1. The IRO Process & How It Relates to Workers’ Compensation Health Care Networks Presenter: Emery Lamar Robinson Title: Training Specialist IV Texas Department of Insurance Health & Workers’ Compensation Network Certification & Quality Assurance Division 333 Guadalupe P. O. Box 149104 Austin, Texas 78714-9104 Mail Code 103-6A Phone: 512-322-2239 Fax: 512-490-1013 Emery.Robinson@tdi.state.tx.us

2. What is an IRO  Independent review organization-An entity that is certified by the Texas Department of Insurance HWCN Division to conduct independent review under Insurance Code chapter 4201 and rules adopted by the commissioner.  [28 TAC RULE §10.2(12)]

3. What is Independent Review  Independent review-A system for final administrative review by an independent review organization of the medical necessity and appropriateness of health care services being provided, proposed to be provided, or that have been provided to an employee.  [28 TAC RULE §10.2(11)]

4. How do you get there?  Adverse determination-A determination, made through utilization review or retrospective review, that the health care services furnished or proposed to be furnished to an employee are not medically necessary or appropriate. [28 TAC RULE §10.2(1)]

5. Labor Code §408.023  A utilization review agent or an insurance carrier that uses doctors to perform reviews of health care services provided under this subtitle, including utilization review and retrospective review, may only use doctors licensed to practice in this state. [Labor Code §408.023(h)]

6. What are the Timelines for Adverse Determinations?  Preauthorization-Third calendar day after the date the request is received. [28 TAC RULE §10.102(g)]  Concurrent hospitalization care- 24 hours. of receipt of the request [28 TAC RULE §10.102(e)]  Post-stabilization treatment or a life-threatening condition- not to exceed one hour from receipt of the request. [28 TAC RULE §10.102(f)]  Retrospective- For adverse determinations made pursuant to retrospective review, the adverse determination must be issued in response to a claim for payment consistent with the timelines set forth in Labor Code §408.027 related to payment of health care providers. [28 TAC RULE §10.102(h)]

7. What about reconsideration of Adverse Determinations?  A person who performs utilization review or retrospective review shall maintain and make available a written description of the reconsideration procedures involving an adverse determination. The reconsideration procedures must be reasonable and include:  A provision stating that a provider other than the provider who made the original adverse determination must perform the reconsideration; [28 TAC RULE §10.103(a)(1)]  A provision that an employee, a person acting on behalf of the employee, or the employee's requesting provider may, not later than the 30th day after the date of issuance of written notification of an adverse determination, request reconsideration of the adverse determination either orally or in writing; [28 TAC RULE §10.103(a)(2)]  Written notification to the requesting party of the determination of the request for reconsideration as soon as practicable, but not later than the 30th day after the date the person performing utilization review or retrospective review received the request. [28 TAC RULE §10.103(5)]

8. What about reconsideration of Adverse Determinations?..cont’d  Notice of the requesting party's right to seek review of the denial by an independent review organization and the procedures for obtaining that review. [28 TAC RULE §10.103(b)(IV)]  Notwithstanding subsection (a) or (b) of this section, an employee with a life-threatening condition is entitled to an immediate review by an independent review organization and is not required to comply with the procedures for a reconsideration of an adverse determination. [28 TAC RULE §10.103(3)(c)]

9. When Must I File An IRO?  A requestor must timely file a request for independent review under subsection (a) of this section as follows:  (1) for a request regarding preauthorization or concurrent review, not later than the 45th day after the date of denial of a reconsideration; or [28 TAC RULE §10.104 (b)(1)]  (2) for a request regarding retrospective medical necessity review, not later than the 45th day after the denial of reconsideration [28 TAC RULE §10.104 (b)(2)]

10. Who do I send the IRO Request To?  Timeliness. A requestor shall file a request for independent review with the insurance carrier (carrier) that actually issued the adverse determination or the carrier's utilization review agent (URA) that actually issued the adverse determination no later than the 45th calendar day after receipt of the denial of reconsideration. The carrier shall notify the Department of a request for an independent review within one working day from the date the request is received by the carrier or its URA. In a preauthorization or concurrent review dispute request, an employee with a life-threatening condition, as defined in §133.305 of this subchapter (relating to MDR--General), is entitled to an immediate review by an IRO and is not required to comply with the procedures for a reconsideration. [28 TAC RULE §133.308(i)]

11. Who Assigns the Independent Review Organization?  The department shall assign the review request to an independent review organization. [28 TAC RULE §10.104 (d)]

12. Texas Administrative Code §133.308(c)  An IRO that uses doctors to perform reviews of health care services provided under this section may only use doctors licensed to practice in Texas.

13. Time Frame For Response by URA/Carrier to the IRO  The URA/Carrier shall provide to the appropriate independent review organization, not later than the third business day after the date the person receives notification of the assignment of the request to an independent review organization:  (A) any medical records of the employee that are relevant to the review;  (B) any documents, including treatment guidelines, used by the person in making the determination. [28 TAC RULE §10.104 (a)(2)]

14. Designated Doctor Exam  Designated Doctor Exam. In performing a review of medical necessity, an IRO may request that the Division require an examination by a designated doctor and direct the employee to attend the examination pursuant to Labor Code §413.031(g) and §408.0041. The IRO request to the Division must be made no later than 10 days after the IRO receives notification of assignment of the IRO. The treating doctor and carrier shall forward a copy of all medical records, diagnostic reports, films, and other medical documents to the designated doctor appointed by the Division, to arrive no later than three working days prior to the scheduled examination. Communication with the designated doctor is prohibited regarding issues not related to the medical necessity dispute. The designated doctor shall complete a report and file it with the IRO, on the form and in the manner prescribed by the Division no later than seven working days after completing the examination. The designated doctor report shall address all issues as directed by the Division. [28 TAC RULE §133.308(n)]

15. Time Frame for IRO Decision The IRO will render a decision as follows:  For life-threatening conditions, no later than eight days after the IRO receipt of the dispute;  For preauthorization and concurrent medical necessity disputes, no later than the 20th day after the IRO receipt of the dispute;  For retrospective medical necessity disputes, no later than the 30th day after the IRO receipt of the IRO fee; and  If a designated doctor examination has been requested by the IRO, the above time frames begin on the date of the IRO receipt of the designated doctor report.  [28 TAC RULE §133.308(o)]

16. IRO Decisions  After an independent review organization's review and decision under this section, a party to a medical dispute that disputes the decision may seek judicial review of the decision. The division of workers' compensation and the department are not considered to be parties to the medical dispute. [28 TAC RULE §10.104 (f)]  A decision of an independent review organization related to a request for preauthorization or concurrent review is binding. The carrier is liable for health care during the pendency of any appeal, and the carrier and network shall comply with the decision. [28 TAC RULE §10.104 (g)]  If judicial review is not sought under this section, the carrier and network shall comply with the independent review organization's decision. [28 TAC RULE §10.104 (h)]

17. IRO Decisions..cont’d  A carrier may claim a defense to a medical necessity dispute if the carrier timely complies with the IRO decision with respect to the medical necessity or appropriateness of health care for an employee. Upon receipt of an IRO decision for a retrospective medical necessity dispute that finds that medical necessity exists, the carrier must review, audit, and process the bill. In addition, the carrier shall tender payment consistent with the IRO decision, and issue a new explanation of benefits (EOB) to reflect the payment within 21 days upon receipt of the IRO decision. [28 TAC §133.308(s)]

18. Network Appeal Procedures  A party to a medical necessity dispute may seek judicial review of a dismissal or the decision as provided in Insurance Code §1305.355 and Chapter 10 of this title (relating to Workers' Compensation Healthcare Networks). [28 TAC §133.308(t)(2)]

19. Who Pays for the IRO?  In network disputes, a preauthorization, concurrent, or retrospective medical necessity dispute for health care provided by a network, the carrier must remit payment to the assigned IRO within 15 days after receipt of an invoice from the IRO. [28 TAC §133.308(r)(1)]

20. What are the IRO Fees?  Fees for independent review shall be based on a two tiered structure of specialty classifications as follows:  (1) Tier one fees will be for independent review of medical or surgical care rendered by a doctor of medicine or doctor of osteopathy. [28 TAC RULE §12.402 (1)]  (2) Tier two fees will be for the independent review in the specialties of podiatry, optometry, dental, audiology, speech- language pathology, master social work, dietetics, professional counseling, psychology, occupational therapy, physical therapy, marriage and family therapy, and chemical dependency counseling, and any subspecialties thereof. [28 TAC RULE §12.402 (2)]  Fees to be paid to independent review organizations by utilization review agents\carriers for each independent review are as follows:  (1) tier one: $650; [28 TAC RULE §12.403 (1)]  (2) tier two: $460. [28 TAC RULE §12.403 (2)]

21. Withdrawal of IRO Request  If a requestor withdraws the request for an IRO decision after the IRO has been assigned by the Department but before the IRO sends the case to an IRO reviewer, the requestor shall pay the IRO a withdrawal fee of $150 within 30 days of the withdrawal. If a requestor withdraws the request for an IRO decision after the case is sent to a reviewer, the requestor shall pay the IRO the full IRO review fee within 30 days of the withdrawal. [28 TAC §133.308(r)(7)]

22. Failure to pay the Fee  Failure to pay or refund the IRO fee may result in enforcement action as authorized by statute and rules. [28 TAC RULE §133.308(r)(4]

23. How to Request an IRO? LHL009 Form Request for Review by an IRO Return to URA/Carrier URA/Carrier sends to TDI- HWCN Division TDI- HWCN Division assigns TDI- HWCN Division sends notification to all parties

24. Where can you get additional information?  A request for independent review must be filed in the form and manner prescribed by the Department. The Department's IRO request form may be obtained from:  The Department's Internet website at www.tdi.state.tx.us; or www.tdi.state.tx.us;  The Health and Worker's Compensation Network Certification and Quality Assurance Division, Mail Code 103-6A, Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104.

25. QUESTIONS? QUESTIONS?