Speakers

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• Speakers
• Amy Morehouse
• Toya Lutz
• Texas Department of Insurance
• Division of Workers Compensation
• Legal Services, Enforcement

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• Complaint Resolution
• Enforcement Process
• Penalty Assessment

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Complaints

• Complaint is received by Complaint Resolution
• Alleged violator has 10 days to respond to
• Response is reviewed by an insurance specialist
  is it sufficient?
• Unjustified complaints
• Violation not detected
• Complaint is closed
• Closing correspondence sent to complainant with
  copy of alleged violators response
• Copy of closing correspondence sent to parties

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Complaints

• Justified complaints
• Violation of statute or rule occurred
• Resolve complaint (compliance achieved)
• Closed for monitoring or referred to Audits
  Investigations
• Monitoring/closure letter sent

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Carrier Violations

• Failure to pay for services that are
  preauthorized
• Timeliness of Medical Bill Payments
• Initial submission of the medical bill
• 45 days to pay or deny the medical bill
• Reconsiderations
• 21 days to pay or deny the medical bill
• Inappropriate denial of medical bills
• Late income benefit payments
• TIBs, IIBs, SIBs
• Failure to comply with orders

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Health Care Provider Violations

• Late filings
• DWC Form 069 Report of Medical Evaluation
• DWC Form 073 Work Status Report
• Letters of Clarification
• Failure to comply with an order to pay IRO fees
  for a retrospective medical necessity dispute
  review.
• Private claims against the injured employee

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Employer Violations

• Late filings
• DWC Form 001 - Employers First Report of Injury
• DWC Form 003 - Employers Wage Statement
• DWC Form 006 Supplemental Report of Injury
• Posting/Coverage
• Failure to post coverage
• Rights and responsibilities to employee

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Employees Violations

• Fraud cases
• Working and Drawing
• Failure to attend
• Benefit Review Conference (BRC)
• Contested Case Hearing (CCH)
• Required Medical Exam (RME)/Designated Doctor
  Exam (DDE)

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DWC Violation Cases Initiated FY 2008
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DWC Violation Cases Initiated FY 2008
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• Case Referrals Come From
• External Complaints Audits and Investigations
• Audit Results Audits and Investigations
• Internal Referrals including Medical Dispute
  Resolution, Hearings, and Executive Staff

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• Enforcement Process
• And
• Penalty Assessment

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ENFORCEMENT PROCESS
DWC LEGAL SERVICES
Enforcement Management Conference (EMC) An EMC
allows the alleged violator an opportunity to
disprove the allegations and provide mitigating
evidence to help DWC determine the appropriate
penalty
Penalty Not Agreed To NOV and CO issued. NOV
contains penalty amount that DWC will request at
hearing. CO contains penalty amount which is the
settlement offer.
Penalty Agreed To Agreed Notice of Violation
(NOV) and Consent Order (CO) for penalty issued
after EMC
More information is needed to determine
appropriate resolution after EMC
CO is signed by both parties and penalty is paid
After facts are resolved settlement is initiated,
and NOV and CO are issued
Request for hearing may be made within 20 days of
the NOV being issued
CO may be signed by both parties and penalty paid
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PENALTY ASSESSMENT

• Violations occurring after September 1, 2005 may
  receive a penalty of up to 25,000.00 per day per
  occurrence.
• Factors Considered
• Texas Labor Code 415.021(c)
• The seriousness of the violation
• The history and extent of previous violations
• Demonstrated good faith of the violator
• Penalty necessary to deter future violations
• Other matters justice may require
• The economic benefit resulting from the
  prohibited act.
• Performance Based Oversight Tiering

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Failure to Comply with an Order10,000-----------
---------------------------25,000
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Failure to Timely take action on a Medical
Bill1,000--------------------------------------
10,000
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Failure to pay for Medical Services that were
Preauthorized10,000-----------------------------
---------18,000
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Carrier Group Name XYZ Insurance Group (average
Tier)
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Whats New in Enforcement!

• Enforcement Management Conferences
• Identify problems and find solutions
• Increased communication between the parties
• Increased settlement and fewer requests for
  hearing
• Fewer Enforcement Management Conferences in the
  future
• Quality Review Cases for Health Care Providers
• Hospital Billing Practices Investigation