Texas Department of Insurance

System Monitoring and Oversight

System Monitoring and Oversight consist of three different program areas which encourage fair treatment of system participants and the prompt delivery of benefits payments.

• Performance Based Oversight (PBO) and Monitoring & Analysis
• Complaint Resolution
• Audit & Investigations

Performance Based Oversight Regulatory System (PBO) and Monitoring & Analysis

Performance Based Oversight (PBO) monitors system participants’ compliance with the Texas Labor Code and Rules.  PBO objectives are achieved through monitoring electronic and paper data, complaint handling, entity audits, and enforcement actions.  PBO encourages and rewards excellence and continuous improvement; fosters improved and timely communications; establishes performance objectives, measures and expectations and focuses on results rather than prescriptive requirements. 

• Learn More About PBO
• 2009 Performance Based Oversight Results 

Monitoring and Analysis (M&A) monitors complaints, disputes, the quality and quantity of system participants’ data submissions.  M&A’s objectives are achieved through monitoring of electronic data submitted to the Texas Department of Insurance, Division of Workers’ Compensation. 

   
Medical Bill Quarterly Reports

TDI-DWC initiated additional audits of reporting medical billing and payment data for certain insurance carriers.  Quarterly reports on medical billing and payment data should be provided using the MS Excel reporting template provided below. 

Medical Bill Quarterly Report Template - as of 3/20/2009, NEW Template containing clarification of requested information 

Carrier Quarterly Compliance Meetings

• 7/23/09 agenda, MFDR Handout, TPA Handout, PowerPoint Presentation
• 4/23/09 agenda, MFDR Handout, PowerPoint Presentation
• 1/21/09 agenda
• 10/22/08 agenda
• 7/16/08 agenda
• 4/23/08 agenda
• 1/23/08 agenda 

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Complaint Resolution

Complaint Resolution seeks to encourage communications and assists Texas workers’ compensation system participants in resolving complaints.  In this process, the staff examines complaints for compliance with the Texas Labor Code and DWC Rules and makes referrals to the Audit and Investigation section of System Monitoring and Oversight when appropriate.  The complaint resolution process routinely results in additional claims payments to system participants. 

• File a complaint related to a WC system participant
• Dispute vs Complaint Fast Facts
• CY 2009 Complaint Information
• CY 2008 Complaint Information
• CY 2007 Complaint Information
• Complaint Information Key

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Audits & Investigations

   
Audits & Investigations conducts compliance and performance audits of workers’ compensation system participants and prepares justified complaints for enforcement action within the Texas Labor Code and DWC Rules. 

• Audit Plan FY2010
• Audit Plan FY2009
• Audit Plan FY2008
• Summary of Changes (IP Audit, IP Data Accuracy, DWC-69 Audit)
• Audit Results FY2008    

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2009 PBO Assessments Page
Go to 2007 PBO Assessments Page

For more information contact: