Advisory 2000-06

Update to Commission Changes in
Medical Dispute Resolution Process

Last April the Commission issued Advisory 2000-02 concerning changes to the medical dispute resolution process, including the beginning of a field office pilot project. This Advisory discusses progress and announces an address change for medical disputes regarding fees.

FEE DISPUTES:
As a result of its very successful pilot project regarding medical fee dispute resolution, the Commission has established a Center of Excellence (COE) in Waco to focus on fee disputes. The Medical Fee Dispute COE will be managed by a registered nurse. This team includes experienced nurses and experienced TWCC customer assistance personnel. The Center became operational August 14^th and will start receiving new medical fee disputes as of September 1^st.

Effective September 1^st, all medical fee disputes should be mailed to:

Texas Workers’ Compensation Commission
Medical Fee Dispute Resolution COE
801 Austin Avenue, Suite 1010
Waco, Texas 76701

All other medical disputes, including medical necessity and preauthorization, even if they include a fee component, should continue to be sent to the TWCC Central Office in Austin.

The Waco COE will continue the practice established in the pilot program of scheduling disputes for resolution. Parties will be notified by fax or email approximately two weeks prior to the scheduled consideration date. Parties who wish to participate will do so by telephone.

Participation by the parties is voluntary. Mediated resolutions will be encouraged. If no agreement is reached, TWCC will make decisions based on the information available to the MDR officer at that time. If the parties reach an agreement prior to the dispute being considered by the Waco COE staff, the fee for dispute resolution will be waived.

The Waco COE expects initially to resolve disputes within three weeks. However, research has shown that as resolution times decrease, the volume of disputes increase. The agency will closely monitor volumes to ensure that resolution times at the center can be kept to 30 days or less. TWCC is also beginning a process for evaluating the causes of fee disputes to determine how it can pro-actively reduce the number of fee disputes.

A team in the Commission’s Central Office will focus on eliminating the 2,500 disputes currently in its backlog. This backlog should be eliminated by year-end.

PREAUTHORIZATION DISPUTES:
As a result of recent Commission medical billing rule changes and other process changes, the average time to resolve pre-authorization disputes will be down to 25 days (from 39 days) by September 1^st. Additional process changes are underway and we expect further improvement by year-end.

MEDICAL NECESSITY DISPUTES:
A number of initiatives are underway and will be announced at a later time.

SUMMARY:
Our customers will see a dramatic change in the handling of new fee disputes submitted to the Waco Center after September 1^st. Resolution times for pre-authorization will have been cut in half this year. We will be announcing significant improvements to our Medical Necessity Dispute Resolution process in the near future.

Signed this 28^th day of August, 2000 

 Leonard W. Riley, Executive Director

Distribution:      TWCC Staff
                            Public Information List
                            Commission Representatives
                            Professional Medical Associations

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