TEXAS LEGISLATIVE UPDATE
Jane Lipscomb Stone
Erin H. Shanley
STONE
LOUGHLIN & SWANSON, L.L.P.
6836 Austin Center Blvd., Suite 280
P.O. Box 30111
Austin, Texas 78755
512/343-1300
512/343-1385 (Fax)
jstone@slsaustin.com
eshanley@slsaustin.com
NATIONAL WORKERS' COMPENSATION DEFENSE
NETWORK
June, 2007
Workers’ Compensation Legislation
Texas Legislative Session 2007
HB 724 - filed by Rep. Burt Solomons (R-Carrollton)
Effective
Date: September 1, 2007
http://www.legis.state.tx.us/tlodocs/80R/billtext/pdf/HB00724F.pdf
Changes to Medical Dispute Resolution
Process
This bill creates a bifurcated
process providing for appeal of all prospective medical dispute resolution
decisions. Spinal surgery decisions
continue to be heard in contested case hearings at DWC field offices. Appeals of the following types of medical
disputes are also heard by hearing officers in the field offices: (1) medical
fee disputes in which the amount in dispute does not exceed $2,000; (2)
independent review organization (IRO) decisions of retrospective medical
necessity for services for which the amount billed does not exceed $3,000; and
(3) IRO decisions regarding the concurrent or prospective medical necessity for
health care services. All other medical
disputes must be appealed to the State Office of Administrative Hearings.
Judicial review of all medical disputes is conducted pursuant to Subchapter G,
Chapter 2001 of the Government Code.
Procedures Allowing Claims
Filed by Health Insurance Carriers
If an accident/health insurer has
paid for health care services for which a workers’ compensation insurer has not
disputed compensability, the accident/health insurer may file a written claim
with the DWC as a subclaimant. A health
care insurer subclaimant may not be reimbursed for payment for health care that
was previously denied by a workers’ compensation carrier under a
preauthorization or medical necessity review.
On the other hand, it is not a defense to a subclaim by a health insurer
that (1) the subclaimant has not sought reimbursement from a health care
provider or the insured, (2) the subclaimant or the health care provider did
not request preauthorization, or (3) the health care provider did not bill the
workers’ compensation carrier within 95 days after the date of service. Procedures are put in place for health insurers’
requests for reimbursement from workers’ compensation carriers. Hearing officers are given authorization to
issue orders to workers’ compensation carriers to reimburse health insurers as
appropriate. However, any disputes over
the amounts owed and over medical necessity must be determined through the
medical dispute resolution process. The general rule is that the request for
reimbursement must be filed not later than six months after the health insurer
received claims information and not later than 18 months after the health
insurer paid for the services. A health
insurer has until 3/1/08 to file a subclaim from claims information received
before 1/1/07.
Changes to Beneficiaries of
Death Benefits
For death claims, death benefits
shall be paid to surviving eligible parents (as defined) of the deceased if
there is no eligible spouse, child, grandchild, or no surviving
dependents. Payments may not exceed one
payment per household and is paid until the parent dies or up to 104
weeks. An eligible parent must file a
claim not later than one year after the injured worker’s death. The time for filing a claim may only be
extended if the parent submits satisfactory proof to the commissioner of a
compelling reason for the delay.
HB 34 - filed by Rep. Burt
Solomons (R-Carrollton)
Effective Date: September 1, 2007
http://www.legis.state.tx.us/tlodocs/80R/billtext/pdf/HB00034F.pdf
Administrative Violations for Improper Attempts to
Influence Delivery of Benefits
This bill provides for an administrative violation if a
person (including an adjuster, case manager, peer reviewer, required medical
examiner, or other person) improperly attempts to influence the delivery of
benefits to an injured employee through threats, payments or receipts of
improper inducements.
HB 472 - filed by
Rep. Burt Solomons (R-Carrollton)
Effective Date: September 1, 2007
http://www.legis.state.tx.us/tlodocs/80R/billtext/pdf/HB00472F.pdf
Third Party Administrators
If an insurer uses the services of a third party
administrator, written notice must be provided not only to the insured, but
also to the injured worker. Additional
administrative requirements are imposed on third party administrators and
insurers who refer a claim to third party administrators. An insurer may not provide compensation or
value to an administrator based on the savings accruing to the insurer because
of adverse determinations regarding claims for benefits. Administrators may also enter into contracts
directly with employers.
HB 473 - filed by
Rep. Burt Solomons (R-Carrollton)
Effective date: September 1, 2007
http://www.legis.state.tx.us/tlodocs/80R/billtext/pdf/HB00473F.pdf
Interlocutory Orders by Benefit Review Officers
Benefit review officers presiding over benefits review
conferences are again given the authority to issue an interlocutory order but
must provide the opposing party the opportunity to respond before
issuance. Orders may address the payment
or suspension of benefits.
Informal or Voluntary Networks Proposing Fees Inconsistent
with Fee Guidelines
Providing that certain procedures are followed, insurance
carriers may use an informal or voluntary network to obtain a contractual agreement
that proposes fees different from those authorized under the DWC’s fee
guidelines.
HB 886 - filed by
Rep. Helen Giddings (D-De Soto)
Effective Date: May 17, 2007
http://www.legis.state.tx.us/tlodocs/80R/billtext/pdf/HB00886F.pdf
Amendments to Return-to-Work Pilot Program for Small
Employers
Section 413.022 of the Labor Code is amended to establish
that small employers may participate in a return-to-work pilot program in which
the DWC will guarantee reimbursement of expenses incurred to implement
modifications in the workplace via an optional preauthorization plan.
HB 888 - filed by Rep. Helen Giddings (D-De Soto)
Effective Date: May ___, 2007
http://www.legis.state.tx.us/tlodocs/80R/billtext/pdf/HB00888F.pdf
Ombudsman Entitlement to Medical Records
If an OIEC ombudsman assisting an injured worker makes a
written request, a health care provider must provide copies of the worker’s
medical records. The carrier is
responsible for the costs associated with the copies. The provider may not require payment prior to
providing the copies.
HB 1003 - filed by Rep. Helen Giddings (D-De Soto)
Effective Date: September 1, 2007
http://www.legis.state.tx.us/tlodocs/80R/billtext/pdf/HB01003F.pdf
Changes in Licensing Requirements for IRO Reviewers
Only doctors licensed to practice in Texas may perform
reviews for independent review organizations.
HB 1005 - filed by Rep. Helen Giddings (D-De Soto)
Effective Date: September 1, 2007
http://www.legis.state.tx.us/tlodocs/80R/billtext/pdf/HB01005F.pdf
Changes to Forfeiture of Right to Reimbursement for
Untimely Submission of Claims
A health care provider who fails to timely submit a claim
for payment to the carrier does not forfeit its right to reimbursement if the
provider submits proof satisfactory to the commissioner that the provider
erroneously filed for reimbursement (within 95 days) with the injured worker’s
health insurer or HMO or another workers’ compensation carrier. A health care provider also does not forfeit
its right to reimbursement if the commissioner determines that the failure
resulted from a catastrophic event that substantially interfered with the
normal business operations of the provider.
If the provider fails to submit the claim to the correct workers’
compensation carrier within 95 days after being notified of its error, the
provider forfeits its right to reimbursement.
The parties may also agree to extend the period for submitting a claim.
HB 1006 - filed by Rep. Helen Giddings (D-De Soto)
Effective Date: September 1, 2007
http://www.legis.state.tx.us/tlodocs/80R/billtext/pdf/HB01006F.pdf
Changes in Licensing Requirements for Peer Reviewers
Only doctors licensed in Texas may perform peer,
utilization, and retrospective reviews of medical care.
HB 2004 - filed by Rep. Helen Giddings (D-De Soto)
Effective Date: September 1, 2007
http://www.legis.state.tx.us/tlodocs/80R/billtext/pdf/HB02004F.pdf
Changes in Requirements for Doctors Performing Various
Functions in the System
A designated doctor, required medical examination doctor,
peer review doctor, utilization review doctor, independent review doctor, or
member of the medical quality review panel must hold a professional
certification in a specialty appropriate to the type of health care that the
injured worker is receiving. A doctor
performing review of chiropractic services must be licensed to engage in the
practice of chiropractic. Likewise, a
person performing peer review, utilization review, or independent review of
dental services or a required dental examination, must be licensed to practice
dentistry. The DWC is given the
authority to adopt rules to determine which professional health practitioner
specialties are appropriate for treatment of certain compensable injuries.
HB 2667 - filed by Rep. Thomas Latham (R-Sunnyvale)
Effective Date: September 1, 2007
http://www.legis.state.tx.us/tlodocs/80R/billtext/pdf/HB02667F.pdf
Coverage for Volunteer Police Force Members
The law now provides that volunteer police force members
must be insured or covered by the applicable state agency or political
subdivision for injuries sustained while in the course and scope of performing
assigned duties.
SB 458 - filed by Sen. Kirk Watson (D-Austin)
Effective Date: September 1, 2007
http://www.legis.state.tx.us/tlodocs/80R/billtext/pdf/SB00458F.pdf
Changes to the Definition of “Health Care”
The term “health care” includes prosthetic or orthotic
devices, which are specifically defined.
SB 471 - filed by Sen. Kenneth “Kim”Brimer (R-Fort Worth)
Effective Date: September 1, 2007
http://www.legis.state.tx.us/tlodocs/80R/billtext/pdf/SB00471F.pdf
Reporting Requirements Relating to Rates for Workers’
Compensation Carriers
The reporting requirements for workers’ compensation
carriers with respect to establishing rates are
deleted and the commissioner is authorized to prescribe the requirements
by rule. The commissioner is authorized
to reduce or eliminate reporting requirements for insurance companies whose
workers’ compensation insurance business falls below a specific minimum premium
volume established by rule.
SB 1169 - filed by Sen. Kyle Janek (R-Houston)
Effective Date: September 1, 2007
http://www.legis.state.tx.us/tlodocs/80R/billtext/pdf/SB01169F.pdf
Additional Reasons for Subsequent Injury Fund Reimbursement
The subsequent injury fund shall reimburse an insurance
carrier for any overpayment of benefits made by the carrier based on an opinion
rendered by a designated doctor if that opinion is reversed or modified by a
final arbitration award or a final order or decision of the commissioner or a
court. A carrier is also entitled to
reimbursement from the subsequent injury fund for death benefits paid to a
worker based on employment other than the employment during which the
compensable injury occurred. A benefit
review officer may consider a written or verbal request for an interlocutory
order and must issue the order no later than the third day after the date of
receipt of the request if the officer determines that an order is appropriate.
SB 1627 - filed by Sen. John Carona (R-Dallas)
Effective date: May __, 2007
http://www.legis.state.tx.us/tlodocs/80R/billtext/pdf/SB01627F.pdf
Prosecution of Parties Committing Workers’ Compensation
Fraud
The legislature authorizes prosecution of a person who
commits fraud under chapter 418 of the Labor Code.
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