1. Division of Workers Compensation Teresa Carney

2. OVERVIEW Workers Compensation Complaints Performance Based Oversight Dispute Resolution

3. Complaint Resolution Complaints are received via mail, fax, e- mail, on-line complaint form Complaints are entered in TDI Complaint Inquiry System (CIS) Acknowledgement letter is sent to complainant

4. Complaint Resolution Request letter is sent to insurance carrier requesting specific information: Resolution to complaint Evidence of compliance Correspondence exchanged Network status

5. Complaint Resolution Carriers have 10 days to respond Response is reviewed by an insurance specialist – is it sufficient? Can the complaint be resolved? Unjustified complaints Violation not detected Complaint is closed Closing correspondence sent to complainant with copy of carrier response Copy of closing correspondence sent to parties

6. Complaint Resolution Justified complaints Violation of statute or rule occurred Resolve complaint (compliance achieved) Closed for monitoring or referred to Audits & Investigations Monitoring/closure letter sent

7. Complaint Statistics – CY 2007 5,322 received through December 3, 2007 4,781 closed 1,716 – Medical Bill Processing 676 – Communication 473 – Fraud allegations 288 – Indemnity Benefit Delivery

8. Complaints Against Carriers Timeliness of Medical Bill Payments Initial submission of the medical bill 45 days to pay or deny the medical bill Reconsiderations 21 days to pay or deny the medical bill Inappropriate denial of medical bills Late income benefit payments TIBs, IIBs, SIBs Failure to comply with orders

9. Complaints Against HCPs Late filings DWC-69, DWC-73, LOC Failure to comply with an order to pay IRO fees for a retrospective medical necessity dispute review. Private claims against the injured employee

10. Audits & Investigations Review complaint referrals Auditor reviews referral for accuracy and complete documentation/evidence Violation determination Violation confirmed Warning letter or penalty recommendation meeting No violation Closure letters

11. Audits & Investigations Conduct audits on system participants FY 08 – poor performers from PBO Other audits as necessary

12. Performance Based Oversight Establishes performance objectives, measures and expectations Encourages and rewards excellence and continuous improvement Focuses on results rather than prescriptive requirements

13. 1. Define Compliance Objectives (Key Regulatory Goals) 2. Measure Overall Performance (Assessments) 3. Report Performance Data (Tiers) 4. Performance Data to Drive Improvement (Incentives) Accountabilit y PBO Steps

14. PBO – Key Regulatory Goals Provide timely and accurate income and medical benefits Encourage safe and timely return of injured employees to productive roles Promote safe and healthy workplaces Ensure each injured employee shall have access to prompt, high-quality, cost-effective medical care

15. PBO – Key Regulatory Goals Increase timely communications within the system Limit disputes to those appropriate and necessary

16. Assessments Conducted at least biennially on insurance carriers and health care providers Conducted through analysis of data Maintained by Division Self-reported data Specified measures

17. Assessment Measures Insurance Carriers Timeliness of initiation of Temporary Income Benefits Timely processing of medical bills Prevailing ratio at Contested Case Hearings Health Care Providers Timeliness of filing Report of Medical Evaluation – DWC 69

18. Regulatory Tiers Poor performers Generally average performers Consistently high performers

19. Incentives Developed by rule Publicly recognize high performers Allow high performer designation as a marketing tool Modified penalties Self audits Tier flexibility

20. PBO Initial Assessment - Details 147 Insurance Carriers 89 Commercial carriers 3 State entities 43 self insureds 12 certified self insureds Selected by volume of IP filings received in CY 2006

21. PBO Initial Assessment - Details 325 Health Care Providers 255 Designated Doctors 267 MDs 12 DC 46 Other Selected based on volume of DWC 69 filings received in CY 2006

22. PBO Results – Insurance Carriers

23. PBO Results – Health Care Providers

24. PBO Results Insurance Carriers 32 in High Tier 95 in Average Tier 20 in Poor Tier Health Care Providers 101 in High Tier 159 in Average Tier 65 in Poor Tier

25. PBO Web Page http://www.tdi.state.tx.us/wc/pbo/pbo.html

26. Dispute Resolution

27. Dispute Resolution Goal To resolve the dispute at the lowest level without a proceeding.

28. Dispute Resolution Processes Medical Dispute Resolution Income Benefit Dispute Resolution

29. Medical Dispute Resolution Preauthorization & Medical Necessity disputes Submitted on TDI form LHL009 Medical Fee disputes Submitted on DWC form DWC060

30. What is Reasonable and Necessary Medical care? Reasonable Meets the standard of care generally accepted by the medical community Necessary Treatment to cure or relieve the effects of the condition caused by the work- related injury

31. Income Benefit Dispute A disputed issue regarding: Compensability Eligibility for, or entitlement to, income or death benefits.

32. Common Types of Income Benefit Disputes Compensability Extent of Injury Disability and Return to Work MMI/IR SIBs

33. Dispute Resolution Process Informal Dispute Resolution Benefit Review Conference Contested Case Hearing Review by Appeals Panel Judicial Review

34. Informal Dispute Resolution Dispute resolution begins once DWC learns a dispute exists. The party requesting a benefit review conference: must certify they have made a good faith effort to resolve the dispute before requesting the conference; and have supporting documentation.

35. Agreements Resolve disputed issues Secure the rights of all parties Are binding on both parties Prevent disputes from resurfacing Provide foundation for resolving other disputed issues

36. Benefit Review Conferences Informal conferences designed to mediate and resolve disputes Identify disputed issues or information needed to resolve disputes Benefit review officer is an impartial individual trained to help parties resolve disputes Two BRCs per disputed issue (max.)

37. Benefit Contested Case Hearings Formal hearings in which evidence is presented and testimony is taken Hearing officers issue written decisions, which are binding, on disputed issues

38. Appeals Panel Three judges assigned to each panel to review appeals of decisions Review is limited to the evidence admitted during the benefit contested case hearing The Hearing Officers decision is allowed to become final or reversed, remanded or a combination of these action

39. Judicial Review Must be filed with appropriate court in county of injury or death Must be filed simultaneously with the court, the Division and served on any opposing party The courts decision must take into account the appeals panel decision on each dispute issue