Quarterly Insurance Carrier Meeting

1
Quarterly Insurance Carrier Meeting

• July 23, 2009
• AGENDA ITEMS
• Welcome
• Complaint Data Update
• Enforcement Update
• Medical Fee Dispute Resolution Update
• TPA Update
• FY 2009 Audit Update
• QA
• Closing

Texas Department of InsuranceDivision of
Workers Compensation
2
Welcome

• Rod Bordelon, Commissioner
• Division of Workers Compensation

3
Complaint Data Update

• Teresa Carney, Director
• System Monitoring Oversight

4
System Performance
5
System Performance
6
System Performance
7
System Performance
8
Enforcement Update

• Catherine Reyer, Associate Commissioner
• Enforcement
• Cass Burton, Manager
• Enforcement

9
Medical Fee Dispute Resolution Update

• Mary Landrum, Director
• Health Care Business Management

10
Received Disputes by Issue CY09
11
Dispute by Month CY08-09
12
Pending Disputes by Issue
13
Dispute CY
14
TPA Update

• Kevin Brady, Deputy Commissioner
• Financial Program

15
FY 2009 Audit Update

• Darrell Cooper, Manager
• Audits Investigations

16
System Monitoring Oversight

• TDI-DWC
• System Monitoring Oversight
• Fiscal Year 2009
• Audit Update
• July 23, 2009

17
Audits Investigations Team

• Manager Darrell Cooper
• Team Leads Diana Ramos, Melita Abrego
• Auditors Irma Harvey, Rosalinda Hamilton,
  Andres Telles, Priscilla Sikos, Melissa Rhea,
  Myrna Marinelarena, Patricia Evora, Adrienne
  Galer
• Admin Assistant Jane Estrada

18
Insurance Carrier Audits

• Initial Payment of TIB Audits
• 2 insurance carriers
• PBO poor performers
• Desk audits
• Review of timely IP and EDI accuracy (5 data
  elements)

19
Insurance Carrier Initial Payment of TIB Audits

• Final Results
• IP timeliness (average) 87.27
• Accuracy (average)
• First day of disability 76.46
• First written notice 92.53
• Initial TIB from date 97.64
• Initial TIB to date 98.39
• Initial TIB paid date 96.78

20
Insurance Carrier Audits

• Medical Bill Processing Audits
• 19 insurance carriers
• PBO poor performers
• Desk audits
• Review of bill processing timeliness and EDI
  timeliness and accuracy (2 data elements)

21
Insurance Carrier Medical Bill Processing Audits

• Final Results
• Bill processing timeliness (average) 97.21
  (High 100 - Low 90.68)
• Timeliness of reporting (average) 75.32
  (High 100 - Low 19.23)
• Accuracy (average)
• Date bill received 91.11
• (High 99.35 - Low 69.51)
• Date paid or denied 83.28 (High 99.68
  - Low 28.32)

22
Insurance Carrier Audits

• Initial Payment of TIB - Data Accuracy Audits
• 10 insurance carriers
• Desk audits
• Initiated 4/30/09
• Review of EDI accuracy (5 data elements)

23
Insurance Carrier TIB Initial Payment Data
Accuracy Audits

• Final Results (6 Audits)
• Accuracy (average)
• First day of disability 75.46
• First written notice 95.74
• Initial TIB from date 95.11
• Initial TIB to date 87.57
• Initial TIB paid date 86.64

24
Insurance Carrier Audits

• Medical Bill Processing - Data Accuracy Audits
• 5 insurance carriers
• Desk audits
• Initiated 5/29/09
• Review of data reporting accuracy (7 data
  elements)

25
Insurance Carrier Medical Bill Data Accuracy
Audits

• Final Results (2 Audits)
• Accuracy (average)
• CPT Code 100.00
• CPT Modifier 1 59.50
• CPT Modifier 2 96.50
• HCP FEIN 100.00
• HCP License Number 94.50
• ANSI Reason Code 1 99.00

26
Insurance Carrier Medical Bill Data Accuracy
Audits

• Final Results (2 Audits)
• Accuracy (average)
• ANSI Reason Code 2 99.50
• ANSI Reason Code 3 98.50
• ANSI Reason Code 4 100.00
• ANSI Reason Code 5 100.00
• Date Bill Received 79.50
• Date Paid or Denied 90.00

27
Health Care Provider Audits

• DWC Form-69 Audits
• 45 health care providers
• PBO poor performers
• Desk audits
• Review of timely filing of the DWC Form-69 via
  facsimile to the insurance carrier

28
Health Care Provider DWC Form-69 Audits

• Final Results
• Timely filing of the DWC Form-69 to the
  insurance carrier (average) 39.55
• (High 100 - Low 0.00)
• DWC Form-69 filed via fax (average)
  48.09 (High 100 - Low 0.00)

29
Audits Investigations Contact

• Questions about audits?
• Darrell Cooper, Manager
• Audits Investigations
• [phone]
• darrell.cooper_at_tdi.state.tx.us

30
Q A

• Teresa Carney, Director
• System Monitoring Oversight

31
Closing

• Teresa Carney, Director
• System Monitoring Oversight