Texas

1
Texas Workers Compensation Changes
Working together to comply with HB7 Summer 2006
2
Agenda

• Introductions
• Updates
• HCN regulations
• Questions

3
Office of Injured Employee Counsel

• Advocate for injured workers
• Resolve complaints

4
Exposure for medical costson non-compensable
claims

• APPLIES ONLY TO EMPLOYERS USING AN HCN
• Carrier is liable for up to 7000 in treatment if
  claim is not accepted
• What does Broadspire do?
• Conduct initial investigation within 24 hours
• Ask treating doctor to immediately address cause
  of injury under 408.0042
• Immediately request peer review, RME and/or
  designated doctor, if necessary
• When possible, accept or deny claims within 14
  days of receipt

5
Exposure for medical costs on non-compensable
claims

• What should an employer do?
• Report claims to Broadspire within 24 hours
• Provide injured worker with a list of HCN
  Treating Providers
• Provide all information to your adjuster, so a
  prompt compensability decision can be made

6
Income Benefits

• Changes
• Retroactive period changing from 4 weeks to 2
  weeks
• Max TIB, LIB and DIB rate is 100 of State
  Average Weekly Wage (SAWW), Max IIB and SIB rate
  is 70 of SAWW

7
Income Benefits

• What does Broadspire do?
• Accurately calculates AWW by using wage statement
  provided by employer
• Nurse case managers aggressively and proactively
  pursue releases to return to work
• Utilizes panel physicians to review impairment
  ratings

8
Income Benefits

• What should an employer do?
• Immediately report all claims
• Promptly file a wage statement when requested

9
Health Care Networks (HCN)

• Background
• Broadspire has decided to continue our
  partnership with Concentra to provide HCN
  services to our clients
• Concentras HCN is comprised of
  providers\hospitals\clinics from both the Focus
  PPO and Beechstreet Networks
• The HCN certification is applicable for clients
  who are utilizing Broadspire Medical Bill Review,
  Utilization Management and Care Management
  Services
• Carriers\Self Insured must have a signed Network
  Access Agreement with Concentra in order to
  participate

10
Health Care Network Service Area

• Concentras Texas Health Care Network service
  area offering will consist of the following
• Greater Dallas (30.4)
• Austin/San Antonio (28.0)
• Greater Houston (18.7)
• South TX (7.7)
• East TX (partial)
• Central TX (partial)
• Lubbock (1.7)
• Amarillo (1.7)
• Corpus Christi

92 of Texas workforce
11
Health Care Networks

• Network Mileage Requirements
• Treating doctors 30 miles in non-rural areas
  and 60 miles in rural area (population lt50,000)
• General hospitals 30 miles in non-rural area
  and 60 miles in rural areas
• Specialists and specialty hospitals 75 miles in
  all areas

12
Health Care Networks

• What will Broadspire do?
• Provide materials for employers to use in
  notifying employees
• Provide access to a network
• 1-800-800-2600 or www.broadspireppo.com

13
Health Care Networks

• What will Broadspire do?
• Profile network doctors and coordinate best
  possible medical care through the network
• Manage continuity of care and change of
  physicians
• Transfer of care 14 days to select or network
  can choose

14
Health Care Networks

• Pre-designation of treating physician
• Must participate in HMO
• Must notify employer at time of injury
• Physician must agree to follow WC statute and
  requirements

15
Health Care Networks

• What should an employer do?
• Provide HCN materials information to your
  employees
• Post HCN Network Notice

16
Health Care Networks

• What should an employer do?
• Obtain signed acknowledgement form from employees
• Advise injured workers to select a physician in
  HCN

17
Pre-Authorization of Treatment

• List of treatments that require pre-authorization
  by Broadspire
• e.g.
• Surgery
• P.T., O.T. and Chiro trx gt 8 visits
• In patient trx
• MRI, CT, bone density scans
• Certain injections

18
Pre-Authorization of Treatment

• What does Broadspire do?
• Refer providers to Utilization Management (UM)
  dept.
• UM dept staffed with RNs and physicians in every
  medical specialty under supervision of
  Texas-licensed chief medical officer
• Direct number 800-800-7660

19
Skilled Case Management

• Section 413.021 - requires carriers to review
  lost time cases to determine if skilled nursing
  services are necessary. Adjusters will not be
  allowed to perform this function
• What does Broadspire do?
• Offers Senior Nurse Reviewer model to carriers,
  TPAs and clients
• review of claims for appropriateness of medical
  management services

20
How Can Broadspire Partner with You?

• Broadspires flexible solutions can be customized
  to readily satisfy your specific business
  objectives
• Casualty and disability claim management services
  
• Risk and safety consulting services
• Considerable experience dealing with statutory
  changes in a number of states
• Apply our experience to achieve the best outcomes
  for our Texas customers
• Broadspire conducts comprehensive, ongoing
  training on HB7 for all Texas claims adjustors

21
Contacts

• State www.tdi.state.tx.us/consumer/cb084
• HCN
• www.broadspireppo.com
• ppnvendorissues_at_choosebroadspire.com
• Broadspire
• Harriet Evnin, 714-579-8118 hevnin_at_choosebroadspi
  re.com
• Brent MacLean, 954-693-1484 brent.maclean_at_chooseb
  roadspire.com

22
Questions?