Texas Labor Code -CHAPTER 413. MEDICAL REVIEW
Texas Workers Compensation Act
Title 5 - Texas Labor Code - Chapters 401-506
TABLE OF CONTENTS
LABOR CODE
CHAPTER 413. MEDICAL REVIEW
SUBCHAPTER A. GENERAL PROVISIONS
§ 413.002. MEDICAL REVIEW. (a) The division shall
monitor health care providers, insurance carriers, independent
review organizations, and workers' compensation claimants who
receive medical services to ensure the compliance of those persons
with rules adopted by the commissioner relating to health care,
including medical policies and fee guidelines.
(b) In monitoring health care providers who serve as
designated doctors under Chapter 408 and independent review
organizations who provide services described by this chapter, the
division shall evaluate:
(1) compliance with this subtitle and with rules
adopted by the commissioner relating to medical policies, fee
guidelines, treatment guidelines, return-to-work guidelines, and
impairment ratings; and
(2) the quality and timeliness of decisions made under
Section 408.0041, 408.122, 408.151, or 413.031.
(c) The division shall report the results of the monitoring
of independent review organizations under Subsection (b) to the
department on at least a quarterly basis.
(d) If the commissioner determines that an independent
review organization is in violation of this chapter, rules adopted
by the commissioner under this chapter, applicable provisions of
this code or rules adopted under this code, or applicable
provisions of the Insurance Code or rules adopted under that code,
the commissioner or a designated representative shall notify the
independent review organization of the alleged violation and may
compel the production of any documents or other information as
necessary to determine whether the violation occurred.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 1995, 74th Leg., ch. 980, § 1.42, eff. Sept. 1, 1995;
Acts 2005, 79th Leg., ch. 265, § 3.227, eff. Sept. 1, 2005.
§ 413.003. AUTHORITY TO CONTRACT. The division may
contract with a private or public entity to perform a duty or
function of the division.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2005, 79th Leg., ch. 265, § 3.228, eff. Sept. 1, 2005.
§ 413.004. COORDINATION WITH PROVIDERS. The division
shall coordinate its activities with health care providers as
necessary to perform its duties under this chapter. The
coordination may include:
(1) conducting educational seminars on commissioner
rules and procedures; or
(2) providing information to and requesting
assistance from professional peer review organizations.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2005, 79th Leg., ch. 265, § 3.229, eff. Sept. 1, 2005.
§ 413.006. ADVISORY COMMITTEES. The commissioner may
appoint advisory committees as the commissioner considers
necessary.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2005, 79th Leg., ch. 265, § 3.230, eff. Sept. 1, 2005.
§ 413.007. INFORMATION MAINTAINED BY DIVISION. (a) The
division shall maintain a statewide data base of medical charges,
actual payments, and treatment protocols that may be used by:
(1) the commissioner in adopting the medical policies
and fee guidelines; and
(2) the division in administering the medical
policies, fee guidelines, or rules.
(b) The division shall ensure that the data base:
(1) contains information necessary to detect
practices and patterns in medical charges, actual payments, and
treatment protocols; and
(2) can be used in a meaningful way to allow the
commission to control medical costs as provided by this subtitle.
(c) The division shall ensure that the data base is
available for public access for a reasonable fee established by the
commissioner. The identities of injured workers and beneficiaries
may not be disclosed.
(d) The division shall take appropriate action to be aware
of and to maintain the most current information on developments in
the treatment and cure of injuries and diseases common in workers'
compensation cases.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2005, 79th Leg., ch. 265, § 3.231, eff. Sept. 1, 2005.
§ 413.008. INFORMATION FROM INSURANCE CARRIERS;
ADMINISTRATIVE VIOLATION. (a) On request from the division for
specific information, an insurance carrier shall provide to the
division any information in the carrier's possession, custody, or
control that reasonably relates to the division's duties under this
subtitle and to health care:
(1) treatment;
(2) services;
(3) fees; and
(4) charges.
(b) The division shall keep confidential information that
is confidential by law.
(c) An insurance carrier commits an administrative
violation if the insurance carrier fails or refuses to comply with a
request or violates a rule adopted to implement this section.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2005, 79th Leg., ch. 265, § 3.232, eff. Sept. 1, 2005.
SUBCHAPTER B. MEDICAL SERVICES AND FEES
§ 413.011. REIMBURSEMENT POLICIES AND GUIDELINES;
TREATMENT GUIDELINES AND PROTOCOLS. (a) The commissioner shall
adopt health care reimbursement policies and guidelines that
reflect the standardized reimbursement structures found in other
health care delivery systems with minimal modifications to those
reimbursement methodologies as necessary to meet occupational
injury requirements. To achieve standardization, the commissioner
shall adopt the most current reimbursement methodologies, models,
and values or weights used by the federal Centers for Medicare and
Medicaid Services, including applicable payment policies relating
to coding, billing, and reporting, and may modify documentation
requirements as necessary to meet the requirements of Section
413.053.
(b) In determining the appropriate fees, the commissioner
shall also develop one or more conversion factors or other payment
adjustment factors taking into account economic indicators in
health care and the requirements of Subsection (d). The
commissioner shall also provide for reasonable fees for the
evaluation and management of care as required by Section 408.025(c)
and commissioner rules. This section does not adopt the Medicare
fee schedule, and the commissioner may not adopt conversion factors
or other payment adjustment factors based solely on those factors
as developed by the federal Centers for Medicare and Medicaid
Services.
(c) This section may not be interpreted in a manner that
would discriminate in the amount or method of payment or
reimbursement for services in a manner prohibited by Section
1451.104, Insurance Code, or as restricting the ability of
chiropractors to serve as treating doctors as authorized by this
subtitle. The commissioner shall also develop guidelines relating
to fees charged or paid for providing expert testimony relating to
an issue arising under this subtitle.
(d) Fee guidelines must be fair and reasonable and designed
to ensure the quality of medical care and to achieve effective
medical cost control. The guidelines may not provide for payment of
a fee in excess of the fee charged for similar treatment of an
injured individual of an equivalent standard of living and paid by
that individual or by someone acting on that individual's behalf.
The commissioner shall consider the increased security of payment
afforded by this subtitle in establishing the fee guidelines.
Notwithstanding Section 413.016 or any other provision of this
title, an insurance carrier may pay fees to a health care provider
that are inconsistent with the fee guidelines adopted by the
division if the insurance carrier or a network under Chapter 1305,
Insurance Code, has a contract with the health care provider and
that contract includes a specific fee schedule.
(e) The commissioner by rule shall adopt treatment
guidelines and return-to-work guidelines and may adopt individual
treatment protocols. Treatment guidelines and protocols must be
evidence-based, scientifically valid, and outcome-focused and
designed to reduce excessive or inappropriate medical care while
safeguarding necessary medical care. Treatment may not be denied
solely on the basis that the treatment for the compensable injury in
question is not specifically addressed by the treatment guidelines.
(f) In addition to complying with the requirements of
Subsection (e),
medical policies or guidelines adopted by the commissioner
must be:
(1) designed to ensure the quality of medical care and
to achieve effective medical cost control;
(2) designed to enhance a timely and appropriate
return to work; and
(3) consistent with Sections 413.013, 413.020,
413.052, and 413.053.
(g) The commissioner may adopt rules relating to disability
management that are designed to promote appropriate health care at
the earliest opportunity after the injury to maximize injury
healing and improve stay-at-work and return-to-work outcomes
through appropriate management of work-related injuries or
conditions. The commissioner by rule may identify claims in which
application of disability management activities is required and
prescribe at what point in the claim process a treatment plan is
required. The determination may be based on any factor considered
relevant by the commissioner. Rules adopted under this subsection
do not apply to claims subject to workers' compensation health care
networks under Chapter 1305, Insurance Code.
(h) A dispute involving a treatment plan required under
Subsection (g) may be appealed to an independent review
organization in the manner described by Section 413.031.
(i) The division shall examine whether injured employees
have reasonable access to surgically implanted, inserted, or
otherwise applied devices or tissues and investigate whether
reimbursement rates or any other barriers exist that reduce the
ability of an injured employee to access those medical needs. The
division shall recommend to the legislature any statutory changes
necessary to ensure appropriate access to those medical needs.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2001, 77th Leg., ch. 1456, § 6.02, eff. June 17, 2001;
Acts 2003, 78th Leg., ch. 962, § 1, 2, eff. June 20, 2003; Acts
2005, 79th Leg., ch. 265, § 3.233, eff. Sept. 1, 2005; Acts
2005, 79th Leg., ch. 728, § 11.143, eff. Sept. 1, 2005.
§ 413.0111. PROCESSING AGENTS. The rules adopted by the
commissioner for the reimbursement of prescription medications and
services must authorize pharmacies to use agents or assignees to
process claims and act on the behalf of the pharmacies under terms
and conditions agreed on by the pharmacies.
Added by Acts 2005, 79th Leg., ch. 265, § 3.234, eff. Sept. 1,
2005.
§ 413.012. MEDICAL POLICY AND GUIDELINE UPDATES
REQUIRED. The medical policies and fee guidelines shall be
reviewed and revised at least every two years to reflect fair and
reasonable fees and to reflect medical treatment or ranges of
treatment that are reasonable or necessary at the time the review
and revision is conducted.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993.
§ 413.013. PROGRAMS. The commissioner by rule shall
establish:
(1) a program for prospective, concurrent, and
retrospective review and resolution of a dispute regarding health
care treatments and services;
(2) a program for the systematic monitoring of the
necessity of treatments administered and fees charged and paid for
medical treatments or services, including the authorization of
prospective, concurrent, or retrospective review under the medical
policies of the division to ensure that the medical policies or
guidelines are not exceeded;
(3) a program to detect practices and patterns by
insurance carriers in unreasonably denying authorization of
payment for medical services requested or performed if
authorization is required by the medical policies of the division;
and
(4) a program to increase the intensity of review for
compliance with the medical policies or fee guidelines for any
health care provider that has established a practice or pattern in
charges and treatments inconsistent with the medical policies and
fee guidelines.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2005, 79th Leg., ch. 265, § 3.235, eff. Sept. 1, 2005.
§ 413.014. PREAUTHORIZATION REQUIREMENTS; CONCURRENT
REVIEW AND CERTIFICATION OF HEALTH CARE. (a) In this section,
"investigational or experimental service or device" means a health
care treatment, service, or device for which there is early,
developing scientific or clinical evidence demonstrating the
potential efficacy of the treatment, service, or device but that is
not yet broadly accepted as the prevailing standard of care.
(b) The commissioner by rule shall specify which health care
treatments and services require express preauthorization or
concurrent review by the insurance carrier. Treatments and
services for a medical emergency do not require express
preauthorization.
(c) The commissioner's rules adopted under this section
must provide that preauthorization and concurrent review are
required at a minimum for:
(1) spinal surgery, as provided by Section 408.026;
(2) work-hardening or work-conditioning services
provided by a health care facility that is not credentialed by an
organization recognized by commissioner rules;
(3) inpatient hospitalization, including any
procedure and length of stay;
(4) physical and occupational therapy;
(5) outpatient or ambulatory surgical services, as
defined by commissioner rule; and
(6) any investigational or experimental services or
devices.
(d) The insurance carrier is not liable for those specified
treatments and services requiring preauthorization unless
preauthorization is sought by the claimant or health care provider
and either obtained from the insurance carrier or ordered by the
commissioner.
(e) If a specified health care treatment or service is
preauthorized as provided by this section, that treatment or
service is not subject to retrospective review of the medical
necessity of the treatment or service.
(f) The division may not prohibit an insurance carrier and a
health care provider from voluntarily discussing health care
treatment and treatment plans and pharmaceutical services, either
prospectively or concurrently, and may not prohibit an insurance
carrier from certifying or agreeing to pay for health care
consistent with those agreements. The insurance carrier is liable
for health care treatment and treatment plans and pharmaceutical
services that are voluntarily preauthorized and may not dispute the
certified or agreed-on preauthorized health care treatment and
treatment plans and pharmaceutical services at a later date.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2001, 77th Leg., ch. 1456, § 4.02, eff. June 17, 2001;
Acts 2003, 78th Leg., ch. 980, § 1, eff. Sept. 1, 2003; Acts
2005, 79th Leg., ch. 265, § 3.236, eff. Sept. 1, 2005.
§ 413.0141. INITIAL PHARMACEUTICAL COVERAGE. The
commissioner may by rule provide that an insurance carrier shall
provide for payment of specified pharmaceutical services
sufficient for the first seven days following the date of injury if
the health care provider requests and receives verification of
insurance coverage and a verbal confirmation of an injury from the
employer or from the insurance carrier as provided by Section
413.014. The rules adopted by the commissioner shall provide that
an insurance carrier is eligible for reimbursement for
pharmaceutical services paid under this section from the subsequent
injury fund in the event the injury is determined not to be
compensable.
Added by Acts 2001, 77th Leg., ch. 1456, § 4.03, eff. June 17,
2001. Amended by Acts 2005, 79th Leg., ch. 265, § 3.237, eff.
Sept. 1, 2005.
§ 413.015. PAYMENT BY INSURANCE CARRIERS; AUDIT AND
REVIEW. (a) Insurance carriers shall make appropriate payment of
charges for medical services provided under this subtitle. An
insurance carrier may contract with a separate entity to forward
payments for medical services. Any payment due the insurance
carrier from the separate entity must be made in accordance with the
contract. The separate entity is subject to the direction of the
insurance carrier, and the insurance carrier is responsible for the
actions of the separate entity under this subsection.
(b) The commissioner shall provide by rule for the review
and audit of the payment by insurance carriers of charges for
medical services provided under this subtitle to ensure compliance
of health care providers and insurance carriers with the medical
policies and fee guidelines adopted by the commissioner.
(c) The rules must require the insurance carrier to pay the
expenses of the review and audit.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2001, 77th Leg., ch. 1456, § 6.03, eff. June 17, 2001;
Acts 2005, 79th Leg., ch. 265, § 3.238, eff. Sept. 1, 2005.
§ 413.016. PAYMENTS IN VIOLATION OF MEDICAL POLICIES AND
FEE GUIDELINES. (a) The division shall order a refund of charges
paid to a health care provider in excess of those allowed by the
medical policies or fee guidelines. The division shall also refer
the health care provider alleged to have violated this subtitle to
the division of compliance and practices.
(b) If the division determines that an insurance carrier has
paid medical charges that are inconsistent with the medical
policies or fee guidelines adopted by the commissioner, the
division shall investigate the potential violation. If the
insurance carrier reduced a charge of a health care provider that
was within the guidelines, the insurance carrier shall be directed
to submit the difference to the provider unless the reduction is in
accordance with an agreement between the health care provider and
the insurance carrier.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2005, 79th Leg., ch. 265, § 3.239, eff. Sept. 1, 2005.
§ 413.017. PRESUMPTION OF REASONABLENESS. The following
medical services are presumed reasonable:
(1) medical services consistent with the medical
policies and fee guidelines adopted by the commissioner; and
(2) medical services that are provided subject to
prospective, concurrent, or retrospective review as required by the
medical policies of the division and that are authorized by an
insurance carrier.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2005, 79th Leg., ch. 265, § 3.240, eff. Sept. 1, 2005.
§ 413.018. REVIEW OF MEDICAL CARE IF GUIDELINES
EXCEEDED. (a) The commissioner by rule shall provide for the
periodic review of medical care provided in claims in which
guidelines for expected or average return to work time frames are
exceeded.
(b) The division shall review the medical treatment
provided in a claim that exceeds the guidelines and may take
appropriate action to ensure that necessary and reasonable care is
provided.
(c) The division shall implement a program to encourage
employers and treating doctors to discuss the availability of
modified duty to encourage the safe and more timely return to work
of injured employees. The division may require a treating or
examining doctor, on the request of the employer, insurance
carrier, or division, to provide a functional capacity evaluation
of an injured employee and to determine the employee's ability to
engage in physical activities found in the workplace or in
activities that are required in a modified duty setting.
(d) The division shall provide through the division's
health and safety information and medical review outreach programs
information to employers regarding effective return to work
programs. This section does not require an employer to provide
modified duty or an employee to accept a modified duty assignment.
An employee who does not accept an employer's offer of modified duty
determined by the division to be a bona fide job offer is subject to
Section 408.103(e).
(e) The commissioner may adopt rules and forms as necessary
to implement this section.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 1999, 76th Leg., ch. 956, § 3, eff. Sept. 1, 1999; Acts
2005, 79th Leg., ch. 265, § 3.241, eff. Sept. 1, 2005.
§ 413.019. INTEREST EARNED FOR DELAYED PAYMENT, REFUND,
OR OVERPAYMENT. (a) Interest on an unpaid fee or charge that is
consistent with the fee guidelines accrues at the rate provided by
Section 401.023 beginning on the 60th day after the date the health
care provider submits the bill to an insurance carrier until the
date the bill is paid.
(b) Interest on a refund from a health care provider accrues
at the rate provided by Section 401.023 beginning on the 60th day
after the date the provider receives notice of alleged overpayment
from the insurance carrier until the date the refund is paid.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993.
§ 413.020. DIVISION CHARGES. The commissioner by rule
shall establish procedures to enable the division to charge:
(1) an insurance carrier a reasonable fee for access
to or evaluation of health care treatment, fees, or charges under
this subtitle; and
(2) a health care provider who exceeds a fee or
utilization guideline established under this subtitle or an
insurance carrier who unreasonably disputes charges that are
consistent with a fee or utilization guideline established under
this subtitle a reasonable fee for review of health care treatment,
fees, or charges under this subtitle.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2005, 79th Leg., ch. 265, § 3.242, eff. Sept. 1, 2005.
§ 413.021. RETURN-TO-WORK COORDINATION SERVICES. (a) An
insurance carrier shall, with the agreement of a participating
employer, provide the employer with return-to-work coordination
services as necessary to facilitate an employee's return to
employment. The insurance carrier shall notify the employer of the
availability of return-to-work coordination services. In offering
the services, insurance carriers and the division shall target
employers without return-to-work programs and shall focus
return-to-work efforts on workers who begin to receive temporary
income benefits. The insurance carrier shall evaluate a
compensable injury in which the injured employee sustains an injury
that could potentially result in lost time from employment as early
as practicable to determine if skilled case management is necessary
for the injured employee's case. As necessary, case managers who
are appropriately licensed to practice in this state shall be used
to perform these evaluations. A claims adjuster may not be used as
a case manager. These services may be offered by insurance carriers
in conjunction with the accident prevention services provided under
Section 411.061. Nothing in this section supersedes the provisions
of a collective bargaining agreement between an employer and the
employer's employees, and nothing in this section authorizes or
requires an employer to engage in conduct that would otherwise be a
violation of the employer's obligations under the National Labor
Relations Act (29 U.S.C. Section 151 et seq.).
(b) Return-to-work coordination services under this section
may include:
(1) job analysis to identify the physical demands of a
job;
(2) job modification and restructuring assessments as
necessary to match job requirements with the functional capacity of
an employee; and
(3) medical or vocational case management to
coordinate the efforts of the employer, the treating doctor, and
the injured employee to achieve timely return to work.
(c) An insurance carrier is not required to provide physical
workplace modifications under this section and is not liable for
the cost of modifications made under this section to facilitate an
employee's return to employment.
(d) The division shall use certified rehabilitation
counselors or other appropriately trained or credentialed
specialists to provide training to division staff regarding the
coordination of return-to-work services under this section.
(e) The commissioner shall adopt rules necessary to collect
data on return-to-work outcomes to allow full evaluations of
successes and of barriers to achieving timely return to work after
an injury.
(f) Repealed by Acts 2003, 78th Leg., 3rd C.S., ch. 10, §
1.02(a).
Added by Acts 2001, 77th Leg., ch. 1456, § 3.02, eff. June 17,
2001. Amended by Acts 2003, 78th Leg., 3rd C.S., ch. 10, §
1.02(a), eff. Oct. 20, 2003; Acts 2005, 79th Leg., ch. 265, §
3.243, eff. Sept. 1, 2005.
§ 413.022. RETURN-TO-WORK PILOT PROGRAM FOR SMALL
EMPLOYERS; FUND.
Text of section effective until September 1, 2009
(a) In this section:
(1) "Account" means the workers' compensation
return-to-work account.
(2) "Eligible employer" means any employer, other than
this state or a political subdivision subject to Subtitle C, who
employs at least two but not more than 50 employees on each business
day during the preceding calendar year and who has workers'
compensation insurance coverage.
(b) The commissioner shall establish by rule a
return-to-work pilot program designed to promote the early and
sustained return to work of an injured employee who sustains a
compensable injury.
(c) The pilot program shall reimburse from the account an
eligible employer for expenses incurred by the employer to make
workplace modifications necessary to accommodate an injured
employee's return to modified or alternative work. Reimbursement
under this section to an eligible employer may not exceed $2,500.
The expenses must be incurred to allow the employee to perform
modified or alternative work within doctor-imposed work
restrictions. Allowable expenses may include:
(1) physical modifications to the worksite;
(2) equipment, devices, furniture, or tools; and
(3) other costs necessary for reasonable
accommodation of the employee's restrictions.
(d) The account is established as a special account in the
general revenue fund. From administrative penalties received by
the division under this subtitle, the commissioner shall deposit in
the account an amount not to exceed $100,000 annually. Money in the
account may be spent by the division, on appropriation by the
legislature, only for the purposes of implementing this section.
(e) An employer who wilfully applies for or receives
reimbursement from the account under this section knowing that the
employer is not an eligible employer commits a violation.
(f) Notwithstanding Subsections (a)-(e), this section may
be implemented only to the extent funds are available.
(g) This section expires September 1, 2009.
Added by Acts 2005, 79th Leg., ch. 265, § 3.244, eff. Sept. 1,
2005.
§ 413.023. INFORMATION TO EMPLOYERS. (a) The division
shall provide employers with information on methods to enhance the
ability of an injured employee to return to work. The information
may include access to available research and best practice
information regarding return-to-work programs for employers.
(b) The division shall augment return-to-work program
information provided to employers to include information regarding
methods for an employer to appropriately assist an injured employee
to obtain access to doctors who:
(1) provide high-quality care; and
(2) use effective occupational medicine treatment
practices that lead to returning employees to productive work.
(c) The information provided to employers under this
section must help to foster:
(1) effective working relationships with local
doctors and with insurance carriers or workers' compensation health
care networks certified under Chapter 1305, Insurance Code, to
improve return-to-work communication; and
(2) access to return-to-work coordination services
provided by insurance carriers.
(d) The division shall develop and make available the
information described by this section.
Added by Acts 2005, 79th Leg., ch. 265, § 3.244, eff. Sept. 1,
2005.
§ 413.024. INFORMATION TO EMPLOYEES. The division shall
provide injured employees with information regarding the benefits
of early return to work. The information must include information
on how to receive assistance in accessing high-quality medical care
through the workers' compensation system.
Added by Acts 2005, 79th Leg., ch. 265, § 3.244, eff. Sept. 1,
2005.
§ 413.025. RETURN-TO-WORK GOALS AND ASSISTANCE. (a) The
division shall assist recipients of income benefits to return to
the workforce. The division shall develop improved data sharing,
within the standards of federal privacy requirements, with all
appropriate state agencies and workforce programs to inform the
division of changes needed to assist income benefit recipients to
successfully reenter the workforce.
(b) The division shall train staff dealing with income
benefits to respond to questions and assist injured employees in
their effort to return to the workforce. If the division determines
that an injured employee is unable to ever return to the workforce,
the division shall inform the employee of possible eligibility for
other forms of benefits, such as social security disability income
benefits.
(c) As necessary to implement the requirements of this
section, the division shall:
(1) attempt to remove any barriers to successful
employment that are identified at the division, the Texas Workforce
Commission, the Department of Assistive and Rehabilitative
Services, and private vocational rehabilitation programs;
(2) ensure that data is tracked among the division,
the Texas Workforce Commission, the Department of Assistive and
Rehabilitative Services, and insurance carriers, including outcome
data;
(3) establish a mechanism to refer income benefit
recipients to the Texas Workforce Commission and local workforce
development centers for employment opportunities; and
(4) develop a mechanism to promote employment success
that includes post-referral contacts by the division with income
benefit recipients.
Added by Acts 2005, 79th Leg., ch. 265, § 3.244, eff. Sept. 1,
2005.
SUBCHAPTER C. DISPUTE RESOLUTION
§ 413.031. MEDICAL DISPUTE RESOLUTION. (a) A party,
including a health care provider, is entitled to a review of a
medical service provided or for which authorization of payment is
sought if a health care provider is:
(1) denied payment or paid a reduced amount for the
medical service rendered;
(2) denied authorization for the payment for the
service requested or performed if authorization is required or
allowed by this subtitle or commissioner rules;
(3) ordered by the commissioner to refund a payment
received; or
(4) ordered to make a payment that was refused or
reduced for a medical service rendered.
(b) A health care provider who submits a charge in excess of
the fee guidelines or treatment policies is entitled to a review of
the medical service to determine if reasonable medical
justification exists for the deviation. A claimant is entitled to a
review of a medical service for which preauthorization is sought by
the health care provider and denied by the insurance carrier. The
commissioner shall adopt rules to notify claimants of their rights
under this subsection.
(c) In resolving disputes over the amount of payment due for
services determined to be medically necessary and appropriate for
treatment of a compensable injury, the role of the division is to
adjudicate the payment given the relevant statutory provisions and
commissioner rules. The division shall publish on its Internet
website the division's medical dispute decisions, including
decisions of independent review organizations, and any subsequent
decisions by the State Office of Administrative Hearings. Before
publication, the division shall redact only that information
necessary to prevent identification of the injured worker.
(d) A review of the medical necessity of a health care
service requiring preauthorization under Section 413.014 or
commissioner rules under that section or Section 413.011(g) shall
be conducted by an independent review organization under Article
21.58C, Insurance Code, in the same manner as reviews of
utilization review decisions by health maintenance organizations.
It is a defense for the insurance carrier if the carrier timely
complies with the decision of the independent review organization.
(e) Except as provided by Subsections (d), (f), and (m), a
review of the medical necessity of a health care service provided
under this chapter or Chapter 408 shall be conducted by an
independent review organization under Article 21.58C, Insurance
Code, in the same manner as reviews of utilization review decisions
by health maintenance organizations. It is a defense for the
insurance carrier if the carrier timely complies with the decision
of the independent review organization.
(e-1) In performing a review of medical necessity under
Subsection (d) or (e), the independent review organization shall
consider the division's health care reimbursement policies and
guidelines adopted under Section 413.011. If the independent
review organization's decision is contrary to the division's
policies or guidelines adopted under Section 413.011, the
independent review organization must indicate in the decision the
specific basis for its divergence in the review of medical
necessity.
(f) The commissioner by rule shall specify the appropriate
dispute resolution process for disputes in which a claimant has
paid for medical services and seeks reimbursement.
(g) In performing a review of medical necessity under
Subsection (d) or (e), an independent review organization may
request that the commissioner order an examination by a designated
doctor under Chapter 408.
(h) The insurance carrier shall pay the cost of the review
if the dispute arises in connection with:
(1) a request for health care services that require
preauthorization under Section 413.014 or commissioner rules under
that section; or
(2) a treatment plan under Section 413.011(g) or
commissioner rules under that section.
(i) Except as provided by Subsection (h), the cost of the
review shall be paid by the nonprevailing party.
(j) Notwithstanding Subsections (h) and (i), an employee
may not be required to pay any portion of the cost of a review.
(k) Except as provided by Subsection (l), a party to a
medical dispute that remains unresolved after a review of the
medical service under this section may seek judicial review of the
decision. The division and the department are not considered to be
parties to the medical dispute for purposes of this subsection.
Judicial review under this subsection shall be conducted in the
manner provided for judicial review of contested cases under
Subchapter G, Chapter 2001, Government Code.
(l) A party to a medical dispute regarding spinal surgery
that remains unresolved after a review by an independent review
organization as provided by Subsections (d) and (e) is entitled to
dispute resolution as provided by Chapter 410.
(m) The decision of an independent review organization
under Subsection (d) is binding during the pendency of a dispute.
(n) The commissioner by rule may prescribe an alternate
dispute resolution process to resolve disputes regarding medical
services costing less than the cost of a review of the medical
necessity of a health care service by an independent review
organization. The cost of a review under the alternate dispute
resolution process shall be paid by the nonprevailing party.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 1995, 74th Leg., ch. 76, § 5.95(49), eff. Sept. 1, 1995;
Acts 1995, 74th Leg., ch. 980, § 1.43, eff. Sept. 1, 1995; Acts
2001, 77th Leg., ch. 1456, § 6.04, eff. June 17, 2001; Acts
2003, 78th Leg., ch. 980, § 2, eff. Sept. 1, 2003; Acts 2003,
78th Leg., ch. 1323, § 1, eff. June 21, 2003; Acts 2005, 79th
Leg., ch. 265, § 3.245, eff. Sept. 1, 2005.
§ 413.032. INDEPENDENT REVIEW ORGANIZATION DECISION;
APPEAL. (a) An independent review organization that conducts a
review under this chapter shall specify the elements on which the
decision of the organization is based. At a minimum, the decision
must include:
(1) a list of all medical records and other documents
reviewed by the organization;
(2) a description and the source of the screening
criteria or clinical basis used in making the decision;
(3) an analysis of and explanation for the decision,
including the findings and conclusions used to support the
decision; and
(4) a description of the qualifications of each
physician or other health care provider who reviews the decision.
(b) The independent review organization shall certify that
each physician or other health care provider who reviews the
decision certifies that no known conflicts of interest exist
between that provider and the injured employee, the injured
employee's employer, the injured employee's insurance carrier, the
utilization review agent, or any of the treating doctors or
insurance carrier health care providers who reviewed the case for
decision before referral to the independent review organization.
Added by Acts 2005, 79th Leg., ch. 265, § 3.247, eff. Sept. 1,
2005.
SUBCHAPTER D. HEALTH CARE PROVIDERS
§ 413.041. DISCLOSURE. (a) Each health care practitioner
shall disclose to the division the identity of any health care
provider in which the health care practitioner, or the health care
provider that employs the health care practitioner, has a financial
interest. The health care practitioner shall make the disclosure
in the manner provided by commissioner rule.
(b) The commissioner shall require by rule that a doctor
disclose financial interests in other health care providers as a
condition of registration for the approved doctor list established
under Section 408.023 and shall define "financial interest" for
purposes of this section as provided by analogous federal
regulations. The commissioner by rule shall adopt the federal
standards that prohibit the payment or acceptance of payment in
exchange for health care referrals relating to fraud, abuse, and
antikickbacks.
(c) A health care provider that fails to comply with this
section is subject to penalties and sanctions as provided by this
subtitle, including forfeiture of the right to reimbursement for
services rendered during the period of noncompliance.
(d) The division shall publish all final disclosure
enforcement orders issued under this section on the division's
Internet website.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2001, 77th Leg., ch. 1456, § 6.05, eff. June 17, 2001;
Acts 2005, 79th Leg., ch. 265, § 3.246, eff. Sept. 1, 2005.
§ 413.042. PRIVATE CLAIMS; ADMINISTRATIVE
VIOLATION. (a) A health care provider may not pursue a private
claim against a workers' compensation claimant for all or part of
the cost of a health care service provided to the claimant by the
provider unless:
(1) the injury is finally adjudicated not compensable
under this subtitle; or
(2) the employee violates Section 408.022 relating to
the selection of a doctor and the doctor did not know of the
violation at the time the services were rendered.
(b) A health care provider commits an administrative
violation if the provider violates Subsection (a).
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2005, 79th Leg., ch. 265, § 3.248, eff. Sept. 1, 2005.
§ 413.043. OVERCHARGING PROHIBITED; OFFENSE. (a) A
health care provider commits an offense if the person knowingly
charges an insurance carrier an amount greater than that normally
charged for similar treatment to a payor outside the workers'
compensation system, except for mandated or negotiated charges.
(b) An offense under this section is a Class A misdemeanor.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993.
§ 413.044. SANCTIONS ON DESIGNATED DOCTOR. (a) In
addition to or in lieu of an administrative penalty under Section
415.021 or a sanction imposed under Section 415.023, the
commissioner may impose sanctions against a person who serves as a
designated doctor under Chapter 408 who, after an evaluation
conducted under Section 413.002(b), is determined by the division
to be out of compliance with this subtitle or with rules adopted by
the commissioner relating to:
(1) medical policies, fee guidelines, and impairment
ratings; or
(2) the quality of decisions made under Section
408.0041 or Section 408.122.
(b) Sanctions imposed under Subsection (a) may include:
(1) removal or suspension from the division list of
designated doctors; or
(2) restrictions on the reviews made by the person as a
designated doctor.
Added by Acts 1995, 74th Leg., ch. 980, § 1.44, eff. Sept. 1,
1995. Amended by Acts 2005, 79th Leg., ch. 265, § 3.249, eff.
Sept. 1, 2005.
SUBCHAPTER E. IMPLEMENTATION OF COMMISSION POWERS AND DUTIES
§ 413.051. CONTRACTS WITH REVIEW ORGANIZATIONS AND HEALTH
CARE PROVIDERS. (a) In this section, "health care provider
professional review organization" includes an independent review
organization.
(b) The division may contract with a health care provider,
health care provider professional review organization, or other
entity to develop, maintain, or review medical policies or fee
guidelines or to review compliance with the medical policies or fee
guidelines.
(c) For purposes of review or resolution of a dispute as to
compliance with the medical policies or fee guidelines, the
division may contract with a health care provider, health care
provider professional review organization, or other entity that
includes in the review process health care practitioners who are
licensed in the category under review and are of the same field or
specialty as the category under review.
(d) The division may contract with a health care provider,
health care provider professional review organization, or other
entity for medical consultant services, including:
(1) independent medical examinations;
(2) medical case reviews; or
(3) establishment of medical policies and fee
guidelines.
(e) The commissioner shall establish standards for
contracts under this section.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2001, 77th Leg., ch. 1456, § 1.02, eff. June 17, 2001;
Acts 2005, 79th Leg., ch. 265, § 3.250, eff. Sept. 1, 2005.
§ 413.0511. MEDICAL ADVISOR. (a) The division shall
employ or contract with a medical advisor, who must be a doctor as
that term is defined by Section 401.011.
(b) The medical advisor shall make recommendations
regarding the adoption of rules and policies to:
(1) develop, maintain, and review guidelines as
provided by Section 413.011, including rules regarding impairment
ratings;
(2) review compliance with those guidelines;
(3) regulate or perform other acts related to medical
benefits as required by the commissioner;
(4) impose sanctions or delete doctors from the
division's list of approved doctors under Section 408.023 for:
(A) any reason described by Section 408.0231; or
(B) noncompliance with commissioner rules;
(5) impose conditions or restrictions as authorized by
Section 408.0231(f);
(6) receive, and share with the medical quality review
panel established under Section 413.0512, confidential
information, and other information to which access is otherwise
restricted by law, as provided by Sections 413.0512, 413.0513, and
413.0514 from the Texas State Board of Medical Examiners, the Texas
Board of Chiropractic Examiners, or other occupational licensing
boards regarding a physician, chiropractor, or other type of doctor
who applies for registration or is registered with the division on
the list of approved doctors;
(7) determine minimal modifications to the
reimbursement methodology and model used by the Medicare system as
necessary to meet occupational injury requirements; and
(8) monitor the quality and timeliness of decisions
made by designated doctors and independent review organizations,
and the imposition of sanctions regarding those decisions.
Added by Acts 2001, 77th Leg., ch. 1456, § 1.02, eff. June 17,
2001. Amended by Acts 2003, 78th Leg., ch. 963, § 1, eff. June
20, 2003; Acts 2005, 79th Leg., ch. 265, § 3.251, eff. Sept. 1,
2005.
§ 413.0512. MEDICAL QUALITY REVIEW PANEL. (a) The
medical advisor shall establish a medical quality review panel of
health care providers to assist the medical advisor in performing
the duties required under Section 413.0511. The panel is not
subject to Chapter 2110, Government Code.
(b) The Texas State Board of Medical Examiners and the Texas
Board of Chiropractic Examiners, with input from their respective
professional associations, shall develop lists of physicians and
chiropractors licensed by those agencies who have demonstrated
experience in workers' compensation or utilization review. The
medical advisor shall consider appointing some of the members of
the medical quality review panel from the names on those lists. The
medical advisor shall also consider nominations for the panel made
by labor, business, and insurance organizations.
(c) The medical quality review panel shall recommend to the
medical advisor:
(1) appropriate action regarding doctors, other
health care providers, insurance carriers, utilization review
agents, and independent review organizations; and
(2) the addition or deletion of doctors from the list
of approved doctors under Section 408.023 or the list of designated
doctors established under Section 408.1225.
(d) A person who serves on the medical quality review panel
is immune from suit and from civil liability for an act performed,
or a recommendation made, within the scope of the person's
functions as a member of the panel if the person acts without malice
and in the reasonable belief that the action or recommendation is
warranted by the facts known to that person. In the event of a civil
action brought against a member of the panel that arises from the
person's participation on the panel, the person is entitled to the
same protections afforded a commission member under Section
402.010.
(e) The actions of a person serving on the medical quality
review panel do not constitute utilization review and are not
subject to Article 21.58A, Insurance Code.
Added by Acts 2001, 77th Leg., ch. 1456, § 1.02, eff. June 17,
2001. Amended by Acts 2003, 78th Leg., ch. 963, § 2, eff. June
20, 2003; Acts 2005, 79th Leg., ch. 265, § 3.252, eff. Sept. 1,
2005.
§ 413.0513. CONFIDENTIALITY REQUIREMENTS. (a)
Information collected, assembled, or maintained by or on behalf of
the division under Section 413.0511 or 413.0512 constitutes an
investigation file for purposes of Section 402.092 and may not be
disclosed under Section 413.0511 or 413.0512 except as provided by
that section.
(b) Confidential information, and other information to
which access is restricted by law, developed by or on behalf of the
division under Section 413.0511 or 413.0512 is not subject to
discovery or court subpoena in any action other than:
(1) an action to enforce this subtitle brought by the
division, an appropriate licensing or regulatory agency, or an
appropriate enforcement authority; or
(2) a criminal proceeding.
Added by Acts 2001, 77th Leg., ch. 1456, § 1.02, eff. June 17,
2001. Amended by Acts 2003, 78th Leg., ch. 963, § 3, eff. June
20, 2003; Acts 2005, 79th Leg., ch. 265, § 3.253, eff. Sept. 1,
2005.
§ 413.0514. INFORMATION SHARING WITH OCCUPATIONAL
LICENSING BOARDS. (a) This section applies only to information
held by or for the division, the Texas State Board of Medical
Examiners, and Texas Board of Chiropractic Examiners that relates
to a person who is licensed or otherwise regulated by any of those
state agencies.
(b) The division and the Texas State Board of Medical
Examiners on request or on its own initiative, may share with each
other confidential information or information to which access is
otherwise restricted by law. The division and the Texas State Board
of Medical Examiners shall cooperate with and assist each other
when either agency is conducting an investigation by providing
information to each other that the sending agency determines is
relevant to the investigation. Except as provided by this section,
confidential information that is shared under this section remains
confidential under law and legal restrictions on access to the
information remain in effect. Furnishing information by the Texas
State Board of Medical Examiners to the division or by the division
to the Texas State Board of Medical Examiners under this subsection
does not constitute a waiver of privilege or confidentiality as
established by law.
(c) Information that is received by the division from the
Texas State Board of Medical Examiners or by the Texas State Board
of Medical Examiners from the division remains confidential, may
not be disclosed by the division except as necessary to further the
investigation, and shall be exempt from disclosure under Sections
402.092 and 413.0513.
(d) The division and the Texas Board of Chiropractic
Examiners on request or on its own initiative, may share with each
other confidential information or information to which access is
otherwise restricted by law. The division and the Texas Board of
Chiropractic Examiners shall cooperate with and assist each other
when either agency is conducting an investigation by providing
information to each other that is relevant to the investigation.
Except as provided by this section, confidential information that
is shared under this section remains confidential under law and
legal restrictions on access to the information remain in effect
unless the agency sharing the information approves use of the
information by the receiving agency for enforcement purposes.
Furnishing information by the Texas Board of Chiropractic Examiners
to the division or by the division to the Texas Board of
Chiropractic Examiners under this subsection does not constitute a
waiver of privilege or confidentiality as established by law.
(e) Information that is received by the division from the
Texas Board of Chiropractic Examiners or by the Texas Board of
Chiropractic Examiners from the division remains confidential and
may not be disclosed by the division except as necessary to further
the investigation unless the agency sharing the information and the
agency receiving the information agree to use of the information by
the receiving agency for enforcement purposes.
(f) The division and the Texas State Board of Medical
Examiners shall provide information to each other on all
disciplinary actions taken.
(g) The division and the Texas Board of Chiropractic
Examiners shall provide information to each other on all
disciplinary actions taken.
Added by Acts 2003, 78th Leg., ch. 963, § 4, eff. June 20, 2003.
Amended by Acts 2005, 79th Leg., ch. 265, § 3.254, eff. Sept. 1,
2005.
§ 413.0515. REPORTS OF PHYSICIAN AND CHIROPRACTOR
VIOLATIONS. (a) If the division or the Texas State Board of
Medical Examiners discovers an act or omission by a physician that
may constitute a felony, a misdemeanor involving moral turpitude, a
violation of state or federal narcotics or controlled substance
law, an offense involving fraud or abuse under the Medicare or
Medicaid program, or a violation of this subtitle, the agency shall
report that act or omission to the other agency.
(b) If the division or the Texas Board of Chiropractic
Examiners discovers an act or omission by a chiropractor that may
constitute a felony, a misdemeanor involving moral turpitude, a
violation of state or federal narcotics or controlled substance
law, an offense involving fraud or abuse under the Medicare or
Medicaid program, or a violation of this subtitle, the agency shall
report that act or omission to the other agency.
Added by Acts 2003, 78th Leg., ch. 963, § 4, eff. June 20, 2003.
Amended by Acts 2005, 79th Leg., ch. 265, § 3.255, eff. Sept. 1,
2005.
§ 413.052. PRODUCTION OF DOCUMENTS. The commissioner by
rule shall establish procedures to enable the division to compel
the production of documents.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2005, 79th Leg., ch. 265, § 3.256, eff. Sept. 1, 2005.
§ 413.053. STANDARDS OF REPORTING AND BILLING. The
commissioner by rule shall establish standards of reporting and
billing governing both form and content.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2005, 79th Leg., ch. 265, § 3.257, eff. Sept. 1, 2005.
§ 413.054. IMMUNITY FROM LIABILITY. (a) A person who
performs services for the division as a designated doctor, an
independent medical examiner, a doctor performing a medical case
review, or a member of a peer review panel has the same immunity
from liability as the commissioner under Section 402.0024.
(b) Immunity from liability under this section does not
apply to a person providing medical treatment to an injured
employee.
Acts 1993, 73rd Leg., ch. 269, § 1, eff. Sept. 1, 1993. Amended
by Acts 2005, 79th Leg., ch. 265, § 3.258, eff. Sept. 1, 2005.
§ 413.055. INTERLOCUTORY ORDERS; REIMBURSEMENT. (a) The
commissioner may enter an interlocutory order for the payment of
all or part of medical benefits. The order may address accrued
benefits, future benefits, or both accrued benefits and future
benefits.
(b) The subsequent injury fund shall reimburse an insurance
carrier for any overpayments of benefits made under an order
entered under Subsection (a) if the order is reversed or modified by
final arbitration, order, or decision of the commissioner or a
court. The commissioner shall adopt rules to provide for a periodic
reimbursement schedule, providing for reimbursement at least
annually.
(c) A party that disputes an order entered under Subsection
(a) is entitled to a hearing. The hearing shall be conducted by the
State Office of Administrative Hearings in the manner provided for
a contested case under Chapter 2001, Government Code. The order is
binding during the pendency of the appeal.
Added by Acts 1999, 76th Leg., ch. 955, § 6, eff. Sept. 1, 1999.
Amended by Acts 2005, 79th Leg., ch. 265, § 3.259, eff. Sept. 1,
2005.
