Disability Management Disability Guidelines Medical Disability Advisor Complaint System
In May 2005, the Texas Legislature passed sweeping reforms of the Texas Workers' Compensation system. Central to these reforms is the division's adoption of disability management rules. In theory, disability management is designed to optimize health care and return-to-work outcomes for injured employees. The goal is to ensure appropriate medical treatment and facilitate communication among system participants.
Disability management includes three components.
- Treatment Guidelines (effective May 1, 2007)
The adopted treatment guidelines are the Official Disability Guidelines (ODG), published by the Work Loss Data Institute ( http://www.worklossdata.com/texasform.htm ). The ODG provides a list of diagnoses with the corresponding medical treatment. By rule, care provided in accordance with the treatment guidelines is presumed to be necessary and reasonably required. Physicians are required to provide treatment in accordance with these guidelines, unless the treatment requires preauthorization. Also by rule, any care provided outside of these guidelines requires preauthorization. An insurance carrier may not deny preauthorization or reimbursement for a treatment solely because the diagnosis or treatment is not included in the Division treatment guidelines.
- Return to Work Guidelines (effective May 1, 2007)
The adopted Return-to-Work Guidelines are found in the Medical Disability Advisor, Workplace Guidelines for Disability Duration (MDA) . The MDA provides expected length of disability duration and identifies points when additional evaluation of the injured employee may be warranted.
- Treatment Planning (effective September 1, 2007)
The effective date for Treatment Planning requirements has recently changed from May 1, 2007 to September 1, 2007. Only Treating Doctors are authorized to submit treatment plans, ancillary and referred providers must work with the Treating Doctor to develop the treatment plan. Treating doctors may bill for development of the treatment plans.
Specifically, treating doctors must submit treatment plans to the carrier for preauthorization when one the following applies.
- The injured employee's diagnosis is not included in the treatment guidelines or Division treatment protocols (for these cases, the treating doctor must preauthorize a treatment plan for the injured employee as soon as the injured employee visits the treating doctor), or
- The care will exceed or is not included in the Division treatment guidelines, the Official Disability Guidelines (ODG), and if the care will be provided after the greater of: 60 days from the date of injury or the optimum days listed in the MDA return to work guidelines, or
- As required by the Commissioner of Workers' Compensation.
For more information on treatment planning requirements, see "Fast Facts: Treatment Planning" at http://www.tdi.state.tx.us/wc/dm/documents/fftreatmentplan.pdf .
The TDI/DWC is providing training and educational resources which are accessible through the agency web site at www.tdi.state.tx.us/wc/dm/index.html .
How to Obtain Official Disability Guidelines (ODG)
According to their website, The Official Disability Guidelines provides the most up to date evidence-based medical treatment and disability duration guidelines to improve as well as benchmark outcomes in workers' compensation and non-occupational disability. To encourage its widespread use, TDI/DWC has negotiated a substantial discount of ODG Treatment for all healthcare providers. Due to the importance of ongoing updates, online use is encouraged, with a discount of 50% to online subscribers. The annual three-volume textbook set is available to Texas subscribers for a 25% discount (reference "Texas" when placing order.)
- Available formats include the following.
- Online subscription-$162.50 (per user/per year.)
- Text book, 3 vol. set-$243.75
For more information and how to order a copy, go to www.worklossdata.com
How to Obtain Medical Disability Advisor, 5th edition (MDA)
According to their website, The Medical Disability Advisor is an essential return-to-work resource that provides healthcare providers a more efficient way to manage and measure the time that employees are absent for health-related reasons. MDA Fifth Edition includes updated disability duration data and tables, CPT codes and descriptions, and evidence-based rehabilitation guidelines.
- Available formats:
- MDA Internet-$395 (per person/per year)
- Text book, 2 vol. set-$695
- MDA for Windows CD-ROM-$695
For more information about how to order, go to www.rgl.net/ or www.MDAinternet.com for a 30-day free trial.
TMA has created a complaint system for workers' compensation.
Two options are available.
- Log in to the TMA website and file your complaint here: https://www.texmed.org/Authentication/LoginUser.aspx?ReturnUrl=%2fformsauthenticated%2fworkerscomp%2fworkerscomp.aspx ; or
- E-mail your complaint to firstname.lastname@example.org and it will be filed on your behalf.
Please include the following information.
- Physicians Name,
- Who to contact for additional information, and
- Specific information about the complaint.
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