Insurance Carrier Quarterly Meeting

The Division of Workers’ Compensation held its quarterly meeting on January 10, 2024. It was held virtual, but according to Commissioner Nelson, DWC might go back to in-person meetings as early as this summer. Commissioner Nelson also mentioned that Mary Landrum would be overseeing a possible move from the Fourth Edition to the Sixth Edition of the Guides to the Evaluation of Permanent Impairment.

Dan LaBruyere is the new Deputy Commissioner of Compliance and Investigation. He made several interesting comments. First, he said that enforcement was taking a new direction in assessing the penalty amounts involving violations identified during audits. His statements were consistent with what FOL has seen in recent months, which is a reduction in penalties arising from audits. This is for both initial payment of TIBs audits and medical bill processing audits. He identified the following as his top three issues: failing to process a medical bill within 45 days; failing to timely respond to a claimant’s request; and failing to pay temporary income benefits. There has been a huge increase in the number of medical bill processing violations in the last year. He also identified two areas that the carriers’ need to be watching. First, if a carrier pays a medical bill more than 59 days after its receipt of that initial medical bill, the carrier owes interest. Second, if income benefits are paid late, they are to be paid in a lump sum and the interest on that late payment should be made on the same date as the principal payment. If a carrier fails to timely pay an income benefit, that is a violation. It is yet another violation if the carrier does not pay the interest at the same time it pays the principal amount on that late payment.

The next speaker was Tammy Campion, Deputy Commissioner of Business Process. She was very pleased with the pharmacy cost and utilization report, which is the culmination of more than a decade of work jointly between the carriers and DWC. About a dozen years ago, DWC moved from the open formulary to the closed formulary, which required preauthorization of N status drugs. There were also rule changes that effectively eliminated most compound drugs. Pharmacy costs and prescriptions from 2009 to 2022 dropped by 73%. During that same period, opioid prescriptions dropped by 86%. Generic prescriptions are up by 21%. All of this means a savings to the industry – total health costs dropped 30% over that same period of time. The fiscal year 2024 research agenda will include the Workers’ Compensation Health Care Network report card, the employer participation report, the income benefit adequacy report and the medical cost and utilization report.

Martha Luevano, Director for Enterprise Automation Services, discussed EDI. She provided information to assist with Texas Claim EDI 3.1.4 filing requirements, rejections and updates to registration. For assistance with those issues, email txdwcedi@verisk.com.  For billing, invoices and billing registration email txdwcbillingquestions@verisk.com.  To request training, email edisupport@tdi.texas.gov.

Mary Landrum, Deputy Commissioner of Health and Safety, recommended to those who need assistance in understanding the designated doctor rules, attend a training session at the DWC office on January 26, 2024. DWC is also putting together a return to work video for employers. She indicated that DWC was looking into allowing treating doctors to certify MMI via telemedicine. However, this would not include assigning an impairment rating. Accordingly, it would appear to only apply in those cases in which the treating doctor was of the opinion that the claimant had no permanent impairment.

Santiago Calderon, Director of the Designated Doctor Operations provided a billing and reimbursement rule update. There is a hearing via Zoom on January 23, 2024 at 11:00 AM. The comment period to respond to the proposed rule is January 29, 2024. The proposed effective date of the new rule is June 1, 2024.

Chris D’Amura, Director of Workplace Safety, made a number of carriers and employers happy when he confirmed that there were proposed rule changes to Rules 162.2, 166.3 and 166.5. The purpose is to update the process and to eliminate a lot of the paperwork currently required under those rules.

Kate Sidora, Director of External and Media Relations, noted that during non-legislative years (even numbered years) DWC attempts to amend its rules and forms to reflect recent legislative changes. This would include changes to the death benefit rules and the DWC forms, specifically revisions of the DWC-042 and the PLN-12. The effective date for death claims was on or after June 10, 2023. The changes to the Chapter 132 rules became effective December 11, 2023.

Ms. Sidora also discussed House Bill 90 dealing with Texas military forces, which became effective September 1, 2023. Texas military forces on state active duty and working under authorized orders are eligible to receive workers’ compensation benefits for posttraumatic stress disorder as a compensable injury based on one or more events happening while on state active duty. She also discussed House Bill 2468, which covers traumatic brain injuries in association with LIBs occurring on or after September 1, 2023. After a number of years dealing with archaic terms that defined a traumatic brain injury, the Legislature arrived at one requiring a major permanent neurocognitive disorder that renders the injured employee permanently unemployable. The Bill also expanded coverage for third-degree burns. For first responders, it carved out yet another path for eligibility for lifetime income benefits by adding serious bodily injuries rendering the employee permanently unemployable as a qualifying condition. The Bill does create a right to review by the insurance carrier.  DWC is looking at new forms or updating their current forms to cover the legislative changes involving LIBs.

Erica De La Cruz, Deputy Commissioner of Claims and Customer Services and Teresa Johnson, Director of Outreach and Claims Services, provided information to assist system participants. However, while it might not have been their intent, all of the services that they discussed were services for the injured workers and not for the employers nor for the carriers. However, since they spoke at the carrier quarterly meeting, my impression is that they would be willing to try and assist a carrier or employer if asked.

The Division’s slide presentation can be found here:

https://www.tdi.texas.gov/wc/events/documents/icqm0124.pdf

If you have any questions, please contact James Sheffield at jrs@fol.com.