Carrier Quarterly Meeting Report Addresses New Rules, Military Hospital Bills, Plain Language Notices
The Texas Division of Workers’ Compensation had its Carrier Quarterly Meeting on January 22, 2020. Commissioner Cassie Brown presided over the meeting and was in attendance during the entire meeting.
Commissioner Brown opened the meeting by briefly referencing the impact of Senate Bill 935 which deals with federal military treatment facilities as well as the recent rules that have been adopted to implement the changes found in Senate Bill 2551. That legislation deals with cancer presumption cases involving first responders. She also mentioned but did not discuss in detail revisions to the DWC Form – 073, Work Status Report. The revised form will reflect that advanced practice registered nurses (APRNS) may complete and file the form as authorized by House Bill 387. Commissioner Brown also noted that there were some ongoing rule projects and that there would be revisions of the standard interrogatories under Division rule 142.13.
Mary Landrum, Director of the Office of Medical Advisor, discussed the events occurring with her office. The Office conducted a return to work audit based on those health care providers who were identified as poor performers during the most recent Performance Based Oversight evaluation. Concerning medical quality reviews, there were 38 reviews concluding with 61% being referred to Enforcement.
Debra Knight, Deputy Commissioner of Enforcement and Investigations had a number of comments concerning Compliance, violations and PBO. She indicated that there had been 11 indemnity benefit accuracy audits, 30 initial payment of TIBs and data accuracy audits and 18 medical bill processing and data accuracy audits. The lowest performance during those audits was of initial payment of TIBs. The performance level was approximately 72.5%. That is an important point because it is the highest weighted measure for the 2020 PBO. In previous years, initial payment of TIBs was weighted at 40%. It is now 50%. Medical bill processing of the initial medical bill is still 30%; medical bill processing of the request for reconsideration is still at 10%; however, the timeliness of the EDI reporting for the initial payment of TIBs and of medical bill have each been reduced from 10% to 5%.
Ms. Knight also discussed new developments in the Fraud Unit. Jessica “Jess” Bergeman is DWC’s new prosecutor with the Fraud Unit. In 2019, there were 2062 referrals. There are 279 cases currently open. There have been eight referrals for prosecution.
In the year 2019, there were 4,127 violation referrals. Approximately half of them concerned communications. Violation referrals against the carriers were generally delays in the payment of income benefits and medical benefits.
This past year, the Division made a change with respect to the issuance of warning letters. Those warning letters used to be issued by AIM, formerly known as System Monitoring & Oversight (SMO). Now, all warning letters are issued by the Enforcement Division.
Joe McElrath, Deputy Commissioner for Business Process, discussed the use of the DWC-029 which is a Request for Standard Detailed Data Reports. The types of standard detailed data reports that are available using this form relate to timely payment of TIBs and EDI reporting; timely processing of medical bills and EDI reporting; timely processing of reconsideration of medical bills and EDI reporting. Any such request should be emailed to DWC-MA@tdi-texas.gov. Questions concerning the the DWC-029 can be answered by sending the question to DWC-MA@tdi-texas.gov.
Mr. McElrath also discussed the DWC-048 which is now called “Request to Get Reimbursed for Travel Costs.” His comments were actually the result of a discussion between FO&L and the Commissioner several months ago. The DWC-048 is a two page document. Claimants typically send only page one of that two-page document to the carrier. At the bottom of page one, the claimant is required to sign and date it. Page two is significant because it is the page that the adjuster completes. The adjuster must answer question number twelve. If the response is a denial or a partial denial, then the adjuster must explain the reason at box number 13. The adjuster must then identify himself/herself, give the license number and date the document. These are at box numbers 14, 15 and 16. That document would be returned to the claimant. If payment is being made, the payment would be sent with that document.
Amy Lee, Special Advisor to the Division of Workers’ Compensation, wanted to remind everyone that there would be a network data call at the end of January. This would cover not only the certified health care networks but also the 504 Networks (Workers’ Compensation Insurance Coverage for Employees of Political Subdivisions).
Matt Zurek, Deputy Commissioner of Health Care Management, discussed Intrathecal Drug Delivery Systems. See Division rule 134.530 (c). That drug delivery system is preauthorized on an annual basis rather than a monthly basis. His chief point was that claimants should be weaned off the those drug delivery systems rather than having them end abruptly.
Mr. Zurek also discussed federal military treatment facilities. See Senate Bill 935 and Division rules 134.150 and 134.155. A federal military treatment facility is part of the military health system of the United States Department of Defense. The best known federal military treatment facility in Texas is Brooke Army Medical Center (BAMC) in San Antonio. Carriers should take final action on a medical bill from a federal military treatment facility (FMTF) no later than 45 days from receipt of that medical bill. The carrier may only deny a medical bill for medical necessity, compensability, extent of injury or liability. The insurance carrier shall pay 100% of the FMTF’s billed charges for medically necessary services related to the compensable injury. These charges may include any accrued interest, administrative penalties or collection fees. The carrier should fax a copy of the first medical bill received from the FMTF to the Division at (512) 804-4673. The Division needs that first bill to identify the claim for future data requests, monitoring billing and payment and to provide education to the insurance carrier and the injured employee as needed.
Senate Bill 935 was a result of the concept of “balance” billing. The FMTFs were submitting bills to the carriers but if the carrier did not pay the entire amount of the bill, the FMTF would go directly against the claimant for the balance of that bill. The US Treasury Department was garnishing those claimant’s wages and was reducing monies from any tax refunds that the claimant received.
Dan Paschal, Deputy Commissioner of DWC Affairs and Strategic Planning, discussed what the Division is describing as a “Plain Language Initiative”. The concept is that everyone communicate such that the communications can be understood the first time it is read by any person who is reading it. The audience is considered anyone who has contact with that information. The Division is currently reviewing its Plain Language Notices and other standard documents that it sends to the system participants. Its objective is to remove text that is not useful; to have useful headings; to write short sentences, to avoid jargon such as acronyms; to use short simple words. Mr. Paschal’s discussion was in the context of the average population having a reading level between that of seventh and eighth grade.
Some of the topics that were discussed during the Carrier Quarterly Meeting can be found on the Division’s website by going to the specific topics.
If you have any questions or would like to discuss any of these points, please contact James Sheffield, III.
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