A Health Care Providers Intake and Registration Practices

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A Health Care Providers Intake and
Registration Practices
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• Amy Rich
• TDI DWC Communications
• Twyla Fuertes
• and
• Tracy Cummins
• Texas Orthopedics, Sports and Rehabilitation
  Associates

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• Objectives
• Understand the Texas workers compensation system
• Know how to identify a workers compensation
  claimant through your intake process
• Understand Billing Requirements

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• Topics to be covered
• Texas Law and Rules
• Responsibilities
• Employer
• Carrier
• Injured Employee
• Health Care Provider
• Intake Screening Questions and Employer Coverage
  Verification
• Billing
• Billing the Injured Employee
• Billing the Employer
• Billing Requirements
• Know billing deadlines and exceptions
• Clean Claims Guide

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Understanding the Texas Workers Compensation
System

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Workers Comp Regulation
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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 political subdivisions
• Examples School districts, counties, state
  government
•  
• 504.011.  METHOD OF PROVIDING COVERAGE.  
• A political subdivision shall extend workers'
  compensation benefits to its employees

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Workers Compensation System

• Employers pay premiums to
• Insurance companies that pay
• benefits to
• Injured employees, or their families.

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• Employer Responsibilities
• www.tdi.state.tx.us/wc/employer/index.html
• 406.002 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
  Network Requirements to the employees

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• Employer Responsibilities
• www.tdi.state.tx.us/wc/employer/index.html
• CHAPTER 120. COMPENSATION PROCEDURES -
  EMPLOYERS
• Report the injury to its insurance carrier and
  keep a date on which it notified the insurance
  carrier
• Provide a copy of the Employers First Report of
  Injury or Illness to the injured employee
• Provide a copy of the injured employees rights
  and responsibilities form

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• Insurance Carrier Responsibilities
• 406.031 An insurance carrier is liable for
  compensation for an employees 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 Notice of Network
  Requirements which must be provided to the
  employees

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• Injured Employees Right to Medical Care
•  408.021.  ENTITLEMENT TO MEDICAL BENEFITS  
• (a)  An employee who sustains a compensable
  injury is entitled to all health care reasonably
  required by the nature of the injury as and when
  needed. The employee is specifically entitled to
  health care that

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• Injured Employees Responsibilities
• Must tell the employer within 30 days of the date
  they were injured or first knew their injury or
  illness might be work related
• Must know if their claim is part of a certified
  network
• If they work for a political subdivision, they
  must follow their rules for selecting a doctor
• Must tell their doctor how they were injured and
  whether the injury is work related
• Must tell the Division within 1 year by
  completing a DWC041
• http//www.tdi.state.tx.us/wc/employee/index.htm
  l

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• Injured Employee Assistance
• The injured employee can contact the Office of
  Injured Employee Counsel (OIEC) by calling the
  toll-free telephone number 1-866-EZE-OIEC(1-866-39
  3-6432). Also, more information is available on
  the Internet at
• www.oiec.state.tx.us

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Health Care Provider Roles and Responsibilities
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• What is required to treat workers compensation
  claimants?
• Active Medical License
• Disclose financial interests to DWC
• Never been sanctioned by DWC (removed from the
  former DWC ADL)
• Change of Treating Doctor form (DWC053) approval
  if patient changing from one treating doctor to
  you as a treating doctor
• Set up profile in TXCOMP (optional)

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• Doctor 401.011(17)
• Doctor of medicine,
• Doctor of osteopathic medicine,
• Doctor of optometry,
• Doctor of dentistry,
• Doctor of podiatry, and
• Doctor of chiropractic

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• Other Health Care Practitioners
• Physician Assistants,
• Nurse Practitioners,
• Physical Therapists,
• Occupational Therapists,
• Psychologists, and
• Others

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• 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)

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• 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.

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• Roles and Responsibilities180.22
• 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.

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• Roles and Responsibilities180.22
• Required Medical Exam Doctor (RME)
• Requested by the carrier to evaluate the
  employees medical condition after a DD
  evaluation.
• Is limited to an evaluation of the
  appropriateness of medical care prior to an
  examination by a DD.
• May not make referrals, initiate or provide
  treatment.

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• 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
  health care that the injured employee is
  receiving (408.0043).

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Health Care Delivery
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• Medical care for workers compensation claims are
  provided through
• Certified Workers Compensation Networks
• Non-network
• Informal/Voluntary Networks

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• Screening questions
• during
• intake and beyond

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Screening 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 your employer and the
  Division?
• Ask this question more than once (could
  worded where did this happen?

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• 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

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• Screening Questions contd
• Network / non-network?
• Is the provider a certified network provider?
• Are there any outstanding disputes on
  compensability and/or extent of injury?

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• RULE 124.2 Carrier Reporting and Notification
  Requirements
• (d) The carrier shall notify the Commission and
  the claimant of a denial of a claim (Denial)
  based on non-compensability or lack of coverage
  in accordance with this section and as otherwise
  provided by this title.

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• Rule 134.600 Preauthorization
• (l) The carrier shall not withdraw a
  preauthorization or concurrent review approval
  once issued. The approval shall include
• 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.

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• Coverage Verification

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Verify Here
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• Employer Coverage Verification
• Coverage information about an employer on a
  specific date
• Updated daily
• Accessed through the TXCOMP system
• Verify Employer Coverage http//www.tdi.state.tx
  .us/wc/indexwc.html
• DWC Insurance Coverage section
• 800-372-7713 or 512-804-4345.
• Certified Self-Insured Employers
• http//www.tdi.state.tx.us/wc/si/index.html

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http//www.tdi.state.tx.us/wc/si/selfinsurlist.htm
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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.ht
  ml
• Phone number [phone]
• Fax number [phone]

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Billing Requirements
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Prohibition Against Billing the Injured
Employee413.042 133.20

• A health care provider may not pursue a private
  claim against a workers' compensation claimant
  for all or part of the cost of a health care
  service provided to 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.

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If the Employer wants to Pay133.20

• 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 copy of
  each bill to the carrier.
• THIS IS ONLY AN INFORMATION COPY. IT IS NOT A
• REQUEST FOR PAYMENT.

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• 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

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• Billing Deadlines and Exceptions
• A medical bill must be submitted within 95 days
  unless

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• Exceptions to the 95 day deadline
• 408.0272 CERTAIN EXCEPTIONS FOR UNTIMELY
  SUBMISSION 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 insurance carrier 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 normal business
  operations of the provider.

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• Questions?

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• Texas Orthopedics, Sports and Rehabilitation
  Associates
• Twyla Fuertes and Tracy Cummins