Carrier Quarterly Meeting Report Addresses ODG, Proposed Rules and Forms

The most recent Carrier Quarterly Meeting took place on October 28, 2019. DWC’s Commissioner, Cassie Brown presided over the meeting. She indicated that DWC was not recommending any maintenance tax rate increases.

In Mary Landrum’s absence, Marla Brooks discussed the Office of Medical Advisor update. Her comments concerned statistics involving reviews done by the Medical Advisor. Those results are on DWC’s website at https://www.tdi.texas.gov/wc/ci/documents/cqm19-10pres.pdf.

Dr. Stephen Norwood, the Editor and Chief of the ODG discussed Appendix D which identifies exceptions to the treatment guidelines (ODG). The purpose behind the treatment guidelines is to safeguard and to expedite access to quality care while limiting excessive or inappropriate medical treatment. The ODG will now either recommend treatment or conditionally recommend treatment or recommend that treatment is not medically necessary. Appendix D is an exception to the Guides because the Guides do not take into account the unique circumstances of a patient. Thus, Appendix D is a safety net for injured workers. There are three types of treatment that are not addressed in the guidelines. There are as follows: 1) Conditions not commonly seen in workers’ compensation cases; 2) cases in which there is an unusual presentation; and 3) ongoing care of chronic conditions.

Appendix D also addresses “non-recommended” treatment. It looks at extenuating cases and specific circumstances. If a provider is seeking a finding that the services or procedures are medically necessary, yet they are not recommended treatment, the provider should include the following documentation: 1) Information about comorbidities; 2) functional improvements already achieved; 3) measurable goals and progress markers; 4) literature evidence; 5) reduction of treatment link, intensity and complexity (for chronic conditions).

Darrell Cooper who overseas Audits, Investigations and Monitoring discussed Compliance and Investigation update. His discussion focused on administrative violations and allegations of fraud.

Jeff Boyt, Assistant General Counsel discussed rule project updates. He discussed the following bills that were passed during the 2019 Legislative Session: 1) Senate Bill 935 which concerns billing rates for military hospitals. The Division is adopting Division rules 180.150 and 180.155. The effective date is January 1, 2020; 2) Senate Bill 2551 which covers presumption cases under Texas Government Code Chapter 607. The Division has proposed amendments to Division rules 124.2, 124.3, 180.8 and 180.26. The rules were published on October 25, 2019 and are scheduled for a hearing on November 20, 2019. The Division has also issued a first draft of a proposed PLN-14, which is on the Division’s website (https://www.tdi.texas.gov/wc/forms/documents/drpln141019.pdf). That notice or notice similar to it must be used by and insurance carrier to notify an injured employee or beneficiary and the DWC that the insurance carrier still needs to investigate whether the claim qualifies for a statutory presumption under Government Code Chapter 607, Subchapter B and whether the insurance carrier is going to pay income or medical benefits on an injured employee’s claim; 3) House Bill 387 which allows APRNs to sign DWC-73 work status reports; 4) Senate Bill 1742 dealing with URAs and the requirement that they be of a same or similar specialty as the physician who is recommending or providing the treatment.

Joe McElrath, Deputy Commissioner of Business Processes discussed a new DWC form which is a request for standard detailed data reports. DWC has adopted a new form which is a DWC Form 029 which became effective November 4, 2019. Insurance carriers may submit the new form to ask for claim-level data that they have already submitted to DWC. The data will be made available to them or another entity on their behalf through a secure file transfer protocol (SFTP) box. The reports provide the detail related to the insurance carrier performance score cards for timely payment of the initial TIBs, timely processing of the initial medical bills, timely processing of request for reconsiderations as well as the EDI reporting for all three actions.

Amy Lee who is with DWC’s Research and Evaluation Group discussed the network report card. The information that she provided may be found on DWC’s website – Update workers’ compensation listing dated September 30, 2019. The factors DWC considered are as follows: Health care costs, utilization review, employee access to care, employee satisfaction, return to work outcomes and health related outcomes. Certified Health Care Networks still have higher front end costs than non-network claims. However, the total medical costs are reduced over the lifetime of a claim in a certified health care network compared to out of network medical treatment.

Kerry Sullivan, Deputy Commissioner of Hearings discussed BRCs. The Hearings Division has attempted to require carriers to reach agreements concerning the extent of the injury when addressing MMI and impairment rating disputes. The Hearings Division has been threatening administrative violations against the carriers who will not sign such agreements during the BRCs. It appears that only carriers were targeted for the DWC-24 agreements and not the injured workers. When this point was raised by FO&L at the Carrier Quarterly Meeting, Mr. Sullivan passed the question to Alan Craddock, Director of Hearings, who did not directly answer the question. This is a troubling issue that needs to be monitored.