A Health Care Provider’s

Intake and

Registration Practices

Amy Rich

TDI-DWC Communications

Objectives

� Understand the Texas workers’ compensation system

� Know how to identify a workers’ compensation claimant through your intake process

� Understand Billing Requirements

Topics to be covered� Texas Law and Rules

– Responsibilities

• Employer• Carrier

• Injured Employee

• Health Care Provider

� Intake Screening Questions andEmployer Coverage Verification

� Billing– Billing the Injured Employee

– Billing the Employer

– Billing Requirements• Know billing deadlines and exceptions

• Clean Claims Guide

Understanding the Texas Workers’

Compensation System

Workers’Compensation

Regulation Texas Labor Code Texas Labor Code Texas Labor Code Texas Labor Code Rules Rules Rules Rules & & & & GuidelinesGuidelinesGuidelinesGuidelinesBulletins Bulletins Bulletins Bulletins & & & & MemosMemosMemosMemosTexas Labor Code

The Act (Law)§§401-506

Rules§§100-180

Bulletins,

Memos,etc.

What is Workers’ Compensation?

A state-regulated insurance program that pays medical bills (medical benefits) and some lost wages (income benefits)for employees with work-related (compensable) illnesses and injuries-regardless of fault.

• Not mandatory except for public employees and certain statutory exceptions like building or construction contractors

– Examples: School districts, counties, state government

504.011. METHOD OF PROVIDING COVERAGE.

A political subdivision shall extend workers' compensationbenefits to its employees…

Workers’ Compensation System

Employers pay premiumsto…

Insurance companies that pay benefits to…

– Injured employees, or their families.

Employer Responsibilitieswww.tdi.state.tx.us/wc/employer/index.html

§406.002 – Except for public employers and as otherwise provided by law, only employers who elect to obtain workers’ compensation coverage are subject to the Labor Code

§406.005 – An employer shall notify each employee as provided by this section whether or not the employer has workers’ compensation insurance coverage

§1305.451 – The employer must provide Notice of Workers’ Compensation Health Care Network Requirements to the employees

Employer Responsibilities*www.tdi.state.tx.us/wc/employer/index.html

CHAPTER 120.COMPENSATION PROCEDURES - EMPLOYERS

• Report the injury to its insurance carrier and keepa date on which it notified the insurance carrier

• Provide a copy of the Employer’s First Report ofInjury or Illness to the injured employee

• Provide a copy of the injured employees rightsand responsibilities form

Insurance Carrier Responsibilities

§ 406.031 – A workers’ compensation insurance carrier is liable for compensation for a covered employee’s injury or illness without regard to fault or negligence

§ 406.032 – An insurance carrier is not liable for compensation in certain circumstances

§1305.451 (TIC) – The insurance carrier must provide the employer with Workers’ Compensation Health Care Notice of Network Requirements which must be provided to the employees

Injured Employee’s Right to Medical Care

408.021. ENTITLEMENT TO MEDICAL BENEFITS

(a) An employee who sustains a compensableinjury is entitled to all health care reasonably required by the nature of the injury as and when needed.

Injured Employee’s Responsibilities*

• Generally, must tell the employer within 30 days of the date they were injuredor first knew their injury or illness might be work related

• Must know if their claim is part of a workers’ compensation health care certified network

• Must tell their doctor how they were injured and whether theinjury is work related

• Generally, must tell the Division within 1 year by completing a DWC form 041

* http://www.tdi.state.tx.us/wc/employee/index.html

Injured Employee Assistance

The injured employee can contact theOffice of Injured Employee Counsel (OIEC)

by calling the toll-free telephone number1-866-EZE-OIEC(1-866-393-6432).Also, more information is available on the

Internet at:

www.oiec.state.tx.us

Health Care Provider

Roles and Responsibilities

What is required to treat workers’

compensation claimants?

• Active Medical License

• Disclose financial interests to DWC

• No applicable sanctions by DWC(removed or denied from the former DWC ADL)

• Change of Treating Doctor form (DWC053)approval if patient changing from one treating doctorto you as a treating doctor

• Need to consider network requirements to treat certified network claimants

• Set up “profile” in TXCOMP (optional)

“Doctor” §401.011(17)

• Doctor of medicine,

• Doctor of osteopathic medicine,

• Doctor of optometry,

• Doctor of dentistry,

• Doctor of podiatry, and

• Doctor of chiropractic

Other Health Care Practitioners

• Physician Assistants,

• Nurse Practitioners,

• Physical Therapists,

• Occupational Therapists,

• Psychologists, and

• Others

Roles and Responsibilities§180.22

Treating Doctor (TD)

Establishes reasonable recovery and RTW goals for the employee, and

• Manages all medical care.

• The injured employee is entitled to his initial

choice of treating doctor (§ 408.022)

– Non-network

– Network – (network list of doctors)

– Political Subdivisions (may have list of doctors)

Roles and Responsibilities§180.22

Referral / Ancillary Provider

• Treats or refers only with approval from TD

• Reports to the TD at least every 30 days.

Consulting Health Care Provider

• Examines and gives medical opinion,does not treat or refer.

Roles and Responsibilities§180.22

Designated Doctor (DD)

• Assigned by DWC to help resolve any questions about the medical condition of the injured employee.

• Requires special training and must be unbiased.

• May not make referrals, initiate or provide treatment.

Roles and Responsibilities§180.22

Required Medical Exam Doctor (RME)

• Requested by the carrier to evaluate the employee’s medical condition after a DD evaluation.

• Is limited to an evaluation of the appropriateness of medical care.

• May not make referrals, initiate or provide treatment.

Roles and Responsibilities§180.22

Peer Review / Utilization Review Doctor (URA)

• Performs an administrative review of the health care of a workers' compensation claim at the insurance carrier's request.

• Must hold a professional certification in a health care specialty appropriate to the type of healthcare that the injured employee is receiving (§408.0043).

Health Care Delivery

Medical care for workers’ compensation claims are provided through:

• Certified Workers’ Compensation Health Care Networks

• Non-network

• Political Subdivisions Arrangements (ex: Alliance)

Note: Informal Voluntary Networks no longer in existence as of 01/01/11

Claims

Certified Workers’

Compensation Health

Care Networks

Non-Network

Subscriber Claim Types

Public Employees

Screening questions

during

intake and beyond

Screening QuestionsScreening QuestionsScreening QuestionsScreening Questions• Is this a job related injury?****

• What is the date of injury?

• Who is the employer?

• Is the employer a subscriber?

• Have you reported this to youremployer and the Division?

****Ask this question more than once(could worded “where did this happen?”)

Rule 124.1 Notice of Injury

If no Employer's First Report of Injury has been filed, any other communication regardless of source, which fairly informs the carrier of the name of the injured employee, the identity of the employer, the approximate date of the injury and information which

asserts the injury is work related.

Your medical bill may serve as the first report of injury

Screening Questions (cont)

• Network / non-network/public employer?

• Is the provider a certified workers’ compensation health care network provider or public employee arrangement provider?

• Are there any outstanding disputes on compensability and/or extent of injury?

RULE §124.2 Carrier Reporting andNotification Requirements

(d) The carrier shall notify the TDI-DWC and the claimant of a denial of a claim (Denial) based onnon-compensability or lack of coverage in accordance with this section and as otherwise provided by this title.

*always bill the w/c carrier unless thereis a “final adjudication”

Rule 134.600 Preauthorization

(l) The carrier shall not withdraw a preauthorization or concurrent review approval once issued. The approval shall include:

(1) the specific health care;

(2) the approved number of health care treatments and specific period of time to complete the treatments; and

(3) a notice of any unresolved dispute regarding the denial of compensability or liability or an unresolved dispute of extent of or relatedness to the compensable injury.

Coverage Verification

Employer Coverage VerificationEmployer Coverage VerificationEmployer Coverage VerificationEmployer Coverage Verification• Coverage information about an employer on a

specific date

• Updated daily

• TDI-DWC webpage to find employer coveragehttp://www.tdi.state.tx.us/wc/data.html#coverage

• DWC Insurance Coverage section– 800-372-7713 option #6 or 512-804-4345.

http://www.tdi.state.tx.us/wc/si/selfinsurlist.html

Health & Workers’ Compensation Networks

Health & Workers’ Compensation Network Certification and QA Division (HWCN) TDI website (IRO information):

http://www.tdi.state.tx.us/company/iro_requests.html

Phone number: (512) 322-4266

Fax number: (512) 490-1013

Billing Requirements

Prohibition Against Billingthe Injured Employee

§413.042 & §133.20

A health care provider may not pursue a private claim against a workers' compensation claimant for all orpart of the cost of a health care service providedto the claimant by the provider unless:

– the injury is finally adjudicated not compensable; or

– the employee violates the law regarding the selection of a doctor and the doctor did not know of the violation at the time the services were rendered.

§413.042. PRIVATE CLAIMS; ADMINISTRATIVE VIOLATION.

If the Employer wants to PayIf the Employer wants to PayIf the Employer wants to PayIf the Employer wants to Pay§133.20133.20133.20133.20

The doctor may decide to accept payment of medical bills from the covered employer, however, the doctor waives the rights to:

• Prompt payment,

• Interest for delayed payment, and

• Division-provided medical dispute resolution.

• The doctor is still required to submit a copyof each bill to the carrier.

“THIS IS ONLY AN INFORMATION COPY. IT IS NOT A

REQUEST FOR PAYMENT.”

TDI-DWC Clean Claims Guide

• Need to review in order to know all the pieces of information needed to complete a medical bill

• Can be found here on our website on the ebill tab:

http://www.tdi.state.tx.us/wc/ebill/index.html

Billing Deadlines and Exceptions

A medical bill must be submitted within 95 days unless…

Exceptions to the 95 day deadline

408.0272 CERTAIN EXCEPTIONS FOR UNTIMELYSUBMISSION OF CLAIM

(1) the provider submits proof satisfactory to the commissioner that the provider, within the period prescribed by Section 408.027(a), erroneously filed for reimbursement with:

(A) an insurer that issues a policy of group accident and health insurance under which the injured employee is a covered insured;

(B) a health maintenance organization that issues an evidence of coverage under which the injured employee is a covered enrollee; or

(C) a workers' compensation insurance carrier other than the insurancecarrier liable for the payment of benefits under this title; or

(2) the commissioner determines that the failure resulted from a catastrophic event that substantially interfered with the normalbusiness operations of the provider.

Questions?

Thank You!