Risk Management User Group

Risk Management User Group October 18, 2007

WELCOMEMichael L. Hay, CRM, CGFM, CPPM

MEETING AGENDA 8:30 – 9:00 Legislative Update Jonathan Bow 9:00 –10:00 Claims Update Gordon Leff 10:00 – 10:15 BREAK 10:15 – 11:00 Document Restoration Tom McGuire, Munters 11:00 – 11:15 Training System Erin Thompson 11:15 – 12:00 Cyber Risk Neeraj Sahni AIG

LEGISLATIVE UPDATE Jonathan Bow Executive Director

CLAIMS UPDATE Gordon Leff Deputy Director Claims Operations

Bills may be obtained from the Texas Legislature Online Website at:http://www.capitol.state.tx.us

H.B. 34 By: Solomons, Leibowitz • The bill amends the Labor Code to prohibit certain payments or inducements regarding a workers' compensation claim and provide an administrative violation for such a payment or inducement.

H.B. 34 By: Solomons, Leibowitz cont. • ADMINISTRATIVE VIOLATION BY PERSON PERFORMING CERTAIN CLAIM MANAGEMENT SERVICES. (a) This section applies to an insurance adjuster, case manager, or other person who has authority under this title to request the performance of a service regarding the management of a workers' compensation claim, including peer review, performance of a required medical examination, or case management.

H.B. 34 By: Solomons, Leibowitz cont. • For purposes of this section, a violation is committed if the adjuster, manager or other person offers to pay, pays, solicits, or received an improper inducement relating to the delivery of benefits to an injured employee; or improperly attempts to influence the deliver of benefit to an injured employee, including through the making of improper threats.

S.B. 1627 • This bill provides that a person who commits an offense of fraud under the Texas Labor Code Chapter 418 (Criminal Penalties) may be prosecuted under that chapter or any other applicable state law, including the Texas Penal Code. These changes became effective June 15, 2007.

SB 458 by: Senator Watson • If an orthotic or prosthetic device is damaged in a workers' compensation injury, the insurance carrier must repair or replace that device.

H.B. 472 By: Solomons The bill prohibits a third-party administrator from knowingly referring a claim or loss for adjustment to a person acting as or claiming to be an insurance adjuster without the appropriate license and prohibits an insurer from referring a claim or loss for administration to a person acting as or claiming to be an administrator without the appropriate certificate of authority. It sets out an insurer's responsibilities when using an administrator's services and requires the insurer to conduct regular reviews and on-site audits of the administrator's operations.

H.B. 473 BY: Solomons • Voluntary or Informal Networks Voluntary or informal networks are now regulated until January 1, 2011 when they will be eliminated and forced to operate only as a certified workers' compensation health care network This bill outlines certain contractual duties under a voluntary network.

H.B. 473 BY: Solomons cont. • Oh and by the way…House Bill 473 requires that the benefit review officer presiding at a benefit review conference, rather than other division staff designated by the workers' compensation commissioner, consider a request for an interlocutory order and give the opposing party the opportunity to respond before issuing such an order.

Allows for CCH regarding determination of the retrospective medical necessity for a health care service for which the amount billed does not exceed $3,000; and 3) an appeal of an independent review organization decision regarding determination of the concurrent or prospective medical necessity for a health care service. H.B. 724 By: Solomons (1) a medical fee dispute in which the amount of reimbursement sought by the requestor in its request for medical dispute resolution does not exceed $2,000; (2) an appeal of an independent review organization decision

Allows for SOAH A party to a medical dispute, other than a medical dispute regarding spinal surgery subject to Subsection (l) and a dispute subject to Section 413.0311, that remains unresolved after a review of the medical service under this section is entitled to a hearing. A hearing under this subsection shall be conducted by the State Office of Administrative Hearings not later than the 60th day after the date on which the party notifies the division of the request for a hearing. The hearing shall be conducted in the manner provided for a contested case under Chapter 2001, Government Code. H.B. 724 By: Solomons Cont.

H.B. 724 By: Solomons Cont. • If an accident or health insurance carrier or other person obligated for the cost of health care services has paid for health care services for an employee for an injury for which the workers' compensation insurance carrier or the employer has not disputed compensability,

H.B. 724 By: Solomons Cont. • the accident or health insurance carrier or other person may recover reimbursement from the insurance carrier in the manner described by Section 409.009 or 409.0091, as applicable.

H.B. 724 By: Solomons Cont. • The health insurance carrier failed to seek reimbursement from the health care provider or the insured, • the-health care provider does not have to seek-preauthorization from the workers' compensation carrier, and • the health care provider did not bill the workers‘ compensation carrier within 95 days of the date of service. (

H.B. 724 By: Solomons Cont. A surviving parent, under certain conditions, to be eligible for death benefits in a workers' compensation case for a benefit period not to exceed two years.

H.B. 886 By: Giddings Instituted a pre authorization program for the return-to-work pilot program for small employers

HB 1003 by Giddings House Bill 1003 amends the Labor Code and the Insurance Code to provide that an independent review organization using doctors to review health care services relating to workers' compensation claims may use only doctors licensed to practice in this state

HB 1006 by Giddings • House Bill 1006 amends the Labor Code and the Insurance Code to limit the performance of such reviews to doctors licensed to practice in this state, to specify that the reviews include utilization and retrospective reviews, and to extend these requirements to an insurance carrier. The bill also amends the Insurance Code to provide that the limit on the amount a health care provider can charge for providing medical information to a utilization review agency is the cost of copying records relating to a workers' compensation claim.

H.B. 1005 By: Giddings • Amends the Labor Code to provide for reimbursement if the claim is filed in a timely manner but is erroneously filed with the wrong insurer or if the commissioner of workers' compensation determines that the failure to submit a timely claim was due to a catastrophic event that substantially interfered with the provider's normal business operations. The bill also allows for an extension of the deadline for submission upon agreement of the parties.

S.B. 1169 By: Janek • require the subsequent injury fund to reimburse an insurance carrier for any overpayment of benefits made by the insurance carrier under Subsection (f) based on an opinion rendered by a designated doctor if that opinion is reversed or modified by a final arbitration award or order, or decision of the commissioner of workers' compensation (commissioner) or a court

S.B. 1169 By: Janek cont Interlocutory Orders: Requires the benefit review officer who presides at the benefit review conference to consider a written or verbal request for an interlocutory order for the payment of benefits and, if the benefit review officer determines that issuance of an interlocutory order is appropriate, to issue the interlocutory order not later than the third day after the date of receipt of the request

HB 2004 by: Giddings • Amends the Labor Code to require certain health care professionals who review a workers' compensation case to hold a professional certification in a health care specialty appropriate to the type of health care that the injured employee is receiving. The bill includes similar provisions applicable to dentists and chiropractors who review services provided in a workers' compensation case, requiring them to be licensed to engage in their respective practices as a condition for performing a peer review, utilization review, or independent review of a case.

S.B. 908 By: Brimer • Senate Bill 908 amends the Labor Code to continue the State Office of Risk Management to September 1, 2019, to incorporate various new and revised across-the-board sunset provisions relating to the office, and to provide for the confidentiality of state employees' workers' compensation claim files.

What’s Hot In Comp ?

Medical Fees for Hospitals • Supplemental Income Benefits (SIBs) • Medical Disability Rules • Return to work

BREAK See you in 15 minutes

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Risk Management User Group