Texas Self-Insurance Association 2009 Educational Conference Compliance Monitoring in the Workers’ Compensation System Teresa Carney Texas

Texas Self-Insurance Association2009 Educational Conference

Compliance Monitoring in the Workers’ Compensation System

Teresa Carney

Texas Department of Insurance Division of Workers’

Compensation


Compliance

• Overall compliance in the workers’ compensation system is achieved through:– Monitoring activities

– Performance Based Oversight

– Audits

– Complaints

– Enforcement


• 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


Monitoring & Analysis

• Complaints

• Data

• Communications

• Performance Based Oversight


Monitoring & Analysis - Complaints

• Types of complaints

• Subject of complaints

• Complainants

• Priority of complaint handling


Monitoring & Analysis - Data

• EDI – claim data

• 837 – medical billing data


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


Medical Data

• Timeliness of processing medical bills– 97.87%

• Timeliness of reporting medical data– 87.77%

• Accuracy– ANSI codes– Paid date– Received date


Why medical data is required?

• Statute– 413.007

• Rule– 134.802


Uses of the medical data

• PBO

• §405 duties– Network report cards– Biennial Report

• Fee guidelines

• Compliance Monitoring


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?


Communications

• Carrier Quarterly Meetings

• Monthly ad hoc calls

• Monthly ad hoc meetings


Monitoring – What’s Next

• Continue to make outreach calls

• Continue carrier quarterly meetings

• Expand monitoring areas– Disputes, accuracy, etc


Performance Based Oversight

• Establishes performance objectives, measures and expectations

• Encourages and rewards excellence and continuous improvement

• Focuses on results rather than prescriptive requirements


1. Define Compliance Objectives (Key

Regulatory Goals)

2. Measure Overall Performance

(Assessments)

3. Report Performance Data

(Tiers)

4. Performance Data to Drive Improvement

(Incentives)

Accountability

PBO Steps


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


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


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


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


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


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


Tiers

• Poor performers

• Generally average performers

• Consistently high performers


Incentives

• Developed by rule (Adopted December 2007 – Rule 180.19)

• Publicly recognize high performers• Allow high performer designation as a

marketing tool• Modified penalties• Limited audits


PBO – What’s Next

• Review any clerical changes

• Finalize tiers

• Distribute tier results

• Post information on website


PBO Web Page

• http://www.tdi.state.tx.us/wc/pbo/pbo.html


Audits

• Conduct audits on system participants

• FY 09 – poor performers from PBO

• Other audits as necessary

• FY10 – Accuracy audits


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



• Medical Bill Processing– 19 audits completed– 97.21% timely in processing– 75.32% timely in reporting to DWC



• Filing of the DWC Form - 69

– 45 completed

– 39.55% timely

– Late filings

– Not faxing the forms


Audits – What’s Next

• Accuracy audits

• Audit Plan – http://www.tdi.state.tx.us/wc/pbo/pbo.html


Complaints

• Process

• Statistics

• Types/Examples


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


Complaints

• Justified complaints– Violation of statute or rule occurred– Resolve complaint (compliance achieved)– Enforcement action recommended


Complaints

• Unjustified complaints– Violation not detected based on information

received


Complaints

• Monitoring complaints– Complaint not fully reviewed – Monitor to see if trend

• Issue• Violator


Complaint Statistics – CY 2008

• 8,621 received

• 8,532 closed– 1,082 justified complaints– 1,564 unjustified complaints– 4,432 monitoring complaints


Complaint Statistics – CY 2008

• 2,251 – Medical Bill Processing complaints– 834 timely processing– 869 improper denials

• 2,562 – Communication complaints– Late DWC Form - 69 filings– Late letter of clarification responses


Complaint Statistics – CY 2009*

• 2,657 received

• 1,640 closed– 169 justified– 346 unjustified– 979 monitoring

• As of 6/1/09


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


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


Carrier Violations

• Late income benefit payments – TIBs, IIBs, SIBs

• Failure to comply with orders

• Inaccurate/late data submission


Health Care Provider Violations

• Late filings– DWC Form - 69, LOC

• Private claims against the injured employee


Employer Violations

• Late filing of required forms– DWC Form - 1 – DWC Form - 3 – DWC Form - 6


Employer Violations

• DWC Form - 1– Act/Rules

• §409.005• 120.2

– Time frames• 8th day after:

– The employee’s absence from work for more than 1 day

– Notice of an occupational disease

– Best practices


Employer Violations


• §408.063• 120.4

– Time frames• 30 days after notice of an injury

– Best practices


Employer Violations


• §408.081• 120.3

– Time frames• 10 days after a pay period

– Best practices


Employer Violations

• Posting/Coverage (Subscribers/Non-subscribers)– Failure to post coverage– Rights and responsibilities to employee – DWC Forms 5, 7


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)


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



• Disputes are a dissatisfaction with an outcome of an action– Denial of medical bill– Denial of a claim– Disagreement with amount of AWW


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


Questions

Documents

Texas Self-Insurance Association 2009 Educational Conference Compliance Monitoring in the Workers’ Compensation System Teresa Carney Texas