Texas Department of Insurance (TDI) 

Workers' Compensation Working Group

June 14, 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
June 14, 2006 Agenda

Workers' Compensation Working Group (WCWG)
June 14, 2006 Meeting Notes

Audrey Selden welcomed the members and reviewed the antitrust statement.

Update on networks: Margaret Lazaretti reported there are two certified workers' compensation (WC) networks. TDI staff are working on 26 pending filings; some are close to being certified. Margaret thanked the members for providing good suggestions to improve the application process and stated that some of the suggestions have already been implemented. One of the implementations is weekly conference calls that are held each Thursday at 2 p.m. Central Daylight Time; dial 1-888-387-8235 and enter passcode 5751967. The call is an opportunity for network applicants or those planning to apply to talk with TDI staff about issues and questions that are identified.

TDI has received 12 complaints involving WC networks, and five are closed. Individual complaints are investigated, and TDI trends complaints to look for patterns of practice. If a pattern regarding complaints is detected, then TDI will take action; enforcement actions that tie back to complaints can be added to the WC network complaints report. Regarding issues with "silent PPOs" and WC networks, Margaret noted she has received some phone calls alleging activities that may represent "silent PPO" practices, and is expecting written complaints. If written complaints are received, TDI will investigate them. She emphasized that if a pattern is detected, then TDI will do a broader review of all carriers.

Jennifer Ahrens reported that the Commissioner's Bulletin B-0021-06 regarding tailored networks is on the website at http://www.tdi.state.tx.us/bulletins/2006/cc1.html.

Regarding WC network outreach, Audrey noted that TDI is partnering with the Independent Insurance Agents of Texas to reach agents with information about WC networks. She encouraged the members to partner with TDI by requesting a speaker or publications for outreach events. Also a new web resource page for injured employees is available at http://www.tdi.state.tx.us/consumer/wcnetie.html.

Network report cards: Amy Lee provided a first draft of the Proposed WC Network Report Card Topics, Measures and Data Sources (see copy attached). HB 7 requires TDI to produce an annual report card for the WC networks; the first report card is due 18 months from the date of the first certified network (September 2007). Amy asked the members for their comments regarding possible measures, data sources, and timing. Regarding the proposed measures, they should be important to all stakeholders, quantifiable, based on available data that TDI has access to or can be accessed without additional cost or time, and applicable to all WC networks. The first draft report card is based on medical data and claim data currently collected by DWC and a survey that will be conducted via a contract with a university-based survey center.

Regarding the two types of claims that WC networks will have, non-network legacy claims and new claims, Amy asked whether the report card should measure both types, and if so, measure them separately or together. Members' comments included:

• Measure both types, and measure them separately.
• Develop clear categories and definitions for each type of claim.
• Coordinate the development of the report card with the annual WC Network Quality Improvement plan so the two efforts are complementary, not duplicative.

Regarding the case mix, an approach to consider is the WC network performance measures developed by URAC; for more information please click on http://www.urac.org/savedfiles/WorkersCompPerformanceMeasures.pdf. URAC's model groups injuries "like with like." Another approach is to weight injuries via their distribution among the whole population.

Regarding the time period for claims evaluation, the best approach may be six months post-injury. Medical billing data will be available in January and February 2007, so TDI will know if they have adequate information to use. At that time, Amy will come back to the WCWG with an update about the data TDI will use for the first report card. She added that the parameters for the second report card (due in 2008) can be revisited as more data becomes available. Also, in February or March 2007, TDI will issue a data call to determine "who is treated by a network" and to validate the medical claims data as to the network/non-network claims. Amy reminded carriers they should begin to collect this information now and she can provide assistance with formats to use for this purpose.

Regarding how the report card should be used, comments included:

• Creg Parks said a report card is a way to identify best practices, similar to the way HEDIS data is used about HMOs. Suggest including a provider satisfaction survey as well. Also consider adding "was the injured employee given a bona fide offer of employment."
• Joe Woods explained that using the report card as the basis for a comparison shopping guide to increase competition in the market, rather than as a regulatory tool, is a good idea.
• Lee Ann Alexander said outcomes are important, TDI should take a wholistic approach.
• Pam Beachley disagreed with the approach that a network had to have a certain claim volume in order to be in the report card.

Amy asked those who wish to join a technical sub-group to contact her at amy.lee@tdi.state.tx.us. Members may wish to ask technical experts in their organizations to participate or recommend experts who could serve on the sub-group.

Commissioner Albert Betts expressed his appreciation to the members for their participation in the WCWG. He emphasized the importance of attendance at sub-group meetings; if the member cannot attend, then please send a representative. At the July 12 meeting, he asked the members to come prepared to tell him what they want from the WC system and their role in making this happen.

Status report on peer review data call: Allen McDonald reported that the sub-group needs to move forward faster, without push back from the various stakeholders. TDI is requesting this data because it is needed in order to make policy decisions and provide factual answers to legislators' questions about peer reviews. TDI is asking the stakeholders to help create the data call rather than provide copies of every peer review document. Pilot testing the data call with one carrier is a great idea, and TDI will do this once there is agreement about the data elements and method for gathering the data. He reminded the group that peer review applies to both network and non-network claims. Those who wish to join the peer review sub-group are invited to send an e-mail to allen.mcdonald@tdi.state.tx.us. Please see copy attached of the Peer Review Subgroup June 6, 2006, meeting summary.

Status report on performance-based oversight: Teresa Carney reviewed the timeline for developing the performance-based oversight (PBO) system. The PBO sub-group meets weekly on Wednesday mornings from 9:30 a.m. to 11:30 a.m. in the Tippy Foster Room at TDI-Metro. Three members attended the June 14 meeting. Members of this sub-group should plan to attend each meeting or send a representative. All observers are welcome to the meetings and to participate. Key project dates include:

• May 2006: Key regulatory goals reviewed by the WCWG; we are going forward with six goals.
• July 2006: Assessment, incentives, and tiers discussed.
• September 2006: Initiate and complete first assessment.
• October 2006: Place carriers into tiers using PBO system.

Amy Lee explained both she and Teresa actively participate in both the PBO and report card sub-groups, and are coordinating data collection and other efforts.

HB 251 rule development: Joseph Montoya provided a draft concept paper on the HB 251 rules (see copy attached) regarding the dispute between a WC carrier and a health carrier, also called a medical carrier. Suggestions from WCWG members include:

• Add provisions to make sure carriers only access data about their insureds.
• Inform the employee that data has been requested about the employee's claims.
• Add a notice provision to the rule.

TDI will research the notice requirement and report back to the WCWG.

Open discussion: Dr. Norwood noted that the Medical Quality Review Panel (MQRP) is restarting, and asked what kind of oversight it has over WC network doctors and what usefulness it has in the WC system, and suggested that a rule may be needed about its role. Allen McDonald explained that the MQRP has purview over all providers, both network and non-network.

Dr. Gude asked about the status of the treatment guidelines rule. Allen said he is convening an internal team and will provide a status report at the July 12 WCWG meeting. The hospital fee guideline sub-group is meeting on June 22.

Nick Huestis noted that the designated doctor provision is expiring and there is no training/certification program in place. Chuck Whitacre said that physicians can apply to Dr. Ford for an exception and receive an extension. Brent Hatch added that DWC is working on a rule as well as the training component including classes and training vendors. The plan is to roll out the rule and the training program at the same time. Brent will provide an update at a future WCWG meeting.

Next meeting: July 12, 1:00 p.m to 4:30 p.m., Room 100 - TDI Hobby

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