  If you are putting that on for next week, one thing I have noticed in some deficiencies are that to make sure the employer knows that his treating doctor does not have to be involved in the ER situation.  I’ve been putting that language in there.  If you could address anything else you need the network to do.  In the notice I am trying to really spell it out that they can go to an emergency room if there is an emergency even if they are in Singapore, it doesn’t matter, just go.  Don’t worry about contacting your treating doctor or the network.  I didn’t know if there is anything else I am missing there.  If you could discuss that.

A:  I believe you have covered everything.  Good comment.