DWC Publishes 2024 Insurance Carrier Performance Based Oversight Assessment Plan
DWC has published the 2024 Insurance Carrier Performance Based Oversight Assessment Plan. DWC regularly evaluates insurance carriers and health care providers for compliance with Texas Labor Code Sec. 402.075 and DWC Rule 180.19. The assessment plan is reprinted below in full.
For more information, contact PBO@tdi.texas.gov or James Sheffield, FOL Managing Shareholder, at jrs@fol.com.
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Performance Based Oversight
2024 Assessment Plan
Insurance Carriers
The Texas Department of Insurance, Division of Workers’ Compensation (DWC) evaluates the performance of workers’ compensation insurance carriers in selected areas of compliance through Performance Based Oversight assessments. See Texas Labor Code 402.075. Insurance carriers are placed into a high, average, or poor regulatory tier based on the outcome.
There are five measures for the 2024 assessment.
Measures
Insurance carriers will be placed into regulatory tiers based on the following measures:
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- Timely payment of initial temporary income benefits by the insurance carrier.
- Timely reporting of initial payment (IP) data to DWC via Texas Claim EDI Release 3.1.4. Note: This measure will not be factored into the tier placement. See Scoring and Tier Placement on page 2.
- Timely processing of initial medical bills by the insurance carrier.
- Timely processing of requests for reconsideration of medical bills by the insurance carrier.
- Timely reporting of medical data to DWC via Texas Medical State Reporting Release 1.0.
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Selection Criteria
Insurance carriers that reported 20 or more initial payments (IP) of temporary income benefits during the assessment data time frame will be included.
Data Time Frame
The data time frame used to assess performance of the insurance carriers for the above measures will be January 1, 2024, through June 30, 2024.
Data Sources
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- For measures 1 and 2: Texas Claim Release 3.1.4 EDI reports accepted (TA) and accepted with errors (TE) from January 1, 2024, through June 30, 2024.
- For measures 3, 4 and 5: Texas Medical State Release 1.0 EDI reports accepted (TA) and accepted with errors (TE) from January 1, 2024, through June 30, 2024.
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Findings & Rebuttals
For each measure reviewed, DWC will determine whether it was handled timely or untimely using the claim and medical data reported by the insurance carrier during the data time frame. DWC will send findings and tier ratings to insurance carriers through their Austin Representative.
Untimely findings for the following measure will be eligible for rebuttal:
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- Timely payment of initial temporary income benefits by the insurance carrier. Rebuttals must be received by the specified deadline. If a response is not received by the deadline, the findings and tier ratings become final.
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Scoring and Tier Placement
| Measures | Score | Weight | Subtotals |
| 1 – Timely payment of TIBS* | Timely Items Total Items Reviewed |
50 points | Score x 50 |
| 2 – Timely reporting of initial payment of TIBS | Timely Items Total Items Reviewed |
NA | NA |
| 3 – Timeliness of processing initial medical bills | Timely Items Total Items Reviewed |
30 points | Score x 30 |
| 4 – Timeliness of processing requests for reconsideration of medical bills | Timely Items Total Items Reviewed |
10 points | Score x 10 |
| 5 – Timeliness of submission of the EDI medical data | Timely Items Total Items Reviewed |
10 points | Score x 10 |
| *Untimely findings are eligible for rebuttal | Total Score | Add Subtotals |
High Tier: 95.00 or greater
Average Tier: 80.00 through 94.99
Poor Tier: 79.99 or less
PBO Schedule 2024
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- January 1 – June 30: Claim and medical data is reported by insurance carriers to DWC.
- July: Data is reviewed by DWC.
- July: Findings and tier ratings are sent to the insurance carriers with a rebuttal deadline for the eligible categories.
- August: Rebuttals for eligible categories are reviewed.
- September: Final findings and tier ratings are sent to the insurance carriers.
- October: DWC publishes results.
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Publication of Tier Rating
A list of all insurance carriers selected, and their corresponding tier ratings are published on DWC’s website at www.tdi.texas.gov/wc/pbo/index.html.
Impact of Tier Ratings
DWC provides incentives for high performance during PBO. DWC will focus oversight efforts on insurance carriers found to be poor performers in PBO.
The following table describes how PBO tier ratings may affect the insurance carrier during other compliance processes at DWC.
| PBO
Insurance Carrier Tier Rating |
DWC Compliance & Investigations
Audits |
DWC Enforcement
Fines/Penalties |
| High | Exempted* | Consider pursuant to 28 TAC |
| Average | Included if selection criteria are met | Consider pursuant to 28 TAC |
| Poor | Included regardless of whether selection criteria are met | Consider pursuant to 28 TAC |
* DWC may audit high tier performers at its discretion
Recognition of High Performers
High performers will be recognized on DWCs website and will receive a signed certificate from the commissioner which can be used as a marketing tool.
Reminder regarding compliance, investigations, and enforcement.
DWC may impose sanctions on any insurance carrier that commits an administrative violation. The insurance carrier’s PBO tier rating is one of the factors that DWC is required to consider.
DWC considers factors in Texas Labor Code §415.021(c) and 28 TAC §180.26 when determining appropriate enforcement actions.
FOLIO
