Chief of state’s workers’ comp division says much reform work has been done but there’s more to do
Insurance Journal: What are some of the major aspects of the Division of Workers’ Compensation’s Strategic Management Plan for implementing workers’ compensation system reforms? Commissioner Albert Betts: In general, this plan sets a direction for the Division in implementing workers’ compensation system reforms under House Bill 7. The plan also describes the reorganization of resources to better carry out those reforms.
In the area of Injured Employee Services, we are focused on improving customer service, simplifying processes and increasing communication among system participants.
Another focus area is Return-to-Work. Through some internal reorganization, increased training for staff on Return-to-Work communications, working with the state’s vocational rehabilitation program and with initiatives such as the Small Employer Return-to-Work Pilot Program, we are emphasizing the importance of getting injured employees who are able to work back on the job sooner. I want to ensure that employees who are injured on the job have access to timely, appropriate, high-quality medical treatment. Quality care occurs when the injured employee is objectively diagnosed and treated within recognized standards of care at a reasonable cost.
In the area of dispute resolution, the Strategic Management Plan lays out steps to streamline the process for both income and medical disputes while striving to make our decisions as timely, efficient, fair and consistent as possible. We are working with dispute resolution staff to ensure consistency in all DWC offices.
IJ: What are the criteria for network qualification?
AB: There are some pretty rigorous requirements for networks to be certified to treat injured employees. Insurance Commissioner Mike Geeslin and myself share concerns that these networks meet or exceed the standards that are already in place for managed care networks. Applicants must show financial solvency, and comply with requirements for contract provisions with providers and for access to care within certain time and mileage parameters. We also have procedures for checking the credentials of providers, and for monitoring the quality of care provided by providers.
Because these networks are a new type of entity for the workers’ compensation system, it may be a challenge for applicants to meet the requirements in a timely fashion. That is one reason that TDI has approved time extensions for a number of the applicants to allow them to meet the certification requirements.
IJ: What are some of the concerns of various stakeholders?
AB: I have been impressed by the willingness of system participants to embrace the reforms under House Bill 7. Many of them have been eager to work with me, as the first Commissioner of Workers’ Compensation, to hopefully lower costs in the system, shorten the durations of medical treatments and return injured employees to work as soon as they are physically able.
We have welcomed comment from system participants at public hearings and through some new work groups. There are a lot of competing interests in workers’ compensation; I am fortunate to be placed in a position to try to balance those interests within the confines of the statute. Whenever I hear a concern from a system participant, I ask myself where that concern fits into my ideal for the outcome of every workers’ compensation claim filed in Texas. For every claim: Income benefits should be appropriate and should be paid on time; medical benefits should be appropriate and should be paid on time; and the injured employee should return to work as soon as possible.
IJ: What are the concerns of health care providers’?
AB: I understand that doctors do not want to take on an unreasonable administrative burden in order to treat injured employees. As we implement system reforms, I believe that doctors should have no more “hassle factor” in treating injured employees than they experience when they see patients in managed health care plans. This will take time, as the new networks begin to play a role in the system’s health care delivery and DWC develops a disability management approach for non-network care. Disability management makes use of treatment guidelines and treatment planning so that the treatments of injuries are more consistent and the provider has more certainty of what is expected of her or him.
Networks have some flexibility in determining the requirements that network providers must follow, such as preauthorization, treatment guidelines and return-to-work guidelines. Additionally, documentation required during billing processes has been reduced for network providers. For both network and non-network settings, the medical necessity dispute process is being streamlined and centralized so that providers have only one process to follow to request independent reviews.
IJ: What progress has been made in establishing a performance-based oversight system for both insurers and health care providers?
AB: Performance-based oversight has come to the forefront of discussions with system participants over the last several months. There is a lot of interest in how DWC will shift its regulatory resources to focus on insurance carriers and health care providers with ongoing compliance problems rather than isolated infractions. As the bill states, this new approach will require the DWC to establish key regulatory goals and to develop regulatory tiers based on performance. We are tentatively planning to launch a pilot project for performance-based oversight later this year. Internally, we have reallocated resources and programs to better manage them under the performance-based oversight system.
IJ: How far along is the reform process?
AB: Much has been done … and a lot more work is ahead. … When you consider that we have merged two state agencies, developed and adopted rules to create Workers’ Compensation Health Care Networks, prioritized more than a dozen other required rule changes, and made major modifications to several administrative processes, I think you can say that we have made a good start. The important thing to me has been to listen to the system participants as we implement the reforms and make sure that I balance their concerns with the mandate that I have been given to make workers’ compensation in Texas one of the best systems in the nation.
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