335.012 Guiding Principles for Improvement of Texas Workers Compensation System

335.012

Guiding Principles for Improvement of Texas Workers' 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 Division of Workers' Compensation:

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:

Return-to-work program requirements;

Employer-assigned, return-to-work coordinators; and

Discounts on premiums.

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; amended CSE Rep. 2-A-14).

Last Updated On

October 07, 2016