On October 22, 2009, the TDI- Division of Workers’ Compensation held its Quarterly Carrier Meeting at the central offices of the Division in Austin, Texas.

Opening remarks were presented by Ron Bordelon, the Commissioner of the Division of Workers’ Compensation.  The remarks were short and primarily addressed the concerns arising from the sunset review that will be undertaken by the sunset committee.  This is, in effect, an opportunity for the Division of Workers’ Compensation to justify its existence.  Commissioner Bordelon directed the carrier’s attention to the review because this may be an opportunity for carrier’s to address particular problems that they see in the implementation in the current practices and procedures of the Division of Workers’ Compensation.

Matt Zurek, Executive Deputy Commissioner, Healthcare Management and System Monitoring, followed the Commissioner and spoke briefly to the monthly ODG updates that are located on the DWC website, as they affect disability management and that Mary Landrum, Director of Healthcare Business Management, is also undertaking the healthcare medical review processes.  Mr. Zurek also spoke regarding updates primarily directed to the pharmacy programs.  He also addressed the return to work reimbursement program and drew the attention of the carriers to the upcoming Federal changes in the fee guideline conversion factor.  (On November 9, 2009 these were received and it is anticipated that the DWC will provide a memo, with respect to their impact to the DWC fee guidelines.)

Theresa Carney, Director of System Monitoring and Oversight, gave a complaint data update.  Ms. Carney noted that the number of complaints had been reduced from 2008, but that communications still remained a major issue between the parties, particularly the healthcare providers and the carriers.  Ms. Carney also advised that many complaints were actually directed for medical bill reimbursement review and that these were being directed to the medical fee resolution process.  Ms. Carney did note that medical bill reimbursement could also include an inappropriate denial of a medical bill.  In effect, it appeared that most complaints involved the medical bill reimbursement and processing areas, as well as general communication problems.

Ms. Carney also addressed the PBO process and advised that the next PBO was currently being planned and that she anticipated that there would be substantial discussions with the stakeholders early next year.  This would be addressed more thoroughly in the January quarterly insurance carrier meeting.  Ms. Carney did state the goal of the review process was to obtain a 95% compliance rate.  This rate appears to have been met with respect to the timely handling of medical bills, but is far short of that rate with respect to the timely payment of income benefits.

Mary Landrum, Director of Healthcare Business Management, addressed the current status of medical disputes.  The top areas of dispute appear to be the reimbursement questions concerning usual and customary charges and fee guideline charge calculations.  The increasing number of these two areas has led to a total increase in the number of pending medical dispute cases, but they are being handled on an approximately 72 day turn around time.  There are areas where medical disputes continue to be outstanding for an extended period of time.  These areas include the stop loss questions, which are currently in litigation, as well as certain hospital fee reimbursement issues.  Approximately 3% of the medical dispute resolution decision and orders are appealed to either a contested case hearing or SOAH.

Cass Burton, Manager of Enforcement, gave an enforcement update.  Mr. Burton reiterated the enforcement priorities with particular emphasis on response to data requests, inappropriate denial of claims and a failure to comply with decisions and orders of the Division.  Mr. Burton explained the concern over the determination of harm and generally alluded to the frustration and the confidence in the system and the overall cost to the participants.  He further addressed the failure to comply with Division orders as not only frustrating the system and causing additional costs to the participants in the system, but also that the Division of Workers’ Compensation has a duty as a regulator to enforce such decisions in accordance with the statutes and rules.

Mr. Burton addressed the enforcement practices currently ongoing by advising that older violations had been grouped into omnibus cases (these would be multiple violation cases against individual carriers).  Mr. Burton advised that at this time they were seeking to clean off the old cases, although they would look to these cases to seek to determine if a pattern of practice could be determined and whether corrective actions had been taken by the carriers.  In any event, enforcement would now provide sufficient time for the carrier to correct problems that were determined to be continuing.  If the problems weren’t corrected, it would be considered an aggravating factor in any subsequent determination.  Mr. Burton did discuss the current DWC mitigation consideration of the enforcement of actions taken by carriers to correct problems that carriers determined had existed, particularly where such actions were taken prior to a Division audit or data request.

Mr. Burton indicated that the PBO would be utilized for the benefit of high tiered carriers in any follow-on audits and that low tier carriers would be audited and improvements would be considered mitigating factors or again, if no improvement had occurred, as aggravating factors.  Mr. Burton did indicate that the PBO results would not be utilized adversely to any low tiered carrier, except as noted.

In any final determination, a corrective action plan will be required as a condition of settlement.

Mr. Burton advised that there would be upcoming reviews that would be all encompassing in order to obtain more effective enforcements.

It appears that under Mr. Burton, the TDI-DWC enforcement will be looking forward to more current problems and seek to resolve any long term outstanding case by either a warning letter or dismissal.

Karen Punckett, Manager of Communications and Outreach, spoke about return to work coordination services and briefly discussed carrier’s responsibilities as to supplying notice to the employer and employee and directed participants to the TDI- DWC return to work website (http://www.tdi.state.tex.us/wc/rtw/index.html).

D.C. Campbell, Director of Research and Evaluation Group, discussed the network report card and advised that there would be a network data call that was very important and that a failure to timely respond could result in enforcement action.