2001 Legislative Compendium: Workers' Compensation

• Prohibits waiver of workers' compensation rights. This measure restored the law overturned by the Texas Supreme Court, which prohibited employers from requiring employees as a condition of employment to waive their workers' compensation rights in exchange for health and indemnity benefits.
• Establishes statutorily a medical advisor position at the Texas Workers' Compensation Commission (TWCC).
• Establishes a Medical Quality Review Panel consisting of health care providers to advise the commission and the medical advisor on health care issues.
• Requires that the medical director of a utilization review entity have a Texas medical license and that physician reviewers be on the approved doctor list.
• Increases authority of the commission to sanction and oversee carriers and utilization review activities.
• Creates an approved physician list for which application is made by providers to the commission.
• Requires that medical necessity disputes be resolved by an independent review organization (IRO) paid for by the insurance company.
• Preauthorization replaces second opinion requirement for spinal surgery, and disputes go to the IRO and are to be paid for by the carrier.
• Requires the commission to develop criteria to decrease the utilization review of providers and develop criteria for greater monitoring of those who unreasonably over-utilize or under-utilize health care services.
• Requires carriers to pay for prescription drugs and over-the-counter medications in the first seven days after the injury if there is verification of injury from either the employer or the carrier.
• Requires treatment guidelines adopted by the commission to be nationally recognized, scientifically proven and outcome-based.
• Provides for voluntary networks to be established, with participation by the injured worker to be voluntary. The worker can choose to stay within the workers' compensation system or participate in a network and can opt out of the network up until either receiving care or 14 days after injury, whichever is earlier. The network is governed by a board that includes health care providers. 
• Requires the use of the relative value units from the Medicare Resource-Based Relative Value Scale (RBRVS) system for fee guidelines but conversion factors still based upon the "fair and reasonable fee" standard, and expressly prohibits the adoption of the Medicare fee schedule.   
• Places greater emphasis on insurers and employers to develop return-to-work programs for injured workers.

When HB 2600 became the statutory vehicle for the use of an RBRVS fee schedule by the workers' compensation program, TMA vigorously sought provisions which specifically prohibited the adoption of the Medicare RBRVS fee schedule, and which require, through the use of appropriate conversion factors, the adoption of fees that are "fair and reasonable." Prior to TMA's aggressive advocacy with the Workers' Compensation Research and Oversight Council and the commission, the objective of many legislators and TWCC was to deliver maximum "savings" in workers' compensation outlays by establishing a fee schedule below current commercial levels and, if possible, below Medicare.

Even before this important reimbursement system issue became a legislative initiative, TWCC began to look at the use of the Medicare fee schedule as part of its administrative charge to regularly update the workers' compensation fee schedule  TMA language ultimately adopted by the legislature requires the use of an RBRVS that is not the Medicare fee schedule per se , incorporates the most current relative values, retains the flexibility to develop non-Medicare conversion factors reflecting Texas costs and conditions, and requires the use of fees that are "fair and reasonable." 

Workers' Compensation TMA Staff Contacts

• Rich Johnson, Director, Division of Medical Economics, (512) 370-1315
• Pat Coffey, Director, Office of Payment Advocacy, (512) 370-1416

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