LIFE, HEALTH

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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Complaint Processes TDI Workers Compensation
Networks
Patricia Brewer Director, Special
Projects Health and Workers Compensation
Network Certification and Quality Assurance
Division
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
TDI Complaint Process

• Complaints are received at TDI via
• Regular, certified, overnight mail
• Fax
• Walk-in consumer
• E-mail
• On-line complaint form

Entered into TDI Complaint Inquiry System
(CIS) Acknowledgment letter sent to
complainant.
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
TDI Complaint Process

• Inquiry letter sent to licensee requesting
  specific information on complaint.
• Texas Insurance Code Section 38.001 requires
  response within 10 days.
• Response is received and matched to complaint.
• Response reviewed by insurance specialist or
  registered nurse to determine
• 1.) Is response sufficient in depth and
• scope?
• 2.) Can the complaint be resolved?
• Additional information is requested, if needed.

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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
TDI Complaint Process

• 1.) Complaint closed
• Closing correspondence to complainant with
  copy of licensees response
• Copy of closing correspondence to licensee
• Complaint closed in CIS
• 2.) Is complaint justified or unjustified?
• 3.) Should complaint be referred to Enforcement?
• 4.) Complaints can be reopened
• when additional information is received
• if violation of rule or statute continues.

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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
TDI Complaint Process
What makes a complaint justified? An apparent
violation of a policy provision, contract
provision, rule or statute. A valid concern that
a prudent layperson would view as a practice or
service that is below customary business or
medical practice standards.
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
TDI Complaint Process

• Examples of justified complaints
• Claim was denied when it should have been
  paid.
• Medically necessary care is denied.
• Provider directories not accessible.
• Failure to provide necessary care within time
  limitations.
• Adequate provider network not maintained.

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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Workers Compensation Health Care Network
Complaint Process

• Complaint resolution system required
• Insurance Code 1305.401 - 1305.405
• 28 TAC 10.120 - 10.122
• Networks complaint system must
• Provide reasonable procedures to resolve oral
  or written complaints.
• Contain process for notice and appeal.
• Network may impose complaint filing limit not to
  exceed 90 days from date of occurrence.

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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Workers Compensation Health Care Network
Complaint Process
What is a complaint?
"Complaint" means any dissatisfaction expressed
orally or in writing by a complainant to a
network regarding any aspect of the network's
operation. The term includes dissatisfaction
relating to medical fee disputes and the
network's administration and the manner in which
a service is provided. The term does not
include (A)  a misunderstanding or a problem of
misinformation that is resolved promptly by
clearing up the misunderstanding or supplying the
appropriate information to the satisfaction of
the complainant or (B)  an oral or written
expression of dissatisfaction or disagreement
with an adverse determination. TIC
1305.004(a)(5)
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Workers Compensation Health Care Network
Complaint Process
Complainant - anyone who files a complaint,
including

• Employee
• Employer
• Health care provider
• A person designated to act on employees behalf
• TIC 1305.004(a)(4)

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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Workers Compensation Health Care Network
Complaint Process

• Seven (7) calendar days to
• Acknowledge receipt
• Acknowledge date of receipt
• Provide description of complaint
  procedures and deadlines
• Thirty (30) calendar days to investigate and
  resolve complaint.

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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Workers Compensation Health Care Network
Complaint Process
Resolution letter must 1.) Explain networks
resolution 2.) Give specific reasons 3.)
Give specialization of any health care
provider consulted 4.) Advise complainant of
right to complain to TDI if dissatisfied
with resolution
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Workers Compensation Health Care Network
Complaint Process

• Network must maintain
• Complaint Log
• Record of and documentation on each
• complaint, complaint proceeding and action
• taken for 3 years after receipt of complaint.
• Complainant entitled to a copy of networks
  record regarding complaint and proceeding.
• TDI has right to review all records

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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Workers Compensation Health Care Network
Complaint Process

• Complaint Log classification categories
• (1) quality of care or services
• (2) accessibility and availability of services
  or providers
• utilization review and retrospective review, as
  applicable
• (4) complaint procedures
• (5) health care provider contracts
• (6) bill payment, as applicable
• (7) fee disputes and
• (8) miscellaneous.

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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Workers Compensation Health Care Network
Complaint Process
NO RETALIATION ALLOWED!! Network may not engage
in any retaliatory action against employer,
employee, or provider because the employer,
employee, provider or representative has filed a
complaint against the network.
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Workers Compensation Health Care Network
Complaint Process

• Special Issues
• Eligibility for continuity of care
• Network refusal to refer out-of-network when
  services are not available from network providers.

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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
TDI Resources
HWCN Division Telephone [phone] FAX (512
) 490-1013 Complaints FAX (512)
490-1012 Consumer Protection 1-800-252-3439 TD
I Website www.tdi.state.tx.us