Texas Department of Insurance (TDI)
Workers’ Compensation Working Group
July 12, 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)
July 12, 2006 Agenda

Workers' Compensation Working Group (WCWG)
July 12, 2006 Meeting Notes

Audrey Selden reviewed the antitrust statement and members introduced themselves.

Update on networks: Jennifer Ahrens announced there are now three WC networks, TDI certified Memorial Hermann, a network primarily for Harris County, at the end of June. Additional networks will likely be certified by the end of July. No applications have been withdrawn. She reported that the weekly conference calls with network applicants and interested parties, as well as conference calls with individual applicants, are working well. TDI's HWCN staff are also developing a newsletter about WC networks. Please continue to send suggestions about how to improve the network process to Jennifer at jennifer.ahrens@tdi.state.tx.us or Margaret Lazaretti at margaret.lazaretti@tdi.state.tx.us. Jennifer reviewed the WC networks complaint summary: 17 have been received and 11 are closed. "Accessibility/availability" indicates that the complaints involved incomplete directories provided via websites, not access to care issues. HWCN staff is also revising the report to make it more informative for WCWG.

Regarding outreach efforts, Audrey announced that a special web resource page for injured employees is available at http://www.tdi.state.tx.us/consumer/wcnetie.html. The page includes a "virtual workshop" on WC networks and links to OIEC's web page and the Rights and Responsibilities for Injured Employees; TDI is having the Rights and Responsibilities translated into Chinese, Korean, and Vietnamese. Next TDI will develop a web resource page for providers. All suggestions for the page are welcome; please send ideas to wcwg@tdi.state.tx.us. When the page is "live," TDI will partner with TMA to distribute the web link to providers. Members reviewed the list of outreach events. Audrey noted that audiences are very receptive and there continues to be a need for information about WC networks and other changes resulting from HB 7. Please continue to invite TDI to events.

Lindsay Johnson asked, could the resource pages include information about how an employee or a provider determines whether the employee or patient is in a WC network? As required by HB 7, when employers choose to be in a WC network they are required to notify employees about the new WC network. If an employee is in a WC network, then the employee should have received such a notice. If an employee is not sure, the employee should contact the company's HR department. TDI will verify this is explained clearly on the web resource pages.

Regarding a situation in which an organization implied that it was "working with TDI" on education/outreach efforts, Commissioner Albert Betts said that TDI is not aware of any organizations doing this; however, please let TDI know if an organization is charging money for such activities. He added that though TDI's efforts are successful in getting the word out, TDI still needs to do more, especially regarding provider education. Members can help by inviting TDI to exhibit at events or provide a speaker for a meeting.

Open discussion: Commissioner Betts asked the members about their expectations for the WC system and for TDI, and how they feel the implementation of HB 7 reforms is going. Members' comments are summarized below.

• Creg Parks commended TDI, he sees movement and that TDI is getting things done. He would like to see more action regarding access to care and more doctors taking WC patients. He asked if non-network injured employees may access a network physician if they cannot find another doctor. Regarding the suggestion to designate an ombudsman for providers, Jennifer suggested that we use the weekly conference call model and host a separate call for providers. Also TDI can facilitate communication between providers and carriers. Providers may send specific questions to wcwg@tdi.state.tx.us and TDI will add the answers to the providers FAQs web page. Providers who are not currently on the DWC providers e-mail list may wish to join; please contact Chuck Whitacre at chuck.whitacre@tdi.state.tx.us.
• Regarding issues reported to TMA, Michael Reed said that providers want injured employees to have access to the best care possible. He added that, at the same time, physicians are having to negotiate WC network contracts with the carriers, and the carriers are not offering good rates. Another issue is that administrative burdens remain high for providers to submit WC claims. A recent survey showed that it cost a provider on average about $20 to prepare a paper WC claim, much higher than the $2-$3 cost of a typical electronic health care claim. Also providers often must file a WC claim multiple times. Pam Beachley explained that the paperwork comes from the WC compensability issue and a carrier's responsibility to verify every claim is related to WC (injury on the job), not group health (pre-existing condition). Jaylene Fayhee noted that the proposed treatment guidelines will help. Creg Parks added that electronic access to an injured worker's medical record would also help. Commissioner Betts noted the e-billing rule has a 2008 effective date, and that the treatment guidelines will be adopted in early August 2006.
• Creg Parks said the biggest problem providers have is that their WC claims are "lost" and there is no one designated at the carrier or at DWC who the provider can call for help.
• Rick Levy observed there is a definite change in the atmosphere. His biggest fear/disappointment is with the WC networks - he feels there is no real doctor choice and the WC networks do not look like group health. If the injured worker goes to the "wrong" doctor and has to pay, then there will be problems. Jennifer explained that TDI is seriously looking into access to care issues. At the same time, WC networks will not always look like group health networks, particularly because the population served by the WC networks is much smaller than that served by group health networks. TDI has to balance the need to get physicians into WC and the requirement to get WC networks off the ground. She added that some WC network applications remain pending because their proposed networks are not adequate.
• Michael Reed stated that in-network WC patients are being balance billed now, by providers who are not in the certified WC networks. Such occurrences should be reported as a complaint immediately to Margaret Lazaretti, please send an e-mail to margaret.lazaretti@tdi.state.tx.us. Under no circumstances should a WC patient who is not in a network be balance billed.
• Lindsay Johnson observed that WC networks will never look like group health because of the indemnity concern. He would like to see more emphasis on return-to-work outcomes.

Commissioner Betts introduced Stan Strickland, the new DWC Deputy Commissioner for Legal & Compliance. Stan is the former Chief of the Financial section of TDI Legal & Compliance, and brings more than 12 years of TDI experience to his new job. Stan will oversee rule development as well as violation referrals.

WC rule updates:

• Peer review rule and data call: Allen McDonald said the designated doctor/required medical exam/peer review rules will be adopted by the end of July 2006. DWC is working with the WCWG sub-group to finalize the data elements for the peer review data call. It will be in the form of an Excel spreadsheet sent to the carriers who will get the data from their TPAs, if applicable. DWC will request two or three months of data starting with August 2006. Carriers may wish to contact their TPAs to begin preparations now. Allen said that the pre-authorization data call will be suspended, and this will be announced soon. Commissioner Betts said that if a carrier refuses to provide the peer review data he will contact the carrier, and an enforcement action will follow if necessary.
• Hospital fee guidelines: Allen explained that the hospital fee guidelines are based on Medicare. He urged members to take time to understand Medicare - it is based on prospective payment followed by adjustments and reconciliation, and is complex. DWC will modify the Medicare model to make it work for WC.
• HB 251: Patricia Gilbert explained the proposed rule will govern the release of data to carriers that will allow them to settle subrogated claims. DWC will receive data from carriers, match it to WC claim information, and return it to the carriers. The proposed rule is on a fast track and will likely be adopted in September/October 2006. The rule includes a notice requirement to injured employees, as well as a fraud check.

Status report on performance-based oversight: Teresa Carney reviewed the discussion paper provided to the WCWG (see copy attached). The scope of this sub-group has been expanded to include placement of carriers and providers into tiers, and incentives. Bonnie Bruce urged WCWG members to participate in this sub-group; meetings are scheduled every Wednesday morning from 9 a.m. to noon in the Tippy Foster room at Metro. Teresa will arrange for members to participate via conference call. Audrey suggested members adopt the "three-deep" concept and send an alternate to represent them at the meetings. Also, members will continue to review and discuss the draft PBO concept paper at future WCWG meetings. Members are welcome to submit their written comments and suggestions for PBO to wcwg@tdi.state.tx.us. In particular, Teresa asked the members to consider the following questions and send responses to TDI.

1. Does Section 402.075 of the Texas Labor Code envision three simple tiers for all participants, or something more complex?
2. Should the placement of system participants into a tier be done relative to a performance standard, relative to each other (bell curve), or via a combination of these?
   • What should the performance standards be?
   • If the bell curve is used, what percentage of participants should be on each tier?
   • If the entire curve of participants falls well below any reasonable standard of acceptable performance, is it really appropriate to call any of them high performers?
   • If a high percentage of participants have performance above 95%, or some other pre-determined number, is it appropriate to call any of them average or poor performers?
3. Should participants with a data volume in the review period that is insufficient for statistical analysis be placed in the Average Tier? Placed into a Default Tier? Not be tiered at all? Performance assessed and placed into sub-tiers?
4. Should participants be able to appeal their placement in a tier, and if so, how do you envision the appeals process would work?
5. Should each new performance assessment and tier placement be done without regard for the previous one (i.e., "clean slate")?
6. For participants with a data volume in the review period that is sufficient for statistical analysis, is it necessary to distinguish between larger volume participants and smaller volume participants if everyone's performance is expressed as a percentage? (Example: A carrier processes medical bills timely X% of the time, where the numerator is the number of timely processed bills in the review period and the denominator is the total number of bills received in the review period.)
7. How should a participant's performance assessments relative to multiple KRGs be combined to achieve a final tier placement?

   Should individual KRGs or Measures be weighted, and if so, how?

At the July 19 meeting, the sub-group will focus on the remaining two key regulatory goals:

• Ensure each injured employee shall have access to prompt, high-quality, cost-effective medical care and
• Limit disputes to those appropriate and necessary.

TDI has set up a special PBO sub-group conference call dial-in number with passcode. The PBO sub-group meetings are on Wednesdays and begin at 9 a.m. Central Daylight Time. To participate in the sub-group meetings via conference call, please follow the instructions below.

1. Dial in: 1-888-391-2102
2. Enter the passcode: 9063381#

Review WCWG topics list: Members discussed the topics suggested at prior meetings; please see list below - those in bold indicate priority topics.

• Access to care
• Conversion of legacy claims to network
• Credentialing
• Criteria TDI uses to look at access issues
• Disability management model and its components: treatment guidelines, treatment planning, the role of the designated doctor, and return to work
• Employee acknowledgment forms - challenges and best practices
• How a physician determines if a patient is in or out of a network
• Independent review organization (IRO) guidelines
• Leased and "ghost" networks and "silent" PPOs
• Physician credentialing
• Preauthorization
• Referral procedures - does the network control where the physician refers a patient?
• Report card content and development process
• Reports from other working groups about related topics
• Survey of physicians
• Updates on rules
• Utilization review agent/IRO process - overview

Additional topics to indicate as priorities include return-to-work guidelines, balance billing of WC patients, and the disability management model. Members also would like a report on the results of the peer review data call. In addition, members suggested that TDI alert the certified WC networks to the fact that interested persons are checking the "doctor lookup" features on their web pages, and the lookup lists should be complete and up to date.

Next meeting: August 9, 2006, 1 p.m. to 4:30 p.m., Room 100, Hobby Building

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