FREQUENTLY ASKED QUESTIONS FOR PROVIDERS

TEXAS WORKERS COMPENSATION REFORMS

Q.  Does HB 7 allow for the use of networks by insurance carriers?

A.  Yes.  HB 7 allows for the creation of workers compensation health networks to provide health care services to injured workers.  Under HB 7, an insurance carrier (including insurance companies, certified self-insured employers, group self-insured employers, and governmental entities) may establish or contract with a workers’ compensation health network.

Q.  What are the requirements for setting up a workers’ compensation health network?

A.  There are specific requirements in HB 7 relating to networks, including financial requirements, contracting requirements, access and availability of care requirements, quality improvement program and case management requirements. 

Q. When will proposed rules on networks be available?

A.  The network rules are to be adopted by the Commissioner of Insurance not later than December 1, 2005.   Proposed rules regarding workers’ compensation health care networks are posted on the TDI website (http://www.tdi.state.tx.us) and published in the September 2, 2005 issue of the Texas Register (30 TexReg 5099).  Written comments on the proposed rules must be submitted as specified in the proposal no later than 5:00 p.m. on October 3, 2005.  Adoption of the proposed rules will be considered in a public hearing under Docket No. 2622 scheduled for Thursday, October 6, 2005 at 9:30 a.m., 1400 N. Congress, Austin, Texas.  The public hearing may be continued through October 7, 2005, if necessary.  A complete timeline for development of these rules can be accessed through the following link: http://www.tdi.state.tx.us/wc/transition/twcc5.html.

Q.  When will there be stakeholder meetings on networks?  

A.  A stakeholder meeting on networks was held on July 12, 2005.  Notification of future stakeholder meetings will be provided on the TDI website and through e-mail to interested parties.

Q.  I am currently on the ADL.  Will I need to join a network to treat workers’ compensation patients?

A.  No.  An injured worker may continue to see any provider on the Approved Doctor List (ADL), which is in effect until September 1, 2007, if the injured worker is not covered by a workers’ compensation health care network plan or if the injured worker lives outside the service area of his network plan.  Emergency care may be provided by non-network providers to any injured worker. 

Q.  Some entities are forming networks now in anticipation of becoming a certified network. How can I identify and contact entities that might be forming workers' compensation health care networks?

A.  You can contact HMOs and preferred provider networks that have enrollees in your area, especially those with which you are already participating, to determine if they intend to obtain certification as workers' compensation health care networks.  If you are already treating injured workers, you might contact the injured workers' insurance carriers to determine if the insurance carriers intend to form their own network or to learn the names of any groups that are forming networks.

Q.  I am interested in joining a workers compensation health care network. How will I know when a network is formed so I can apply as a provider?

A. HB 7 stipulates that a person may not operate a workers' compensation health care network unless the person holds a certificate issued under Insurance Code Chapter 1305 and related rules.  These rules are scheduled for adoption by December 1, 2005, and TDI will begin accepting applications for certification starting January 1, 2006.  In anticipation of filing an application for certification, interested entities may be forming their networks before January 2006.  The names of certified workers compensation health care networks will be public information that is available upon request.  In addition, we anticipate that we will be posting the names of networks on the TDI web site as they become certified.

Q.  Can a group of specialists be certified as a workers' compensation health care network?

A. No, a group that includes only one or two specialties will not meet the requirements of HB 7.  In order to be certified, a workers' compensation health care network must demonstrate that it has contracted with a sufficient number of treating doctors, specialists, ancillary providers and institutional providers in order to furnish comprehensive health care services to injured employees.  A group of specialists may contract to join a network that meets the requirements of the statute.

Q.  I am not part of a network.  Can a network provider refer patients to my specialty practice?

A.  Yes, but only in certain circumstances.  When an injured worker is covered under a workers’ compensation network policy, he or she must choose a treating doctor from the list of treating doctors maintained by the network.  If specialty treatment or other health care services are required, the injured worker must be referred by thetreating doctorto other network providers for such care.  However, if the specialty treatment or other health care services are not available within the network, a treating doctor must refer the injured worker to a provider outside the network, after approval by the network.

Q.  Who will be a treating doctor in a network?

A.  The network determines the specialty or specialties of doctors who may serve as treating doctors .  However, even if a specialty is excluded as being a treating doctor for that network, providers of that specialty may provide health care services if they are in the network and the injured worker is referred to that provider by the treating doctor. 

Q.  Can a workers' compensation health care network deny me the right to be a participating provider in its network?

A.  HB 7 requires a workers' compensation health care network to demonstrate that its network is adequate and has sufficient providers to meet the needs of injured workers. However, the bill does not require a network to contract with every provider who applies. The bill provides that a network is not required to accept an application for participation from a qualified provider if the network determines that the network has contracted with a sufficient number of qualified providers.

Q.  An injured employee I am currently treating informed me that his employer made him sign a form and provided the employee information about a new workers’ compensation network.  The employee said he must now select a provider from the network.  Can the employer do this?

A.  Yes.  HB 7 requires that an employee who lives in a network’s service area who sustained a compensable injury before September 1, 2005, must receive medical treatment through a network provider if the insurance carrier liable for that care elects to use a workers' compensation health care network to provide medical benefits to injured employees and provides notice of network requirements to the employee.  If you have contracted with the insurance carrier's network, the employee may not have to change doctors.  However, if you are not part of the insurance carrier’s network, the employee may have to change to a treating doctor within the network.

Q.  Will I be paid for the services I provided to an injured employee before he or she became covered under  a carrier’s workers’ compensation health network plan? 

A. Yes.  Under HB 7, the employer's insurance carrier is liable for payment of non-network medical care under Title 5, Labor Code, for an injured employee who has not received notice of network requirements.    An injured employee who lives within the network's service area and has received the notice is required to obtain medical treatment within the network for a compensable injury.  After the employee receives notice, an insurance carrier must pay for non-network care under certain circumstances, including:

• emergency care;
• health care services provided to an employee who does not live within the service area of any network established by the insurance carrier; and
• health care services provided out of network, with an approved referral from the network.  

Q. If I am an employee’s primary care physician under his health insurance plan, can I serve as the employee’s treating doctor for a compensable injury?

A. Perhaps.  If the employee’s health insurance is a health maintenance organization (HMO) plan and the employee selected you to be his or her primary care physician prior to the work-related injury, the employee may select you as the treating doctor for the work-related injury.  However, you must agree to follow all the terms and conditions of the network's contract and comply with the Workers' Compensation Health Care Network Act (Chapter 1305, Insurance Code) and applicable rules.  After the agreement is reached, if you need to refer the employee to other providers for care, you must refer to network providers.

Q. Can an employee select another treating doctor from the network if the employee is dissatisfied with my services?

A.  Under HB 7, an employee who is dissatisfied with his or her initial treating doctor has the right to select an alternate treating doctor from the network's list of treating doctors who provide services in the employee's service area.  The employee must notify the network in the manner prescribed by the network.  The network may not deny the selection of an alternate treating doctor who is within the network.  An employee who is unhappy with the alternate treating doctor must get approval from the network to make additional treating doctor changes.

Q.  What requirements apply under HB 7 if an insurance carrier disputes the compensability or extent of an injury of an employee receiving in-network medical care?

A.  HB 7 requires carriers to notify a network health care provider in writing if the carrier decides to dispute the compensability of a claim.  The carrier is prohibited from denying a medical bill on the basis of compensability for health care services that were provided before the insurance carrier’s written notification to the provider.  HB 7 also provides that if the insurance carrier successfully contests compensability, the carrier is liable up to a maximum of $7,000 for health care provided before the insurance carrier’s written notification.

Q.  What requirements does HB 7 impose regarding treatment guidelines for networks?

A.  HB 7 requires each network to adopt treatment guidelines.  The treatment guidelines and individual treatment protocols must be evidence-based, scientifically valid, and outcome-focused and be designed to reduce inappropriate or unnecessary health care while safeguarding necessary care.  In addition, treatment guidelines must be flexible enough to allow deviations from the norms when justified on a case-by-case basis.

Q.  What if the treatment guidelines do not address a treatment that a network treating doctor determines an injured worker needs?

A.  HB 7 prohibits denial of treatment solely on the basis that the treatment for the compensable injury in question is not specifically addressed by the treatment guidelines.  Insurance carriers, networks and utilization review agents may not deny treatment solely on the basis that the treatment for the compensable injury in question is not specifically addressed by the treatment guidelines.

Q.  Will pharmacies and pharmaceuticals be part of the networks?

A.  No.  Prescription medication and services will be reimbursed as provided by the Texas Workers’ Compensation Act and applicable rules adopted by the Commissioner of Workers’ Compensation. 

For further information about WC Networks, contact: WCNET@tdi.state.tx.us

For further information about WC Statistics, contact: http://www.tdi.state.tx.us/wc/regulation/roc/index.html