Presentation on theme: "A Guide to Workers’ Compensation Health Care Networks"— Presentation transcript:
1 A Guide to Workers’ Compensation Health Care Networks HWCN DivisionTexas Department of Insurance
2 Goals of House Bill (HB) 7 Each employee shall be treated with dignity and respect when injured on the jobEach injured employee shall have access to a fair and accessible dispute resolution processEach injured employee shall have access to prompt, high-quality medical care within the framework established by the Texas Workers’ Compensation ActEach 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 providerDuring the 79th Regular Legislative Session the Legislature enacted HB7. On this slide are the goals of the bill.
3 Goals for WC NetworksAuthorize the establishment of workers’ compensation health care networks for the provision of workers’ compensation medical benefitsProvide standards for the certification, administration, evaluation, and enforcement of the delivery of health care services to injured employees by networksHB 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 employeesCertified in accordance with Insurance Code Chapter 1305 and Commissioner rulesEstablished by, or operating under contract with, an insurance carrierA 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 AssociationCorporationOrganizationTrustLimited liability companies and partnershipHospital districtCommunity mental health centers, mental health and mental retardation centerHMOPPOThis slide lists examples of the types of entities that can form a workers compensation health care network.
6 Certification Process Application – 26 pendingTwo certified networksTexas Star Network/ConcentraConcentra HCN60-day review by TDIApplicant may request an extensionTDI may deny request for extensionAs 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 affidavitsInsurance carrier, provider & third-party contractsManagement contractsFinancial information including a business planService area description and mapsList of contracted, credentialed providersProof of accessible, available, comprehensive careTreatment and return to work guidelinesMonitoring plan for providersDoctor and health care practitioner financial disclosureComponents 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 planService area description and maps identifying each county, part of a county or zip code to be servedLists 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 withProvidersGroup of ProvidersContracts are confidentialContracts are not subject to disclosure as an open recordA 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 riskHold-harmless clause for injured employeesProvider agrees to network treatment guidelinesNo denial based solely on treatment not listed on treatment guidelinesContinuity of treatment/90 daysProvider appeal process for terminationsAdvance notice of economic profilingNo retaliation for filing complaints or appeals on behalf of injured employeesNetwork 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 terminationNotices to injured employees of provider terminationReimbursement fee schedulesIn-office provider notices re: complaints to TDIAgreement to participate in certified networkFinancial incentives are not allowedNetwork doesn’t have to accept applications of providers if sufficient number contractedA 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 providersProviders could be in more than one networkIt will be up to the networks to maintain current directories for TDI to access as neededNetworks 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 specialistsIn rural areas, the mileage limit is 60 miles for treating providers and 75 miles for specialistsThere may be some areas where the standard of care is to travel farther for routine careIf 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 TDIThere are specific requirements for the network to include in its access planTDI will not certify a network that is arranging care solely through access plansThis 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 NetworkOnce a network is certified, changes to the original application must be filed with TDITwo types of changes:For approval 30 days prior to implementing:Changes to management contractsChanges to physical location of books & recordsMaterial modification of network configurationChange to existing service area or addition of new service areaAll other changes within 30 days of implementationAfter 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 recordsMaterial modification of its network configuration (i. e. Provider panel) orAn 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 licenseUnless 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 areaNecessary hospital services within the service area must be:Available and accessible24 hours a day7 days a weekProvided by contracts with general, special, and psychiatric hospitalsIn 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 therapyChiropracticA 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 day7 days a weekWithout restrictions = where the services are renderedExcept 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 networkNetwork’s toll-free number and addressStatement that injury event requires selection of treating doctorAll care from network providers except ER or approved out-of-network servicesExplanation of hold-harmlessStatement of employee liability for out-of-network care not approved by networkEmergency care informationThe 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 reviewContinuity of treatment provisionsDescription of complaint system; no retaliationSummary of procedures relating to adverse determination and Independent ReviewsList of network providers, access limitations and providers accepting new patientsDescription of network’s service areaTimely provision of health care servicesThe notice must alsoProvide 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 networkDescribe 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 describedThe 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 TDIForm must include:Statement of employee’s responsibility to obtain network servicesIf employee is injured and lives in service area, then the employee must:Must select a treating doctorMay ask HMO PCP to be treating doctorMust obtain all services from network providers except emergency careEmployer 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 planWithin 3 days after the date a new employee is hiredUpon 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 careHealth 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 contractHealth 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 networkHealth care services provided to an injured employee before the employee received notice of network requirements and information about the appropriate network and service areaThe 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 doctorsIf dissatisfied with choice, employee may choose an alternate & must notify the network in the manner prescribedNetwork may not deny a selection of an alternate treating doctorSpecialists and HMO PCP as treating doctorEach 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 IssuesWhat is not considered initial selection of treating doctor:A doctor providing emergency careA doctor salaried by the employerAny 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 networkSpecialty careService not available in networkTimely referralsTDI will monitorTreating doctor dies, retires, or leaves networkAn 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 ParametersMust adopt treatment guidelines, return-to-work guidelines, and individual treatment protocolsTreatment guidelines and protocols must be evidence-based, scientifically valid, outcome- focused, and designed to reduce inappropriate or unnecessary health care while safeguarding necessary careNetworks 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 rulesCarriers must notify network providers in writing if an injury is not compensableAmount 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 preauthorizationIf preauthorized, then the treatment cannot subsequently be denied based on medical necessityTreatment could be denied for other reasonsNetworks 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 complaintsNotify complaint of right to complain to TDIMay use 90-day deadline for filing a complaintComplaint information must be saved for three years from date the complaint was receivedNetworks must keep complaint logs for each complaintThe 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 atSend complaint to:HWCN Division, Mail Code 103-6ATexas Department of InsurancePO Box , Austin, Texas Fax complaint toSend complaint to: orThis slide lists the information needed to file a complaint with TDI.
35 WCWG All stakeholders represented Web resource page includes meeting agendas and summariesTopics discussed:WC network developmentAll networks including “tailored networks” must be certified separatelySilent PPO panel discussionPerformance-based oversightOutreach to providers, employees, employers
36 Questions? Send an e-mail to firstname.lastname@example.org Please include your contact information and phone numberCall TDI Health and Workers’ Compensation Network (HWCN) stafforIf you have any questions about this presentation, please us ator call the numbers on the screen.