1. A Guide to Workers’ Compensation Health Care Networks
HWCN Division
Texas Department of Insurance

2. Goals of House Bill (HB) 7
Each employee shall be treated with dignity and respect when injured on the job
Each injured employee shall have access to a fair and accessible dispute resolution process
Each injured employee shall have access to prompt, high-quality medical care within the framework established by the Texas Workers’ Compensation Act
Each injured employee shall receive services to facilitate the employee’s return to employment as soon as it is considered safe and appropriate by the employee’s health care provider
During the 79th Regular Legislative Session the Legislature enacted HB7. On this slide are the goals of the bill.

3. Goals for WC Networks
Authorize the establishment of workers’ compensation health care networks for the provision of workers’ compensation medical benefits
Provide standards for the certification, administration, evaluation, and enforcement of the delivery of health care services to injured employees by networks
HB 7 authorizes the establishment and certification of workers compensation health care networks to provide health care to injured workers.
The bill provides a framework for certifying the networks, for evaluating their performance and for enforcing the statutes and regulations related to the networks’ delivery of health care services.

4. What is a “Workers' Compensation Health Care Network”?
An organization that is:
Formed to provide health care services to injured employees
Certified in accordance with Insurance Code Chapter 1305 and Commissioner rules
Established by, or operating under contract with, an insurance carrier
A workers compensation health care network is an organization that is formed to provide care to injured workers. The network must be certified by TDI as required by Insurance Code Chapter 1305 and Title 28, Texas Administrative Code, Part ____ Chapter 10. Insurance carriers (including certified self-insured employers and certain self-insured governmental entities) may establish or contract with a certified network to provide care to injured workers.

5. Who can be a WC network? Examples include: Individual Partnership
Association
Corporation
Organization
Trust
Limited liability companies and partnership
Hospital district
Community mental health centers, mental health and mental retardation center
HMO
PPO
This slide lists examples of the types of entities that can form a workers compensation health care network.

6. Certification Process
Application – 26 pending
Two certified networks
Texas Star Network/Concentra
Concentra HCN
60-day review by TDI
Applicant may request an extension
TDI may deny request for extension
As of the HWCN Division has 26 pending applications for network certification and has certified 2 networks: Texas Star Network/Concentra and Concentra HCN. When a network files a complete application for certification including all required exhibits, the Department reviews the completed application for compliance with the applicable statutes and regulations. TDI has 60 days to complete the review and approve or deny the application. If an applicant is unable to achieve compliance with the certification requirements within this time, the applicant may request an extension of the 60 day period. The Department can deny this request.

7. Major Components of Application
Officers and directors biographical affidavits
Insurance carrier, provider & third-party contracts
Management contracts
Financial information including a business plan
Service area description and maps
List of contracted, credentialed providers
Proof of accessible, available, comprehensive care
Treatment and return to work guidelines
Monitoring plan for providers
Doctor and health care practitioner financial disclosure
Components of an application for network certification include information such as:
The applicant’s basic organizational structure and biographical affidavits for its officers and directors.
A copy of the forms of the network’s contracts with insurance carriers, network providers, and third-parties.
Executed management contracts.
Financial statements and a business plan
Service area description and maps identifying each county, part of a county or zip code to be served
Lists of contracted, credential physicians and providers including addresses, medical specialties, and indicate whether the provider is accepting new patients and which providers are certified to perform maximum medical impr4ovement determinations and impairment rating services.
Proof that the network has sufficient number of contracted physicians and providers that are accessible and available to furnish all required health care services .
A description of the network’s treatment guidelines and return-to work guidelines and the network medical director’s certification that the guidelines are evidence-based, scientifically valid, and outcome-focused as required by statute.
A plan for monitoring whether providers have been provided and are following these guidelines.
A plan for obtaining doctor and provider certification of filing the required financial disclosure with DWC.

8. Texas Star Network Service Area
This slide is an example of a service area map for Texas Star Network which is a certified network.

9. Concentra HCN Service Area
This slide represents the Concentra HCN service area map. Concentra HCN is also a certified network.

10. Provider Contracts Network application includes:
Copy of the form of any contract with
Providers
Group of Providers
Contracts are confidential
Contracts are not subject to disclosure as an open record
A network’s application for certification must include a copy of the form of any contract with providers or with a group of providers. It is important to note that the form of the contract is confidential and is not subject to disclosure as an open record.

11. Requirements for Provider Contracts
No transfer of risk
Hold-harmless clause for injured employees
Provider agrees to network treatment guidelines
No denial based solely on treatment not listed on treatment guidelines
Continuity of treatment/90 days
Provider appeal process for terminations
Advance notice of economic profiling
No retaliation for filing complaints or appeals on behalf of injured employees
Network contracts with providers must comply with certain statutory and regulatory requirements. For example:
A network contract or subcontract with provider cannot be construed to involve a transfer of risk.
A contract must contain a hold-harmless clause that prohibits the contracted provider from billing the patient.
The provider must agree to follow the network’s treatment and return-to-work guidelines.
Treatment cannot be denied solely on the basis that the treatment is not listed in the treatment guidelines.
The contract must provide 90 day advance notice of provider termination and for continuity of treatment for up to 90 days. A provider is entitled, upon request, to appeal the termination to an advisory appeal panel of providers of the same licensure and same/similar specialty. The network cannot complete termination or notify patients until the earlier of the termination effective date or the date of the panel’s recommendation.
The contract must provide that the network will notify the provider in advance if it intends to conduct economic profiling .
The contract must also provide that the network cannot retaliate against a provider for filing complaints or appeals on behalf of injured workers.

12. Requirements for Provider Contracts
Advance notice to provider of termination
Notices to injured employees of provider termination
Reimbursement fee schedules
In-office provider notices re: complaints to TDI
Agreement to participate in certified network
Financial incentives are not allowed
Network doesn’t have to accept applications of providers if sufficient number contracted
A provider must be given advance notice of termination and notices must be given to injured workers.
The contract must include the fee schedule setting forth the provider’s reimbursement for services.
And provider must agree to post a notice in the office advising patients how to file complaints against the network.
The contract must contain a provision stating that provider agrees to provide care to injured workers who are required to receive care through a certified workers compensation health care network.
A network and carrier may not use a financial incentive or make any payment to a provider that would induce the provider to limit medically necessary care.
It is important to note that a network does not have to accept a qualified provider’s application for network participation if the network has determined that it has contracted with a sufficient number of qualified providers including providers of the same license type or specialty.

13. How will we know which doctors are in which network?
Networks are required to create provider directories to include all of their contracted providers
Providers could be in more than one network
It will be up to the networks to maintain current directories for TDI to access as needed
Networks must create and maintain updated provider directories that list all contracted providers in the service area. The directory must indicate which providers are accepting new patients and which are trained and certified to perform maximum medical improvement determinations and impairment rating services. There is no statutory language that prohibits providers from being in more than one network.

14. Is there a limit on how far someone will be required to travel to see a network doctor?
In urban areas, there are limits of 30 miles for treating providers and 75 miles for specialists
In rural areas, the mileage limit is 60 miles for treating providers and 75 miles for specialists
There may be some areas where the standard of care is to travel farther for routine care
If a network cannot demonstrate that it has access to treating providers and specialists within the required mileage radii, an access plan must be filed with TDI
There are specific requirements for the network to include in its access plan
TDI will not certify a network that is arranging care solely through access plans
This slide lists the mileage radii for access to treating providers including general hospital care and specialists. In areas of the state where providers are not located within these distances, the standard of care may be to travel further in order access routine or specialty care.
If a network cannot show that it provides access to contracted treating providers, specialists and facilities within the required mileage radii, the network must file an access plan with TDI that explains why they do not have contracted providers as required by statute and how the network will provide necessary services to injured employees. The plan may include authorizing out-of-network care.
It goes without saying that TDI will not certify a network that is arranging care solely through access plans.

15. Changes to the Network
Once a network is certified, changes to the original application must be filed with TDI
Two types of changes:
For approval 30 days prior to implementing:
Changes to management contracts
Changes to physical location of books & records
Material modification of network configuration
Change to existing service area or addition of new service area
All other changes within 30 days of implementation
After a network receives its certification, any changes that it makes to its original application must be filed with TDI.
Changes to management contracts,
Changes to the physical location of a networks’ books and records
Material modification of its network configuration (i. e. Provider panel) or
An expansion or reduction of its existing service area or the addition of a new service.
These changes have to be filed with TDI for approval 30 days prior to implementation.
All other changes must be filed with TDI within 30 days of implementation,

16. Network Access Requirements
All services must be provided by a provider who holds a current appropriate license
Unless the provider is exempt from license requirements

17. Network Access Requirements
The provider panel must:
Include an adequate number of treating providers (doctors and specialists)
Be available 24 hours a day, seven days a week, within the network service area
Necessary hospital services within the service area must be:
Available and accessible
24 hours a day
7 days a week
Provided by contracts with general, special, and psychiatric hospitals
In order to provide comprehensive care to injured employees the provider panel must include an adequate number of treating doctors, specialists and hospitals. Services must be available 24 hours a day, seven days per week within the service area.

18. Network Access Requirements
Other services required to be available and accessible in the service area are:
Physical and occupational therapy
Chiropractic
A network must provide access to physician and occupational therapy and chiropractic services through contracted providers.

19. Network Access Requirements
Emergency care must be available and accessible:
24 hours a day
7 days a week
Without restrictions = where the services are rendered
Except for emergencies, the network shall:
Not later than 21 calendar days after the date of the original request, arrange for services on a timely basis (includes Specialist Referrals)
Read this slide

20. Employee Information and Responsibilities
Written notice for employees must include in a clear, complete, and accurate format:
Statement that entity is a WC network
Network’s toll-free number and address
Statement that injury event requires selection of treating doctor
All care from network providers except ER or approved out-of-network services
Explanation of hold-harmless
Statement of employee liability for out-of-network care not approved by network
Emergency care information
The adopted rules (28 TAC §10.60(c)(3)) allows the notice of network requirements to be in an electronic format provided a paper version is available upon request.
Employees must be given written notice of their responsibilities and the network’s requirements. The notice must include:
A statement that the entity is a certified workers compensation health care network and provide the network’s toll-free number and address.
A statement that if the employee is injured, he must select a treating doctor from the list of the network’s treating doctors. Or employee can select his or her HMO Primary care provider if the employee designated the provider as the employee’s PCP prior to injury and the provider agrees to network’s requirements.
A statement that if the employee lives in the network’s service area, all care must be received from network providers except for emergency care of approved out-of-network services.
The notice must explain that the network provider will be paid by the insurance carrier and will not bill the employee for a compensable injury.
The notice must also advise that the employee may be liable for payment for out-of-network care not approved by the network.
The notice must disclose that the employee may receive emergency care from out-of-network providers.

21. Employee Information and Responsibilities
Written notice must include in a clear, complete, and accurate format:
List of services requiring preauthorization or concurrent review
Continuity of treatment provisions
Description of complaint system; no retaliation
Summary of procedures relating to adverse determination and Independent Reviews
List of network providers, access limitations and providers accepting new patients
Description of network’s service area
Timely provision of health care services
The notice must also
Provide a list of the services that require preauthorization or concurrent review.
Include information regarding the continuity of care in the event the network treating doctor is terminated from the network
Describe the complaint system including the prohibition against retaliation and also disclose whether the network imposes a 90 day limit on filing complaints.
Include a summary or the carrier’s or network’s procedures for adverse determinations and the availability of the independent review process.
Include the names of addresses of network providers group by specialty. Treating doctors must be listed separately from specialists and the directory must indicate which doctors are accepting new patients. The directory must be updated quarterly.
The network’s service area must be described
The notice must disclose that except for emergencies the network must arrange for services, including specialist referrals, on a timely basis on request. Such services must be provided within the time appropriate to the circumstances and condition of the employee but not later than 21 days after the date of the request.

22. Employee Acknowledgement Form
Carrier and employer may use a form that complies with this section or a sample form available from TDI
Form must include:
Statement of employee’s responsibility to obtain network services
If employee is injured and lives in service area, then the employee must:
Must select a treating doctor
May ask HMO PCP to be treating doctor
Must obtain all services from network providers except emergency care
Employer is required to deliver the notice of employee responsibilities and network requirements and obtain a signed acknowledgement form from each employee:
When the employer elects a network plan
Within 3 days after the date a new employee is hired
Upon learning that an injury has occurred.
The employer must also post the notice in the workplace.
An employee who refuses to sign the acknowledgement form is still subject to network requirements.

23. Insurance Carrier Liability for Out-of-Network Health Care
Emergency care
Health care provided to an injured employee who does not live within the service area of any network established by the carrier or with which the carrier has a contract
Health care provided by an out-of-network provider pursuant to a referral from the injured employee’s treating doctor that has been approved by the network
Health care services provided to an injured employee before the employee received notice of network requirements and information about the appropriate network and service area
The insurance carrier is liable for out-of-network care as follows:
READ THE SLIDE.

24. Treating Doctor Selection
The network determines which specialties can serve as treating doctors
If dissatisfied with choice, employee may choose an alternate & must notify the network in the manner prescribed
Network may not deny a selection of an alternate treating doctor
Specialists and HMO PCP as treating doctor
Each network will determine which physician specialties can serve as network treating doctors. An employee is entitled to choose a treating doctor from the list provided by the network of all treating doctors under contract in the employee’s service area. If the employee is dissatisfied with the initial choice of treating doctor the employee can choose an alternate treating doctor from the list. The network may not deny the selection of an alternate treating doctor. However, a request to select a subsequent treating doctor must be justified by the employee and approved by the network.
Instead of choosing a treating doctor from the list provided by the network, an injured employee can select as their treating doctor a doctor who the employee selected prior to injury as their PCP under an HMO plan. The network shall grant the employees request if the HMO PCP agrees to abide by the terms of the network’s contract and comply with applicable statute and rules.
In addition, an employee with a chronic, life-threatening injury or chronic pain related to a compensable injury may apply to the network’s medical director to use a specialist that is in the same network as the employee’s treating doctor.

25. Special Issues
What is not considered initial selection of treating doctor:
A doctor providing emergency care
A doctor salaried by the employer
Any doctor who provides care before the employee is notified of the network, except for a doctor selected under (HMO PCP)
Because an employee can only change treating doctors one time without network approval, its important to note what is not considered an initial selection of treating doctor. These situations do not constitute an initial selection of treating doctor:

26. Special Issues Employee lives outside network service area
Referral outside network
Specialty care
Service not available in network
Timely referrals
TDI will monitor
Treating doctor dies, retires, or leaves network
An employee who lives outside of the network service area is not required to receive care within the network. However, the employee may elect to participate in the network upon mutual agreement between the employee and insurance carrier.
If employee’s treating doctor requests a referral to an out-of-network provider for medically necessary services that are not available from in network providers, the network must approve or deny the referral within the time appropriate under the circumstances but no later than 7 days after the date the referral is requested. TDI will monitor excessive referrals out-of-network for specialty or other services because the services are not available in network as indicators of network inadequacy.
A change in treating doctor due to a doctor’s death, retirement or withdrawal from the network does not constitute a selection of an alternate or subsequent treating doctor.

27. Treatment Parameters
Must adopt treatment guidelines, return-to-work guidelines, and individual treatment protocols
Treatment guidelines and protocols must be evidence-based, scientifically valid, outcome- focused, and designed to reduce inappropriate or unnecessary health care while safeguarding necessary care
Networks Must adopt treatment guidelines, return-to-work guidelines, and individual treatment protocols and must contractually require providers to follow the guidelines.
Treatment guidelines and protocols must be evidence-based, scientifically valid, outcome- focused, and designed to reduce inappropriate or unnecessary health care while safeguarding necessary care and the network’s medical director must certify that the guidelines and protocols meet this standard.

28. Payment Structure Reimbursement determined by contract
Billing by and reimbursement to contracted and out-of-network providers must be done in accordance with the Texas Workers’ Compensation Act and applicable rules
Carriers must notify network providers in writing if an injury is not compensable
Amount of reimbursement to network providers is determined by the provider’s contract with the network. Depending upon contract negotiations and the availability of the provider specialty, the reimbursement could be above or below the fee guideline for non-network worker’s compensation plans.

29. Preauthorized Treatment
Network is required to list procedures that require preauthorization
If preauthorized, then the treatment cannot subsequently be denied based on medical necessity
Treatment could be denied for other reasons
Networks are required to disclose the procedures that require preauthorization in the provider contract and in the notice to employees of network requirements.
If a procedure is preauthorized, the treatment cannot subsequently denied on the basis that the treatment was not medically necessary; however, the treatment could be denied for other reasons.

30. Network’s Complaint Process
Must include:
Reasonable procedures for resolving oral and written complaints
Notify complaint of right to complain to TDI
May use 90-day deadline for filing a complaint
Complaint information must be saved for three years from date the complaint was received
Networks must keep complaint logs for each complaint
The network’s complaint process must include reasonable procedures for resolving oral and written complaints and shall notify the complaint of their right to complaint to TDI if dissatisfied.
Network may opt to require a 90 day deadline for filing a complaint to the network but must notify employee in the notice of network frequireents and employee responsibilities. .

31. How to Complain to TDI Anyone may submit a complaint
Use online complaint form at
Send complaint to:
HWCN Division, Mail Code 103-6A
Texas Department of Insurance
PO Box , Austin, Texas 
Fax complaint to
Send complaint to: or
This slide lists the information needed to file a complaint with TDI.

32. Rules to Review

33. WC Network Web Resource Page

34. Workers’ Compensation Working Group (WCWG)

35. WCWG All stakeholders represented
Web resource page includes meeting agendas and summaries
Topics discussed:
WC network development
All networks including “tailored networks” must be certified separately
Silent PPO panel discussion
Performance-based oversight
Outreach to providers, employees, employers

36. Questions? Send an e-mail to wcnet@tdi.state.tx.us
Please include your contact information and phone number
Call TDI Health and Workers’ Compensation Network (HWCN) staff or
If you have any questions about this presentation, please us at
or call the numbers on the screen.