A Guide to Workers’ Compensation Health Care Networks

1. A Guide to Workers’ CompensationHealth Care Networks HWCN Division Texas Department of Insurance

2. Goals of House Bill (HB) 7 • Each employee shall be treated with dignity and respect when injured on the job • Each injured employee shall have access to a fair and accessible dispute resolution process • Each injured employee shall have access to prompt, high-quality medical care within the framework established by the Texas Workers’ Compensation Act • Each injured employee shall receive services to facilitate the employee’s return to employment as soon as it is considered safe and appropriate by the employee’s health care provider

3. Goals for WC Networks • Authorize the establishment of workers’ compensation health care networks for the provision of workers’ compensation medical benefits • Provide standards for the certification, administration, evaluation, and enforcement of the delivery of health care services to injured employees by networks

4. What is a “Workers' Compensation Health Care Network”? An organization that is: • Formed to provide health care services to injured employees • Certified in accordance with Insurance Code Chapter 1305 and Commissioner rules • Established by, or operating under contract with, an insurance carrier

5. Who can be a WC network? Examples include: • Individual • Partnership • Association • Corporation • Organization • Trust • Limited liability companies and partnership • Hospital district • Community mental health centers, mental health and mental retardation center • HMO • PPO

6. Certification Process • Application – 26 pending • Two certified networks • Texas Star Network/Concentra • Concentra HCN • 60-day review by TDI • Applicant may request an extension • TDI may deny request for extension

7. Major Components of Application • Major components of application • Officers and directors biographical affidavits • Insurance carrier, provider & third-party contracts • Management contracts • Financial information including a business plan • Service area description and maps • List of contracted, credentialed providers • Proof of accessible, available, comprehensive care • Treatment and return to work guidelines • Monitoring plan for providers • Doctor and health care practitioner financial disclosure

8. Texas Star Network Service Area

9. Concentra HCN Service Area

10. Provider Contracts Network application includes: • Copy of the form of any contract with • Providers • Group of Providers • Contracts are confidential • Contracts are not subject to disclosure as an open record

11. Requirements for Provider Contracts • No transfer of risk • Hold-harmless clause for injured employees • Provider agrees to network treatment guidelines • No denial based solely on treatment not listed on treatment guidelines • Continuity of treatment/90 days • Provider appeal process for terminations • Advance notice of economic profiling • No retaliation for filing complaints or appeals on behalf of injured employees

12. Requirements for Provider Contracts • Advance notice to provider of termination • Notices to injured employees of provider termination • Reimbursement fee schedules • In-office provider notices re: complaints to TDI • Agreement to participate in certified network Financial incentives are not allowed Network doesn’t have to accept applications of providers if sufficient number contracted

13. How will we know which doctors are in which network? • Networks are required to create provider directories to include all of their contracted providers • Providers could be in more than one network • It will be up to the networks to maintain current directories for TDI to access as needed

14. Is there a limit on how far someone will be required to travel to see a network doctor? • In urban areas, there are limits of 30 miles for treating providers and 75 miles for specialists • In rural areas, the mileage limit is 60 miles for treating providers and 75 miles for specialists • There may be some areas where the standard of care is to travel farther for routine care • If a network cannot demonstrate that it has access to treating providers and specialists within the required mileage radii, an access plan must be filed with TDI • There are specific requirements for the network to include in its access plan • TDI will not certify a network that is arranging care solely through access plans

15. Changes to the Network • Once a network is certified, changes to the original application must be filed with TDI • Two types of changes: • For approval 30 days prior to implementing: • Changes to management contracts • Changes to physical location of books & records • Material modification of network configuration • Change to existing service area or addition of new service area • All other changes within 30 days of implementation

16. Network Access Requirements • All services must be provided by a provider who holds a current appropriate license • Unlessthe provider is exempt from license requirements

17. Network Access Requirements The provider panel must: • Include an adequate number of treating providers (doctors and specialists) • Be available 24 hours a day, seven days a week, within the network service area Necessary hospital services within the service area must be: • Available and accessible • 24 hours a day • 7 days a week • Provided by contracts with general, special, and psychiatric hospitals

18. Network Access Requirements Other services required to be available and accessible in the service area are: • Physical and occupational therapy • Chiropractic

19. Network Access Requirements Emergency care must be available and accessible: • 24 hours a day • 7 days a week • Without restrictions = where the services are rendered Except for emergencies, the network shall: • Not later than 21 calendar days after the date of the original request, arrange for services on a timely basis (includes Specialist Referrals)

20. Employee Information and Responsibilities • Written notice for employees must include in a clear, complete, and accurate format: • Statement that entity is a WC network • Network’s toll-free number and address • Statement that injury event requires selection of treating doctor • All care from network providers except ER or approved out-of-network services • Explanation of hold-harmless • Statement of employee liability for out-of-network care not approved by network • Emergency care information

21. Employee Information and Responsibilities • Written notice must include in a clear, complete, and accurate format: • List of services requiring preauthorization or concurrent review • Continuity of treatment provisions • Description of complaint system; no retaliation • Summary of procedures relating to adverse determination and Independent Reviews • List of network providers, access limitations and providers accepting new patients • Description of network’s service area • Timely provision of health care services

22. Employee Acknowledgement Form • Carrier and employer may use a form that complies with this section or a sample form available from TDI • Form must include: • Statement of employee’s responsibility to obtain network services • If employee is injured and lives in service area, then the employee must: • Must select a treating doctor • May ask HMO PCP to be treating doctor • Must obtain all services from network providers except emergency care

23. Insurance Carrier Liability for Out-of-Network Health Care • Emergency care • Health care provided to an injured employee who does not live within the service area of any network established by the carrier or with which the carrier has a contract • Health care provided by an out-of-network provider pursuant to a referral from the injured employee’s treating doctor that has been approved by the network • Health care services provided to an injured employee before the employee received notice of network requirements and information about the appropriate network and service area

24. Treating Doctor Selection • The network determines which specialties can serve as treating doctors • If dissatisfied with choice, employee may choose an alternate & must notify the network in the manner prescribed • Network may not deny a selection of an alternate treating doctor • Specialists and HMO PCP as treating doctor

25. Special Issues What is not considered initial selection of treating doctor: • A doctor providing emergency care • A doctor salaried by the employer • Any doctor who provides care before the employee is notified of the network, except for a doctor selected under 1305.105 (HMO PCP)

26. Special Issues • Employee lives outside network service area • Referral outside network • Specialty care • Service not available in network • Timely referrals • TDI will monitor • Treating doctor dies, retires, or leaves network

27. Treatment Parameters • Must adopt treatment guidelines, return-to-work guidelines, and individual treatment protocols • Treatment guidelines and protocols must be evidence-based, scientifically valid, outcome- focused, and designed to reduce inappropriate or unnecessary health care while safeguarding necessary care

28. Payment Structure • Reimbursement determined by contract • Billing by and reimbursement to contracted and out-of-network providers must be done in accordance with the Texas Workers’ Compensation Act and applicable rules • Carriers must notify network providers in writing if an injury is not compensable

29. Preauthorized Treatment • Network is required to list procedures that require preauthorization • If preauthorized, then the treatment cannot subsequently be denied based on medical necessity • Treatment could be denied for other reasons

30. Network’s Complaint Process • Must include: • Reasonable procedures for resolving oral and written complaints • Notify complaint of right to complain to TDI • May use 90-day deadline for filing a complaint • Complaint information must be saved for three years from date the complaint was received • Networks must keep complaint logs for each complaint

31. How to Complain to TDI • Anyone may submit a complaint • Use online complaint form at www.tdi.state.tx.us • Send complaint to: HWCN Division, Mail Code 103-6A Texas Department of Insurance PO Box 149104, Austin, Texas  78714-9104 • Fax complaint to 512-490-1012 • Send e-mail complaint to: HmoNewComplaints@tdi.state.tx.usor ConsumerProtection@tdi.state.tx.us

32. Rules to Review • http://www.tdi.state.tx.us/wc/rules/planning/ruleschart.html

33. WC Network Web Resource Page • http://www.tdi.state.tx.us/wc/wcnet/index.html

34. Workers’ Compensation Working Group (WCWG) http://www.tdi.state.tx.us/consumer/wcnetiwg.html

35. WCWG • All stakeholders represented • Web resource page includes meeting agendas and summaries • Topics discussed: • WC network development • All networks including “tailored networks” must be certified separately • Silent PPO panel discussion • Performance-based oversight • Outreach to providers, employees, employers

36. Questions? • Send an e-mail to wcnet@tdi.state.tx.us • Please include your contact information and phone number • Call TDI Health and Workers’ Compensation Network (HWCN) staff • 800-252-3439 or • 512-322-4266