Workers Compensation Peer Review Data Call: Preliminary Results

1
Workers Compensation Peer Review Data Call
Preliminary Results

• Workers Compensation Research and Evaluation
  Group

2
Purpose of Divisions Data Call

• To collect objective information regarding
• The frequency and cost of peer reviews requested
  by insurance carriers
• The reasons why peer reviews are requested
• The types (licensure) of doctors performing peer
  reviews
• The opinions of peer review doctors and
• The actions taken (or not) by insurance carriers
  as a result of the peer review.

3
Summary of Data Call

• Division of Workers Compensation (Division)
  issued data call in late July 2006
• This is the first time this type of information
  has been collected on WC peer reviews
• 25 insurance carriers were asked to submit data
  on every peer review they received during
  September and October 2006
• These 25 insurance carriers represented
  approximately 70 of the medical payments in
  2003 and
• Data was submitted to the Division at the end of
  December 2006.

4
General Data Call Results

• A total of 11,437 peer reviews received during
  Sept/Oct 2006 by the 25 insurance carriers
  included in the data call
• These peer reviews were conducted on
  approximately 8,583 WC claims
• Approximately 655 doctors (58 Texas licensed/42
  non-Texas licensed) conducted these reviews.

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Frequency, Cost and Type of WC Peer Reviews
Requested
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Percentage of Peer Reviews Conducted by Primary
Reason
Source Texas Department of Insurance, Workers
Compensation Research and Evaluation Group,
Analysis of Divisions Peer Review Data Call,
2007. Note 1 Three peer reviews were missing
information indicating the primary reason they
were conducted. Note 2 Other reasons include
reviews of impairment ratings, adjustment to
reserves, etc.
7
Percentage of Peer Reviews Conducted by Cost
Range and Primary Reason
Source Texas Department of Insurance, Workers
Compensation Research and Evaluation Group,
Analysis of Divisions Peer Review Data Call,
2007. Note 1 Forty-five peer reviews were
missing information indicating the primary
reason they were conducted or the cost of the
review. Note 2 Other reasons include reviews
of impairment ratings, adjustment to reserves,
etc.
8
Type and Licensure of Doctors Performing Peer
Reviews
9
Percentage of Peer Reviews Conducted by
Texas/Non-Texas Licensed Doctors by Primary
Reason
Source Texas Department of Insurance, Workers
Compensation Research and Evaluation Group,
Analysis of Divisions Peer Review Data Call,
2007. Note 1 Five peer reviews were missing
information indicating the primary reason they
were conducted or the licensure of the peer
review doctor. Note 2 Other reasons include
reviews of impairment ratings, adjustment to
reserves, etc.
10
Percentage of Peer Reviews Conducted by Type of
Doctor and Primary Reason
Source Texas Department of Insurance, Workers
Compensation Research and Evaluation Group,
Analysis of Divisions Peer Review Data Call,
2007. Note 1 Ten peer reviews were missing
information indicating the primary reason they
were conducted or the type of peer review doctor
conducting the review. Note 2 Other reasons
include reviews of impairment ratings, adjustment
to reserves, etc. Other providers include
social workers, nurses, nurse practitioners, etc.
11
Peer Review Opinions and Carrier Actions
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Peer Review Opinions by Primary Reason Peer
Review Was Requested
Source Texas Department of Insurance, Workers
Compensation Research and Evaluation Group,
Analysis of Divisions Peer Review Data Call,
2007. Note Peer review opinions related to
issues such as extent of injury, ability to
return to work, treatment planning and other
issues are not included here since this analysis
has not yet been completed.
13
Peer Review Opinions by Primary Reason Peer
Review Was Requested and Texas/Non-Texas Licensure
Source Texas Department of Insurance, Workers
Compensation Research and Evaluation Group,
Analysis of Divisions Peer Review Data Call,
2007. Note Peer review opinions related to
issues such as extent of injury, ability to
return to work, treatment planning and other
issues are not included here since this analysis
has not yet been completed.
14
Carrier Actions as a Result of Peer Reviews
Conducted

• Overall, approximately 45 of all peer reviews
  reported in the data call resulted in some sort
  of adverse action taken by the insurance carrier
  (e.g., denial of medical necessity, denial of
  claim, denial of benefits).

15
Percentage of Medical Necessity Peer Reviews that
Resulted in an Adverse Carrier Action by
Texas/Non-Texas Licensure
Source Texas Department of Insurance, Workers
Compensation Research and Evaluation Group,
Analysis of Divisions Peer Review Data Call,
2007. Note Peer review opinions related to
issues such as extent of injury, ability to
return to work, treatment planning and other
issues are not included here since this analysis
has not yet been completed.
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Additional Analyses To Be Conducted

• Specialties of MD/DO peer review doctors
• Comparison of peer review doctor specialties with
  specialties of doctors being reviewed
• Peer review opinion and carrier action outcomes
  for other primary reasons the peer review was
  requested
• Carrier actions compared to peer review opinions
• Information on the types of claims being
  reviewed and
• Approved Doctor List (ADL) status of peer review
  doctors