State News : Texas

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The Division is about to take aim at insurance carrier peer reviewers.

The agency is in the process of creating a Peer Review Plan-Based Audit, which it says will define

the scope, methodology, and selection criteria of its review process. A draft of the Plan Based Audit

is posted it on the Division website. It says that its purpose is to:

• Promote the delivery of quality healthcare in a cost-effective manner;

• Ensure peer reviewers adhere to requirements when issuing peer review reports for extent

of injury and/or medical necessity issues;

• Ensure peer reviewers review and maintain records when performing peer review; and

• Ensure that peer reviewers hold the appropriate credentials when performing peer review.

Once the Plan-Based Audit is finalized, the Division will begin collecting and reviewing select peer

reviews that address extent of injury and medical necessity issues. It appears that the Division will

be focusing on (among other things) whether peer reviewers (1) rely on evidence-based medicine,

(2) use Division treatment guidelines, and (3) comply with Division Rule 180.28 which governs peer

review requirements, reporting, and sanctions.

The Division seeks comment from stakeholders on the current draft. Suggestions for improvement

can be emailed to by 5 p.m. Central Time on November 4.