Division Discusses Claim Number Requirement at Carrier Quarterly Meeting

The Division of Workers’ Compensation conducted its quarterly carrier information and EDI meetings in Austin on July 29, 2015. The EDI meeting concluded with a spirited discussion on the most controversial topic – the requirement in new Rule 134.802(a)(3), which defines the term “claim administrator claim number” to highlight that only one claim administrator claim number may be reported through the life of the workers’ compensation claim. This is a problem without an easy solution.

Beginning September 1, 2015, Rule 134.802(a)(3) requires medical bill reporting to include the same claim administrator claim number throughout the life of the claim. This means a subsequent carrier or TPA should be reporting the bill using the prior carrier or TPA’s claim number and not a newly assigned claim number. Teresa Carney, Director of System Monitoring and Oversight for the Division, stated that this requirement is reflected in Release 1 of the IAIABC Guide, which Texas follows. She also stated that the requirement is not new, and that it has long been the Division’s expectation that the original claim number should be reported. Ms. Carney noted that during the rule adoption process for the Chapter 134.800 rules, the Division received no public comment questioning the proposed requirement.

The preamble to the rule adoption order states:

A claim administrator claim number is a unique identifier that is necessary to appropriately match medical EDI data to the workers’ compensation claim. The Division emphasizes that the claim administrator claim number must not change with the acquisition of claims, claim transfer to a different third party administrator, business mergers, or any other reason. The insurance carrier is responsible for ensuring that its agents, including trading partners, have the required data for submission in a medical EDI record.

During the EDI portion of the meeting, several system stakeholder representatives argued that the rule adoption order was unclear, and at least one representative contended that the Division’s interpretation of the IAIABC Guide was contrary to the interpretation of the IAIABC itself. Complying with the reporting requirement presents system challenges for many carriers and the decision whether to enforce the rule as written or to engage in further rulemaking will present new Commissioner Ryan Brannan with the first big policy decision of his administration.

Carriers and TPAs must work closely with their trading partners on this issue. It is a fluid issue and one about which we expect further regulatory guidance to be given in the near future.

The focus of discussion during the primary quarterly meeting was on the collection of data related to compounding of prescription drugs, the upcoming transition to ICD-10, as well as miscellaneous claims EDI issues.

Matt Zurek, Executive Deputy Commissioner for Health Care Management and System Monitoring, provided an update on the agency’s efforts to better collect and analyze compounding drug data. Although the data is not in final form, Mr. Zurek stated that an emerging picture suggests that there have been increases in both prescribing and pricing of compound drugs between 2010 and 2014. This is consistent with anecdotal reports from industry representatives. Mr. Zurek stated that the September 1, 2015, implementation of new reporting requirements for medical bill processing of compound drugs should bring the picture more sharply in focus in the months ahead.

ICD-10 reporting begins on October 1, 2015. Mr. Zurek stated that the agency has been working closely with health care providers and their trade associations to prepare for the transition. Many of the larger practices are ready to make the transition, but the agency believes that the transition will not be a simple process.

The billing requirement is governed by date of service. If the date of service is before October 1, 2015, ICD-9 reporting requirements should be used. Services rendered on or after October 1, 2015 should include ICD-10 reporting. Mr. Zurek emphasized that CMS has adopted a payment policy that precludes health care providers from including pre-October 1 service items and post-October 1 service items on the same bill. Presently, Mr. Zurek says that CMS has encouraged providers to begin reporting data that is “within the family of international classification of diseases” for ICD-10 data. This means that the data need not necessarily extend to the full 7-digit ICD-10 code, but must include at least the first 3-4 digits of the ICD-10 code.

Ms. Carney talked about the claims EDI reporting process. Historically the agency has prioritized the timely and accurate reporting of medical bill data to the exclusion of claims data. This may be coming to an end. The Division has begun issuing educational letters regarding claims EDI data errors. Ms. Carney recommended that carriers and TPA pay attention to the issues raised in those letters because, at some point, those issues may become the subject of more serious enforcement actions. For the time being, the agency’s primary objective will be to compel timelier reporting of claims data. Some carriers, she said, are already making public information requests for their own claims reporting data in order to conduct self-audits of their claims data reporting. Unlike medical data, however, there is no standardized report for such requests and carriers seeking this data must pay the Division for the programming costs required to produce the data.

Mary Landrum, Director of the Division’s Health Care Business Management department, described two plan-based audits that are currently ongoing. The first involves the 10 health care providers who are ordering the highest numbers of functional capacity evaluations. The Office of Medical Advisor is assisting with these audits to determine whether the prescribing providers have an adequate rationale for their FCE prescriptions. This is a labor intensive process for the OMA.

The second audit is reviewing the reporting habits and credentialing of the eight most prolific peer review physicians in the system. The agency is reviewing the reports of those physicians for compliance with Rule 180.28, which contains a detailed description of the reporting requirements for peer reviews. In addition to credentialing, Ms. Landrum stated that the peer review reports are being audited for compliance with the requirements that the providers consider all relevant medical records regarding the claim.

During the EDI meeting, Ms. Carney also touched on an audit issue regarding the Income Benefit Accuracy audits that the agency has been conducting over the last two years. These audits are reviewing the timeliness and accuracy of death benefits and lifetime income benefit payments. Ms. Carney said that carriers should expect these audits to continue. She emphasized the importance of training for DB and LIBs cases.

The Division presentations included PowerPoint slides at both meetings. We anticipate that those PowerPoint presentations will be posted to the DWC website within a week.

If you have questions concerning the issues raised at either of these two meetings, please contact James Sheffield, Steve Tipton, or Bobby Stokes.