Texas Department of Insurance Division of Workers Compensation. Insurance Carrier/Utilization Review Agent Plan-Based Audit

Transcription

1 Texas Department f Insurance Divisin f Wrkers Cmpensatin Insurance Carrier/Utilizatin Review Agent Plan-Based Audit Octber 22, P age

2 Sectin I: General Statement and Overview The Texas Department f Insurance, Divisin f Wrkers Cmpensatin (TDI-DWC) is required by Texas Labr Cde t mnitr health care prviders, insurance carriers, independent review rganizatins, and wrkers cmpensatin claimants wh receive medical services t ensure the cmpliance f thse persns with rules adpted by the Cmmissiner relating t health care, including medical plicies and fee guidelines. Furthermre, Texas Labr Cde allws the Medical Quality Review Panel (MQRP) t recmmend t the medical advisr apprpriate actin regarding dctrs, ther health care prviders, insurance carriers, utilizatin review agents (URAs), and independent review rganizatins. The TDI-DWC will manage the medical quality review prcess in a manner that is fair t all wrkers cmpensatin system participants, pen, and transparent t the extent cnsistent with state cnfidentiality laws, and prvide the subject f a review the pprtunity t participate thrughut the review prcess as set frth in the Medical Quality Review prcedure. Medical quality reviews aid the TDI-DWC bth t mnitr cmpliance with the Texas Wrkers Cmpensatin Act (Act) and TDI-DWC Rules and t help ensure that injured emplyees in the wrkers cmpensatin system receive medically necessary and apprpriate health care that is timely and cst-effective, and facilitates functinal recvery and apprpriate return-t-wrk utcmes. URAs are registered r licensed entities that review requests fr health care services being prvided (cncurrent), prpsed t be prvided (prspective) r already prvided (retrspective). URAs determine whether services are medically necessary and apprpriate and may als determine if services are experimental and investigatinal. The Managed Care Quality Assurance (MCQA) Office prcesses applicatins fr entities seeking registratin, licensure r licensure renewal as a URA within the state f Texas. Sectin II: Purpse fr Plan-Based Audit Prmte the delivery f quality health care in a cst-effective manner; and Ensure that insurance carriers and/r URAs adhere t the Official Disability Guides and medically accepted standards f care fr cnducting utilizatin review, including the apprpriate selectin f reviewing health care prviders. Sectin III: Scpe and Methdlgy fr Plan-Based Audit Insurance carriers and/r URAs wh have retrspectively denied Evaluatin and Management Office Visits t injured emplyees: where the ffice visit was billed with Current Prcedural Terminlgy (CPT) cdes and ; where the ffice visit was retrspectively denied by the insurance carrier/ura using Service Adjustment Reasn Cde 50 prir t recnsideratin; and where the ffice visit was fr a nn-netwrk claim and paid amunt fr the denied ffice visit was $0. 2 P age

3 Office visits will be identified by the CPT cde as billed by health care prviders and reprted thrugh Medical State Reprting data (i.e., Medical EDI data). Denial cdes will be identified by the Service Adjustment Reasn Cdes as prvided n EOBs by insurance carriers and reprted thrugh Medical State Reprting data. The prcedure fr determining the medical necessity and apprpriateness f health care services is set frth in Sectin II f the Medical Quality Review Prcedure. See als Texas Labr Cde Sectins , , and Sectin IV: Selectin Criteria fr Plan-Based Audit Time frame t select data: Dates f injury after May 1, 2007; and Exclusin: Office Visits ccurred during January 9, 2011 thrugh December 31, Insurance carriers wh have less than 30 medical necessity denials that meet the selectin criteria. The statistical tlbx develped by the State Auditr s Office may be used t determine: Subject Selectin: Select n mre than 10 insurance carriers wh retrspectively denied ffice visits fr medical necessity and had: the highest percentage f ffice visits denied per the selectin time frame; and at least 30 medical necessity denials that meet selectin criteria. Case Selectin: Select a sample size at a 95% cnfidence level with a minimum f five cases selected. Sectin V: Rles and Respnsibilities Infrmatin Management Services (IMS), Divisin f Wrkers Cmpensatin Prvides a list f insurance carriers based n the scpe, methdlgy, and selectin criteria. Selects the subjects and case files fr medical quality review based n selectin criteria. 3 P age

4 Health Care Quality Review (HCQR), Divisin f Wrkers Cmpensatin Ntifies subjects (insurance carriers) chsen fr medical quality review and requests dcuments. Upn receipt f dcuments, HCQR identifies the URAs assciated with the selected cases and ntifies thse URAs f the medical quality review. All URAs that are part f the selectin criteria will be selected as part f this plan-based audit, unless an exclusin applies. Requests frm IMS anther subject r case if the nurse investigatr verifies in writing that a subject r case was nt selected in accrdance with the apprved plan-based audit criteria. Selects MQRP members t perfrm a review in accrdance with Texas Labr Cde Sectins , , and and 28 Texas Administrative Cde Sectins and Prvides an Executive Summary t the Cmmissiner f Wrkers Cmpensatin upn cnclusin f plan-based audit. Medical Advisr, Divisin f Wrkers Cmpensatin The Medical Advisr shall develp questins fr the MQRP Experts. Thse questins shall be apprved by all undersigned parties prir t any recrds being sent t the MQRP Experts. Sectin VI: Cnflicts This Insurance Carrier/Utilizatin Review Agent plan-based audit incrprates the apprved Medical Quality Review Prcedure. Hwever, if a specific cnflict exists between this plan-based audit and the Medical Quality Review Prcedure, this plan-based audit prevails. 4 P age

5 Sectin VII: Apprvals 5 P age