What do the PBO Results for Health Care Providers Tell us about the Texas WC System?

The Performance Based Oversight results for health care providers were posted by the Division of Workers’ Compensation last week. National blogger Dave DePaolo writes that “that report showed an alarming minority, up to 25%, of workers’ compensation treating physicians surveyed failed to complete or filed required work status reports timely or accurately.”

Work status reports and back-to-work documentation are two of four categories under which doctors are assessed through the biennial PBO process for health care providers. Other categories are timeliness in filing medical evaluation forms and filing documents supporting their use of magnetic resonance imaging. Doctors file both forms with insurance carriers and the state Division of Workers’ Compensation.

“The measurements that physicians perform the worst on are the administrative requirements of the DWC, rather than the clinical measurements, which physicians score quite well on,” Warren Cooper, the Texas Medical Association’s director of health care delivery services, told WorkCompCentral.

83 health care providers were reviewed in the latest PBO report, published Monday, for the timeliness of their medical evaluation reports (DWC Form-069). 61 were high performers, 18 were average performers and four were poor performers.

High, average and poor are defined by regulation.

But, of the 124 health care providers reviewed for the completeness of the work status report (DWC Form-073), 55 were high performers, 38 were average performers and 31 had scores placing them in the poor-performer tier.

DePaolo questions whether “work comp paperwork, and subsequent discipline assuming poor ratings, motivated a shift to general health if the circumstances permitted.” In other words, he wonders whether the documentation required in a workers’ compensation claim driving some physicians to encourage their patients to pursue recovery in the group health arena, rather than to pursue their workers’ compensation remedies.

DePaolo is asking the wrong question. The better question upon which to focus, in our view, is to study the effect that a minority of doctors’ failure to complete simple forms in an accurate and timely manner may have on the overpayment of income benefits and the inability of subscribing employers to offer return to work opportunities to their employees.

Everyone knows that one of the things that distinguishes group health from workers’ compensation is the interrelationship between medical status reporting and the delivery of income benefits. When a doctor fails to timely or accurately complete an injured worker’s Work Status Report, the consequences can be hard on both the employer and the employee. The 31 physicians who failed to meet these simple expectations of the system that pays them for their services need to do a much better job, or stop taking comp cases.