 Texas Self-Insurance Association 2009 Educational Conference Compliance Monitoring in the Workers’ Compensation System Teresa Carney Texas Department of Insurance Division of Workers’ Compensation

 Texas Self-Insurance Association 2009 Educational Conference Compliance Overall compliance in the workers’ compensation system is achieved through: –Monitoring activities –Performance Based Oversight –Audits –Complaints –Enforcement

 Texas Self-Insurance Association 2009 Educational Conference Monitor the workers’ compensation system for compliance through complaints, data/trend analysis and Performance Based Oversight 3 Sections: –Monitoring & Analysis –Complaint Resolution –Audits & Investigations System Monitoring & Oversight

 Texas Self-Insurance Association 2009 Educational Conference Monitoring & Analysis Complaints Data Communications Performance Based Oversight

 Texas Self-Insurance Association 2009 Educational Conference Monitoring & Analysis - Complaints Types of complaints Subject of complaints Complainants Priority of complaint handling

 Texas Self-Insurance Association 2009 Educational Conference Monitoring & Analysis - Data EDI – claim data 837 – medical billing data

 Texas Self-Insurance Association 2009 Educational Conference Claims Data Timeliness of initial payment of TIBs –80.18% Timeliness of reporting initial payment of TIBs –90.50% Accuracy –Paid date –Witten notice Claims administrator

 Texas Self-Insurance Association 2009 Educational Conference Medical Data Timeliness of processing medical bills –97.87% Timeliness of reporting medical data –87.77% Accuracy –ANSI codes –Paid date –Received date

 Texas Self-Insurance Association 2009 Educational Conference Why medical data is required? Statute – Rule –

 Texas Self-Insurance Association 2009 Educational Conference Uses of the medical data PBO §405 duties –Network report cards –Biennial Report Fee guidelines Compliance Monitoring

 Texas Self-Insurance Association 2009 Educational Conference Monitoring Plans - Quality Assurance Who has them? Trading Partner specific? Issue specific? Elements reviewed? Time frame reviewed? Should all monitoring plans be the same? Can you produce one upon request?

 Texas Self-Insurance Association 2009 Educational Conference Communications Carrier Quarterly Meetings Monthly ad hoc calls Monthly ad hoc meetings

 Texas Self-Insurance Association 2009 Educational Conference Monitoring – What’s Next Continue to make outreach calls Continue carrier quarterly meetings Expand monitoring areas –Disputes, accuracy, etc

 Texas Self-Insurance Association 2009 Educational Conference Performance Based Oversight Establishes performance objectives, measures and expectations Encourages and rewards excellence and continuous improvement Focuses on results rather than prescriptive requirements

 Texas Self-Insurance Association 2009 Educational Conference 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

 Texas Self-Insurance Association 2009 Educational Conference 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 Increase timely communications within the system Limit disputes to those appropriate and necessary

 Texas Self-Insurance Association 2009 Educational Conference 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

 Texas Self-Insurance Association 2009 Educational Conference 2009 Assessment Measures Insurance Carriers –Timeliness of initiation of Temporary Income Benefits (TIBs) –Timeliness of reporting initial TIBs payment –Timely processing of medical bills –Timeliness of reporting medical data

 Texas Self-Insurance Association 2009 Educational Conference 2009 Assessment Measures Health Care Providers –Timeliness of filing Report of Medical Evaluation, DWC Form - 69 –Timeliness in filing Work Status, DWC Form -73 –Completeness of DWC Form -73

 Texas Self-Insurance Association 2009 Educational Conference PBO Initial Assessment - Details 274 Health Care Providers Selected based on volume of DWC Form - 69 filings received and volume of DWC Form – 73s billed

 Texas Self-Insurance Association 2009 Educational Conference 2009 PBO Assessment - Details 138 Insurance Carriers –87 Commercial carriers –3 State entities –38 self insureds (poly subs, municipalities) –10 certified self insureds Selected by volume of IP filings received in CY 2007

 Texas Self-Insurance Association 2009 Educational Conference Tiers Poor performers Generally average performers Consistently high performers

 Texas Self-Insurance Association 2009 Educational Conference Incentives Developed by rule (Adopted December 2007 – Rule ) Publicly recognize high performers Allow high performer designation as a marketing tool Modified penalties Limited audits

 Texas Self-Insurance Association 2009 Educational Conference PBO – What’s Next Review any clerical changes Finalize tiers Distribute tier results Post information on website

 Texas Self-Insurance Association 2009 Educational Conference PBO Web Page

 Texas Self-Insurance Association 2009 Educational Conference Audits Conduct audits on system participants FY 09 – poor performers from PBO Other audits as necessary FY10 – Accuracy audits

 Texas Self-Insurance Association 2009 Educational Conference FY 09 Audit Findings Initial Payment of TIBs – Timeliness –2 audits completed –Late Payments Initial Payment of TIBs – Accuracy –Initiated in May 2009 Medical Bills – Accuracy –Initiated in May 2009

 Texas Self-Insurance Association 2009 Educational Conference FY 09 Audit Findings Medical Bill Processing –19 audits completed –97.21% timely in processing –75.32% timely in reporting to DWC

 Texas Self-Insurance Association 2009 Educational Conference FY 09 Audit Findings Filing of the DWC Form - 69 –45 completed –39.55% timely –Late filings –Not faxing the forms

 Texas Self-Insurance Association 2009 Educational Conference Audits – What’s Next Accuracy audits Audit Plan –

 Texas Self-Insurance Association 2009 Educational Conference Complaints Process Statistics Types/Examples

 Texas Self-Insurance Association 2009 Educational Conference Complaint Process 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

 Texas Self-Insurance Association 2009 Educational Conference Complaints Justified complaints –Violation of statute or rule occurred –Resolve complaint (compliance achieved) –Enforcement action recommended

 Texas Self-Insurance Association 2009 Educational Conference Complaints Unjustified complaints –Violation not detected based on information received

 Texas Self-Insurance Association 2009 Educational Conference Complaints Monitoring complaints –Complaint not fully reviewed –Monitor to see if trend Issue Violator

 Texas Self-Insurance Association 2009 Educational Conference Complaint Statistics – CY ,621 received 8,532 closed –1,082 justified complaints –1,564 unjustified complaints –4,432 monitoring complaints

 Texas Self-Insurance Association 2009 Educational Conference Complaint Statistics – CY ,251 – Medical Bill Processing complaints –834 timely processing –869 improper denials 2,562 – Communication complaints –Late DWC Form - 69 filings –Late letter of clarification responses

 Texas Self-Insurance Association 2009 Educational Conference Complaint Statistics – CY 2009* 2,657 received 1,640 closed –169 justified –346 unjustified –979 monitoring As of 6/1/09

 Texas Self-Insurance Association 2009 Educational Conference Complaint Statistics – CY 2009* 411 – Medical Bill Processing complaints –147 timely processing –146 improper denials 825 – Communication complaints –Late DWC Form - 69 filings –Late letter of clarification responses

 Texas Self-Insurance Association 2009 Educational Conference Carrier Violations 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 –Preauth –DD exams

 Texas Self-Insurance Association 2009 Educational Conference Carrier Violations Late income benefit payments –TIBs, IIBs, SIBs Failure to comply with orders Inaccurate/late data submission

 Texas Self-Insurance Association 2009 Educational Conference Health Care Provider Violations Late filings –DWC Form - 69, LOC Private claims against the injured employee

 Texas Self-Insurance Association 2009 Educational Conference Employer Violations Late filing of required forms –DWC Form - 1 –DWC Form - 3 –DWC Form - 6

 Texas Self-Insurance Association 2009 Educational Conference Employer Violations DWC Form - 1 –Act/Rules § –Time frames 8 th day after: –The employee’s absence from work for more than 1 day –Notice of an occupational disease –Best practices

 Texas Self-Insurance Association 2009 Educational Conference Employer Violations DWC Form - 3 –Act/Rules § –Time frames 30 days after notice of an injury –Best practices

 Texas Self-Insurance Association 2009 Educational Conference Employer Violations DWC Form - 6 –Act/Rules § –Time frames 10 days after a pay period –Best practices

 Texas Self-Insurance Association 2009 Educational Conference Employer Violations Posting/Coverage (Subscribers/Non- subscribers) –Failure to post coverage –Rights and responsibilities to employee –DWC Forms 5, 7

 Texas Self-Insurance Association 2009 Educational Conference Employee Violations Fraud cases –Working and Drawing Failure to attend: –Benefit Review Conference (BRC) –Contested Case Hearing (CCH) –Required Medical Exam (RME)/Designated Doctor Exam (DDE)

 Texas Self-Insurance Association 2009 Educational Conference Complaint versus Dispute

 Texas Self-Insurance Association 2009 Educational Conference Complaint versus Dispute Complaints are situations when there is dissatisfaction on case –Duty to perform has not occurred –Medical bill not processed or was late –Indemnity check was not received or was late –Order was not complied with –My adjuster/provider/other was rude

 Texas Self-Insurance Association 2009 Educational Conference Complaint versus Dispute Disputes are a dissatisfaction with an outcome of an action –Denial of medical bill –Denial of a claim –Disagreement with amount of AWW

 Texas Self-Insurance Association 2009 Educational Conference Complaints – What’s Next Continue to process complaints –Increase timeliness of processing time –Review letters/process for improvement Identify trends Educate both alleged violators & complainants

 Texas Self-Insurance Association 2009 Educational Conference Questions