Texas Department of Insurance

1
Texas Department of Insurance

• HWCN Division

2
Examination of Certified Workers Compensation
Networks

• An Overview of the
• Examination Process

3
Authority and Purpose

• The Health Workers Comp Network Certification
  Quality Assurance (HWCN) Division of the Texas
  Department of Insurance (TDI) conducts
  examinations of Certified WC Networks (Network)
  to determine compliance with Chapter 1305, Texas
  Insurance Code (TIC), and 28 Texas Administrative
  Code (TAC), Chapter 10, including other
  applicable requirements.

4
Exam Timeframeand Location

• First Exam is conducted approximately one year
  after the Network was Certified and has active
  injured employees during the network.
• Exams may be triennial.
• If the Networks office is located in Texas,
  TDIs Exam Team will visit the Network for one
  day to conduct the On-Site portion of the Exam.
  If the Networks office is not located in Texas,
  Network personnel will be requested to travel to
  TDIs Austin, TX headquarters for one day.

5
The Exam Team

• TDIs exam team will consist of a Team Leader
  and other HWCN Division staff members.
• The Team Leader will be the Networks primary
  contact during the exam process.
• The Network will pay for costs directly
  attributed to the exam, including actual salaries
  of examiners, transportation, lodging, meals, and
  parking fees. More information can be found at
  http//www.tdi.state.tx.us/rules/2007/1217-059.htm
  l.

6
The Opening Letter

• Approximately 60 days prior to the date of TDIs
  site visit, the Exam Team Leader will send an
  Opening Letter to the Network.

7
The Opening Letter

• Confirms the date of the on-site exam
• Requests reports and/or studies regarding
  return-to-work outcomes
• Requests a Questionnaire be completed and
  returned to TDI within 30 days of receiving the
  Opening Letter.
• Complaints
• Providers
• Delegation Agreements
• Utilization Review
• Access Availability

8
Opening Letter cont.

• Requests the following be returned to TDI within
  10 days of receiving the Opening Letter
  (electronic versions preferred)
• Complaint Appeal Logs
• Utilization Review Logs
• List of Participating Providers (Excel format
  preferred)
• Network Provider Maps indicating 30, 60, 75-mile
  radii for
• Treating Doctors
• General/Acute Hospitals
• Specialists (separate maps for each specialty)

9
File Requests

• After TDI receives all previously requested logs
  lists, the Team Leader will request specific
  files from a random sample be received by TDI
  within 10 days of our request
• Complaint and Appeal Files
• Utilization Review Files
• Credentialing Files
• Other documents as needed to complete Exam

10
NOTE

• TDI staff attempts to identify all documents that
  must be available prior to and during the exam,
  but it may be necessary to request additional
  information and documentation to complete the
  examination.

11
Desk Review

• At TDIs headquarters in Austin, Texas, the Exam
  Team begins reviewing all documents provided to
  TDI utilizing WCN checklists found on TDIs
  website at http//www.tdi.state.tx.us/forms/form19
  .html.
• Conference calls with key Network staff may be
  requested during this period.

12
On-site Exam

• Entrance Conference
• Review of Quality Improvement Committee Minutes
  and Annual Report
• Interviews with Key Network Staff
• Claims, Complaints, Credentialing, Utilization
  Review, and Quality Improvement Directors
• Medical Director
• Chief Operating/Executive Officer
• Exit Conference

13
Post Exam

• Draft Exam Report is sent to the Network within
  10 business days of the On-site Exam
• Network has 10 business days to review and
  provide additional documentation
• Official Exam Report is sent to Network within
  30 days of receiving additional documentation OR
  30 days from the date of the On-Site Exam, if no
  additional documentation is provided to TDI
• Network will submit a corrective action plan to
  TDI within 30 days of receiving the Official Exam
  Report
• Network has the right to appeal portions of the
  Exam, if applicable

14
Accreditation?

• If a Certified Workers Compensation Network
  holds a non-conditional accreditation from any of
  the accrediting organizations listed in 28 TAC
  10.81(c), the Network must provide evidence to
  TDI to be presumed compliant.

15

• TEXAS DEPARTMENT OF INSURANCE
• Health and WC Network Certification QA
• Mail Code 103-6A 512-490-1013 fax
• HWCN_at_tdi.state.tx.us
• IRO
• MC 103-5A 512-490-1011 fax
• WC Networks
• MC 103-5B 512-490-1028 fax
• WCNET_at_tdi.state.tx.us
• 333 Guadalupe P.O. Box 149104
• Austin, Texas 78714-9104
• 866-554-4926 toll free 512-322-4266
• www.tdi.state.tx.us