TEXAS MEDICAL ASSOCIATION HOUSE OF DELEGATES
Resolution 410 (A-07)
Subject: Workers' Compensation Prompt Pay
Introduced by: HarrisCounty Medical Society
Referred to: Reference Committee on Socioeconomics
Whereas, Many workers' compensation health plans doing business in Texas do not accept electronic claims and require that they be sent by U.S. mail; and
Whereas, When called to inquire about payment, some health plans have stated "we never received the claim," or "we never received the clinical documentation"; and
Whereas, After one physician's office mailed the claim three times, it was told that it was never received; and
Whereas, After repeated mailings, the physician's office contacted the workers' compensation health plan again and was told they do not have a fax machine and the billing information must be re-sent by U.S. mail; and
Whereas, These procedures by workers' compensation health plans delay payment and increase physician administrative costs which decrease net reimbursement; and
Whereas, Texas prompt pay rules for commercial insurance plans cover this issue; therefore be it
RESOLVED, That the Texas Medical Association work for legislative action to require workers' compensation health plans to have the same prompt pay rules as commercial health plans.
Relevant TMA Policy
335.012 Guiding Principles for Improvement of TexasWorkers' Compensation System . While provider networks are not the complete solution for improving the workers' compensation system, the Texas Medical Association adopted the following guiding principles for advocacy in the sunset review of the Texas Workers' Compensation Commission:
A reduction in administrative burdens through:
Available electronic billing procedures where feasible;
Streamlined, expedited compensability determination;
Streamlined disability management; and
Streamlined dispute resolution.
Incentives and requirements for employers:
Incentives and requirements for employees:
Network coordinated health care;
Return-to-work incentives; and
Access to high quality treating doctors.
Incentives and requirements for providers:
Guaranteed payment for injured worker visits;
Negotiated fees from a statutory floor with no ceiling for "in network" services;
Adequate network of specialty physicians for appropriate, needed referrals;
Availability of electronic billing where feasible;
Reduced administrative burdens, including limited preauthorizations or retrospective reviews;
More extensive utilization review and possible imposition of Disability Management System only if practice patterns meet agreed-to outlier criteria;
Provisions for 90-day termination of a contract without cause and no legal recourse against network could apply if outlier status continues beyond educational and related interventions;
Network report cards available to all participants; and
Use of treatment guidelines as agreed to by contract.
Adequate regulatory oversight of networks using the Texas Department of Insurance (TDI) model for managed care carriers including:
Network adequacy standards;
Prompt pay/clean claims regulations;
Financial reserve requirements;
Standard TDI credentialing rules and applications;
Prohibition on silent networks;
Prohibition on financial incentives to limit medically necessary care; and
By contract, expedited compensability determination (TF-WC Rep. 1-I-04).
TMA House of Delegates: TexMed 2007