DWC Amends Rule on UR Credentialing

The Texas Division of Workers’ Compensation has now adopted amendments to a rule that are designed to implement a legislative change mandating UR credentialing changes. The Agency previously posted the proposed rule for review and comment by system stakeholders in November 2020.

The new amendments to Rule 180.1 purport to conform the definition of appropriate credentials with Texas Labor Code §408.0043(c). The rule requires physicians who perform utilization review, independent review, and peer review in the workers’ compensation system to have the same or similar specialty as the physician whose requested medical service is under review.

Background on Proposed Amendment to UR Credentialing Rule

During the 2019 legislative session the Legislature passed Senate Bill 1742, which amended Texas Labor Code §408.0043 and became effective September 1, 2019. Senate Bill 1742 amended portions of the Texas Insurance Code and the Texas Labor Code in several ways, some of which affect the manner in which Utilization Review, Independent Review and Peer Review can be conducted in Texas. Portions of the bill apply directly to Texas workers’ compensation claims both in and out of Health Care Networks.

The bill implemented two broad changes. First, it imposed a Texas licensure requirement in a number of different areas. Second, it required that doctors performing peer reviews, utilization reviews or independent reviews be of the same or a similar specialty as the physician performing the service. For workers’ comp purposes, the bill requires that doctors hold Texas licenses in the following instances:

• • Where a utilization review agent or an insurance carrier uses doctors to perform reviews of health care services in connection with an HCN. Amending § 1305.351(d).
  • Where an independent review organization uses doctors to perform reviews of health care services in connection with an HCN. Amending § 1305.355(d).
  • Where a utilization review agent or an insurance carrier uses doctors to perform reviews of health care services provided under the Texas Workers’ Compensation Act, including utilization review. Amending § 408.023(h).
  • Where an independent review organization uses doctors to perform reviews of health care services provided under the Texas Workers’ Compensation Act. Amending § 413.031(e-2).

In addition, an amendment to § 408.0043 required a peer review doctor or a doctor performing utilization review of a health care service or independent review of a health care service to be of the same or a similar specialty as the physician whose service is being reviewed.

Review this New Rule Carefully

Flahive, Ogden & Latson strongly recommends that carriers review their utilization review, independent review and peer review processes to assure compliance with §408.0043 and newly amended Rule 180.1.