February 23, 2016 WC Bulletin No. 2016-2 To: Persons Interested in Workers’ Compensation Issues From: Steve Nichols, Manager, Workers’ Compensation Services Re: Report on DWC’s January 27, 2016 Quarterly Insurance Carrier Meeting This bulletin is intended to provide Insurance Council of Texas members with a report on the Texas Department of Insurance’s Division of Workers’ Compensation January 27, 2016 Quarterly Insurance Carrier Meeting. The Division of Workers’ Compensation (DWC) held the Quarterly Insurance Carrier Meeting at the DWC’s central office in Austin, Texas. Executive Summary Commissioner of Workers’ Compensation Ryan Brannan made brief opening remarks. See Page 2 of the bulletin for a summary of the commissioner’s remarks. DWC staff presented updates on:

(1) Health Care Management Update: Matthew Zurek, Executive Deputy Commissioner of Healthcare Management & System Monitoring, provided a health care management update which included a discussion of the transition from ICD-9 to ICD-10 diagnostic codes with the Texas workers’ compensation system. See Page 3 of the bulletin.

(2) Complaint and Data Monitoring Update: Teresa Carney, the DWC’s Director of System

Monitoring & Oversight, provided an update on complaints received and acted upon by the DWC as of June 30, 2015. See Pages 4 – 8 of the bulletin.

(3) Enforcement Update: Sandra Nicholas, TDI’s Associate Commissioner Enforcement and Leah

Gillum, Team Leader of the Workers’ Compensation Litigation Office, provided an update on workers’ compensation enforcement activities. See Pages 8 – 11 of the bulletin.

(4) Office of Medical Advisor Activities Update: Mary Landrum, Director of Health Care Business Management, provided an update on the activities of the Office of Medical Advisor (OMA) and the Medical Quality Review Panel (MQRP). See Page 11 of the bulletin.

(5) Medical Fee Dispute Resolution Update: Martha Luevano, the DWC’s Manager of Medical Fee Dispute Resolution, provided an update on the medical fee dispute resolution process. See Pages 12 through 14 of the bulletin.

WC Bulletin No. 2016-2: Report on DWC’s January 27, 2016 Quarterly Insurance Carrier Meeting A Copyrighted Publication of the Insurance Council of Texas

(6) DWC Rule-Making Projects Update: Emily McCoy, the DWC’s Director of the Office of Workers’ Compensation Counsel, provided a rule-making projects update. See Pages14 through 16 of the bulletin.

(7) Performance Based Oversight Update: Teresa Carney, the DWC’s Director of System

Monitoring & Oversight, provided an update on the 2015 Performance Based Oversight (PBO) Assessment for health care providers and notice of dates for the 2016 Insurance Carrier PBO Assessment. See Pages 16 through 18 of the bulletin.

A Question and Answer Session was held at the end of the meeting. See Page 18 of the bulletin. The following meeting agenda items were presented and discussed during the meeting: Opening Remarks by Commissioner of Workers’ Compensation Ryan Brannan Commissioner of Workers’ Compensation Ryan Brannan welcomed the meeting participants. The Commissioner Brannan reported that the Division of Workers’ Compensation (DWC) reached out to stakeholders and asked them for input on possible 2017 legislative recommendations. He noted that the DWC has received input from stakeholders. Commissioner Brannan said that the DWC is currently reviewing the Plain Language Notices (PLN) as they are “not as plain as we had thought.” He noted that the DWC will be working on each of the PLN forms to simplify them. The commissioner said that the DWC would also be reaching out to system stakeholders via the publication of a memorandum that provides details issues with how the forms are being misused or not completed correctly. Note: On February 2, 2016, the DWC posted and distributed a memorandum titled “Insurance Carrier Claim Adjusting and Plain Language Notices; PLN-1 and PLN-11 on the agency’s website. The memo was authored by Teresa Carney, the DWC’s Director of System Monitoring & Oversight. The memo reminded insurance carriers and other system participants that the Texas Workers' Compensation Act and related rules contain several provisions regarding an insurance carrier's duty to reasonably adjust claims, including completing and filing plain language notices (PLNs). The DWC memo noted that the timely filing of notices helps ensure that injured employees are notified of actions taken on their claims, including the reasons for such actions. These notices also provide injured employees with important information about their rights to request a benefit review conference (BRC) to dispute any denial or refusal to pay benefits. The DWC reminded insurance carriers that they are required to file the PLN-01, Notice of Denial of Compensability/Liability and Refusal to Pay, and PLN-11, Notice of Disputed Issue(s) and Refusal to Pay Benefits in accordance with agency rules. The DWC also pointed out that the Notices must provide full and complete statements in plain language that clearly explain the denial or dispute. Generic statements without a clear explanation of reasons for the action are not sufficient. Examples of statements that do not meet the requirements can be found in Subsections (f) and (h) of Rule 124.2. A generic statement that simply states the carrier's position with phrases such as "employee returned to work," "adjusted for light duty," "liability is in question," "compensability in

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WC Bulletin No. 2016-2: Report on DWC’s January 27, 2016 Quarterly Insurance Carrier Meeting A Copyrighted Publication of the Insurance Council of Texas dispute," "under investigation," or other similar phrases with no further description of the factual basis for the action taken does not satisfy the requirements of Rule 124.2. The DWC also reminded insurance carriers of the requirement to file the PLN-1 or PLN-11 timely in accordance with Rule 124.3(a) and (e), and Rule 132.17(b). The memo included a reminder of compliance issues associated with the failure to process claims promptly in a reasonable and prudent manner. The DWC reminded insurance carriers of specific administrative violations associated with the claims handling process. The commissioner concluded his remarks by stating that the DWC wants to make sure that the PLNs are being used correctly. He noted that DWC staff would be monitoring the use of PLNs. Health Care Management Update Matthew Zurek, Executive Deputy Commissioner of Healthcare Management & System Monitoring, reported that the DWC has effectively addressed the big backlog of medical disputes that were pending at the agency when he arrived and took his current position. Zurek said that there were 17,000 disputes pending before the agency when he started working at the DWC. He said that due to the hard work of the Medical Fee Dispute Resolution Section, the backlog has been cut to 1,000 medical fee disputes. Zurek recognized and commended the hard work of the Medical Fee Dispute Resolution Section and Martha Luevano, Manager of the Medical Fee Dispute Resolution Section. Zurek reported that the DWC has been focusing on driver safety since the number of work-related deaths associated with automobile and truck accidents are high in Texas. He noted that the DWC has been working with The National Safety Council (NSC) and the NSC’s Our Driving Concern: Employer Traffic Safety program. He noted that the Insurance Council of Texas (ICT) had Lisa Robinson of the NSC speak at ICT’s 2015 Workers’ Compensation Conference about the program.

The Our Driving Concern: Employer Traffic Safety is a program of the National Safety Council in cooperation with the Texas Department of Transportation that is aimed at reducing work-related traffic fatalities. The NSC is reaching out to Texas employers to promote safe driving practices among their employees, both on and off the job, and proactively combat the costly toll of crashes by helping them understand risky driving behaviors and liability exposure. Additional information about the program can be found at http://txdrivingconcern.org/ and http://www.nsc.org/learn/NSC-Initiatives/Pages/Texas-Our-Driving-Concern-Has-Moved.aspx.

The NSC a flyer available about the Our Driving Concern: Employer Traffic Safety which insurance companies and their insurance agents can share with their insured employers who insure vehicles: http://txdrivingconcern.org/wp-content/uploads/2015/11/About_Our_Driving_Concern_2014.pdf.

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WC Bulletin No. 2016-2: Report on DWC’s January 27, 2016 Quarterly Insurance Carrier Meeting A Copyrighted Publication of the Insurance Council of Texas Zurek announced that the DWC would hold a half-day training session on February 1, 2016 at which the NSC’s Our Driving Concern: Employer Traffic Safety “train the trainer” training would be presented. The DWC has occupational driving safety information and resources available on their website at http://www.tdi.texas.gov/wc/safety/drivesafe.html. Note: The NSC has announced that they are willing to hold “train the trainer” training sessions for insurance company safety staff and employers who can then provide the training to employer vehicle fleet drivers. Contact Lisa Robinson of the NSC at (512) 466-7383 or Lisa.Robinson@nsc.org to coordinate a training session and for more information about the program. The free training program covers a variety of traffic safety topics for you to take the information back to your company and present it to your employees. • Our Driving Concern: Making a Difference • Distracted Driving • Impaired Driving • Aggressive Driving • Passenger Restraint The NSC currently has two FREE training sessions scheduled for March 2016 – San Antonio, Texas on March 22, 2016 and San Marcos, Texas on March 23, 2016. Online registration for the training is available for both the San Antonio and San Marcos training locations. Complaint and Data Update Teresa Carney, the DWC’s Director of System Monitoring & Oversight, provided an update on complaints received during Calendar Year 2015 and the actions taken by the DWC on the complaints. Carney reported that the DWC received 4,776 complaints during Calendar Year (CY) 2015.

Source: Texas Department of Insurance (TDI) Division of Workers’ Compensation, January 27, 2016

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WC Bulletin No. 2016-2: Report on DWC’s January 27, 2016 Quarterly Insurance Carrier Meeting A Copyrighted Publication of the Insurance Council of Texas Carney said the Top 3 Complaint Types were:

(1) Communications (2,224 complaints) which are generally the late filing of required forms, e.g. the DWC-69, Report of Medical Examination and DWC-005, Employer Notice of No Coverage or Termination of Coverage;

(2) Medical Benefits Delivery (1,211 complaints) which are generally complaints regarding the failure to provide an Explanation of Benefits, late medical bill payments, and etc.;

(3) Indemnity Benefit Delivery (582 complaints) which are generally late initiation of temporary income benefits (TIBS), late payment of week to week TIBs and inaccurate payment of income benefits.

Source: Texas Department of Insurance (TDI) Division of Workers’ Compensation, January 27, 2016 Carney reported that the number of complaints received during CY 2015 was down 12 percent as compared to the number of complaints received in CY 2014. She noted that the DWC posts a complaints report is posted on a monthly basis on the agency website.

Source: Texas Department of Insurance’s Division of Workers’ Compensation, January 27, 2016

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WC Bulletin No. 2016-2: Report on DWC’s January 27, 2016 Quarterly Insurance Carrier Meeting A Copyrighted Publication of the Insurance Council of Texas Carney reported that the DWC closed 3,083 complaints in CY 2015. She noted that the DWC took the following actions on the closed complaints: ● 1,015 monitor letters were sent to the subjects of the complaints; ● 1,292 complaints investigated and closed with a finding of no violation(s) confirmed; ● 776 complaints investigated and closed as confirmed with violation of the Texas Labor Code

and/or DWC rules: ○ 292 closed with warning letters sent to the subject of the complaint; ○ 183 closed with education letters being sent to the subject of the complaint; and ○ 276 referred to the Texas Department of Insurance’s Enforcement Division.

Source: Texas Department of Insurance’s Division of Workers’ Compensation, January 27, 2016 Carney provided an update on insurance industry performance on the payment of initial temporary income benefits (TIBS) for Calendar Year 2015. She reported that the timely payment of initial TIBs dropped to 81.33 percent in December of 2015 but has otherwise remained at the 83 percent to 84 percent compliance level. Carney said that she expects the insurance industry aggregate compliance rate for the timely payment of initial TIBs to go up due to 2016 Insurance Carrier Performance Based Oversight assessment process data time frame for insurance carriers being January 1, 2016 through June 30, 2016. Carney noted that the percentage of compliance reported by her reflects raw data with no investiga-tions done to determine if compliance rate was actually greater.

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WC Bulletin No. 2016-2: Report on DWC’s January 27, 2016 Quarterly Insurance Carrier Meeting A Copyrighted Publication of the Insurance Council of Texas

Source: Texas Department of Insurance’s Division of Workers’ Compensation, January 27, 2016 Carney reported the insurance industry’s performance on the timely reporting of initial TIBs via the EDI data submission process was 95.5 percent in December 2015. She noted that the compliance rate for the timely submission of the data has consistently been in the 95 percential range.

Source: Texas Department of Insurance’s Division of Workers’ Compensation, January 27, 2016 Carney provided an update on insurance industry performance on the processing of medical bills and timely reporting of medical billing data during Fiscal Year (FY) 2015. She reported that the insurance industry processed and paid medical bills in a timely fashion 98.48 percent of the time during the fourth quarter of FY 2015. Carney noted that the timely processing of medical bills has consistently been in the high 90s percentile range.

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WC Bulletin No. 2016-2: Report on DWC’s January 27, 2016 Quarterly Insurance Carrier Meeting A Copyrighted Publication of the Insurance Council of Texas Carney reported that the timely EDI reporting of medical billing data was accomplished 90.05 percent during the fourth quarter of FY 2015. She noted that the timeliness of reporting ranged from a low of 76.45 percent to a high of 94.60 percent during FY 2015. Carney said she expects the timeliness of reporting of medical billing data to increase to the 95 percentile range during the on-going insurance carrier performance-based oversight (PBO) data time period due to no corrections being made during that timeframe. She noted that the DWC does not allow insurance carriers and their EDI vendors to submit corrected data during the PBO data time period. The data time period for the 2016 insurance carrier PBO Assessment is January 1, 2016 through June 30, 2016.

Source: Texas Department of Insurance’s Division of Workers’ Compensation, January 27, 2016 Carney reported that several insurance carriers and/or their EDI vendors are still not reporting the National Provider Identifier number. She also reported that the date the medical bill was processed is being misreported. Carney noted that the timely payment of initial temporary income benefits was 84.22 percent in September 2015. She noted that the compliance percentages represent raw data and do not take into account salary continuation and other issues. Enforcement Update Sandra Nicolas, TDI’s Associate Commissioner of Enforcement noted that TDI’s Compliance Division pursues strategies to improve efficiencies in market compliance and case processing. Nicolas said in doing so, the Compliance Division:

(1) Uses clear, express statutory authority for all enforcement cases; (2) Informs workers’ compensation stakeholders about compliance goals;

(3) Partners with the DWC’s program areas to foster compliance;

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WC Bulletin No. 2016-2: Report on DWC’s January 27, 2016 Quarterly Insurance Carrier Meeting A Copyrighted Publication of the Insurance Council of Texas

(4) Assists the Office of the Medical Advisor with medical quality reviews and enforcement actions; and

(5) Provides swift, appropriate actions for statutory and rule violations.

Nicolas provided a workers’ compensation enforcement case status update noting that the Workers’ Compensation Litigation Office had closed 231 cases and had 59 cases pending as of December 31, 2015.

Source: Texas Department of Insurance’s Enforcement Division, January 27, 2016 Nicolas reported that as of December 31, 2015, the Workers’ Compensation Litigation Office had 33 cases against insurance companies and 24 cases against health care providers pending review and action.

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WC Bulletin No. 2016-2: Report on DWC’s January 27, 2016 Quarterly Insurance Carrier Meeting A Copyrighted Publication of the Insurance Council of Texas Workers’ Compensation Enforcement Pending Cases by Subject Type as of December 31, 2015

Source: Texas Department of Insurance’s Enforcement Division, January 27, 2016 Toya Lutz, Team Leader of the Workers’ Compensation Litigation Office, provided an overview of the workers’ compensation enforcement cases closed as of December 31, 2015. Lutz said there were 119 insurance carrier enforcement cases, 101 health care provider enforcement cases, and 11 other enforcement subject type cases closed. Lutz also provided an overview of case closure by disposition and subject type.

Workers’ Compensation Enforcement Cases Closed by Subject Type as of 12/31/2015

Source: Texas Department of Insurance, Enforcement Division, January 27, 2016

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WC Bulletin No. 2016-2: Report on DWC’s January 27, 2016 Quarterly Insurance Carrier Meeting A Copyrighted Publication of the Insurance Council of Texas

Cases Closed by Disposition and Subject Type

Source: Texas Department of Insurance, Enforcement Division, January 27, 2016 Office of Medical Advisor Update Mary Landrum, Director of Health Care Business Management, provided a report on the Calendar Year 2015 activities of the Office of Medical Advisor (OMA) and the Medical Quality Review Panel (MQRP). Landrum reported the following: ● Investigated 248 complaints with 19 percent being recommended for a Medical Quality Review

Panel (MQRP) review, 58 percent being closed without any action, 13 percent being closed with a letter of education issued and 10 percent referred to TDI’s Enforcement Division without any review by the MQRP;

● Initiated 35 MQRP reviews that included complaint, audit and monitoring based reviews, and

Performance Based Oversight (PBO) assessments; and ● Concluded 35 MQRP reviews. 77 percent of the cases were referred to TDI’s Compliance

Division for enforcement action and 23 percent with other case dispositions that included letters of education, referrals to medical licensing boards and closures with no action.

Landrum reported that the MQRP initiated and completed 1,461 Performance Based Oversight assessments during CY 2015.

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WC Bulletin No. 2016-2: Report on DWC’s January 27, 2016 Quarterly Insurance Carrier Meeting A Copyrighted Publication of the Insurance Council of Texas Medical Fee Dispute Resolution Update Martha Luevano, the DWC’s Manager of Medical Fee Dispute Resolution (MFDR), provided an update on the medical fee dispute resolution disputes docketed, resolved and pending at the end of Calendar Year 2015. Luevano reported that the DWC has reduced its backlog of medical fee disputes from 1,900 to 939 disputes with most of the disputes having been adjudicated within 90 day from the date the disputes were docketed. Luevano said the DWC has set a goal to reduce the backlog of medical fee disputes from 939 to under 700 disputes. She noted that the DWC has also set a goal to adjudicate 90 percent of the disputes within 90 days of the docketing of the disputes. Luevano provided the following overview of the number of medical fee disputes docketed and closed during calendar years 2011 through 2015.

Medical Fee Disputes Docketed and Closed: 2011 – 2015 Trends

Source: Texas Department of Insurance, Division of Workers’ Compensation, January 27, 2016 Luevano provided an overview of the total number of active disputes pending at the DWC at the end of Calendar Years 2011 – 2015. She noted that there had been a net reduction of 4,961 disputes pending at the DWC.

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WC Bulletin No. 2016-2: Report on DWC’s January 27, 2016 Quarterly Insurance Carrier Meeting A Copyrighted Publication of the Insurance Council of Texas

Total Active Disputes Pending at the End of Calendar Years 2011 – 2015

Source: Texas Department of Insurance, Division of Workers’ Compensation, January 27, 2016 Luevano reported that the fee dispute categories for active disputes include Air Ambulance Fee Disputes with 436 disputes pending review, Professional Service Fee Disputes with 101 disputes pending review, DWC Specific Services Disputes with 99 disputes pending review, Section 409.0091 Subclaimant Disputes with 79 pending review, Pharmacy Disputes with 63 pending review and Other Disputes with 68 disputes pending review.

Active Fee Disputes as of January 1, 2016

Source: Texas Department of Insurance, Division of Workers’ Compensation, January 27, 2016

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WC Bulletin No. 2016-2: Report on DWC’s January 27, 2016 Quarterly Insurance Carrier Meeting A Copyrighted Publication of the Insurance Council of Texas Luevano said the DWC has projected that there will be an estimated 4,000 medical fee disputes filed during Calendar Year 206. She provided an overview of the percentage of each category of dispute that the DWC anticipates being filed in 2016. Luevano reminded insurers of the requirement that they submit a response for each medical fee dispute that is filed with the DWC. She noted that Rule 133.307(d)(2) requires an insurance carrier to:

(a) timely respond to a request for medical fee dispute resolution; (b) provide initial and appeal explanation of benefits (EOB) not included with the request for

medical fee dispute resolution; (c) provide the appropriate plain language notice if the EOB denial is compensability, extent or

liability; and (d) provide document that supports that an adverse determination was made in accordance with

Section 19.005, if the EOB denial relates to medical necessity. Luevano reported that the DWC does not always receive a response from the insurance carrier and often does not receive all of the information required by Rule 133.307(d)(2). Rules Update Emily McCoy, Director of the DWC’s Office of Workers’ Compensation Counsel, provided an update on the DWC’s rule-making activities and projects. McCoy reported that the DWC is in the process of proposing rules to implement legislation passed during the 2015 legislative session. She also reported that the DWC is also working on a non-substantive reorganization of Rule 134.204 regarding workers’ compensation specific services and other minor rule amendments.

A summary of the DWC’s rule-making projects follow: Proposed Amendments to Rule 104.1 The proposed rule amendment aligns Rule 104.1 regarding rule petitions with HB 763, 84th Legislature, Regular Session (2015) by requiring that a petitioner is an interested party under Section 2001.021 of the Texas Government Code. The amended rule was formally proposed on December 11, 2015. The public comment period for the proposed rules ended at 5:00 p.m. Central Standard Time (CST) on January 11, 2016. The DWC is expected to adopt the amended rule in the near future. Proposed Amendments to Rules 129.1 and 129.11 The proposed rule amendments to Rules 129.3(b), 129.3(f)(2), and 129.11(b) increase the hourly wage from $8.50an hour to $10 an hour that qualifies an injured employee to be paid at the higher TIBs rate of 75 percent of the employee’s pre-injury average weekly wage for the first 26 weeks of

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WC Bulletin No. 2016-2: Report on DWC’s January 27, 2016 Quarterly Insurance Carrier Meeting A Copyrighted Publication of the Insurance Council of Texas disability. Amendments to Rules 129.3(b), §129.3(f)(1), and §129.11(b)(1) clarify that the $8.50 rate still applies to workers' compensation claims with a date of injury before September 1, 2015. The rule amendments are necessary to implement SB 901 which was passed by the Texas Legislature during the 2015 legislative session. The amended rule was formally proposed on October 9, 2015. The public comment period for the proposed rules ended at 5:00 p.m. Central Standard Time (CST) on November 22, 2015. The DWC is expected to adopt the amended rule in the near future. Amendment of Death Benefits Rule – Rule 132.7 The proposed rule amendments to Rule 132.7 provide that a remarried former spouse of a first responder killed on the job is entitled to receive death benefits for life. The rule amendment is required to implement HB 1094 which amended the Texas Labor Code to provide that a remarried former spouse of a first responder killed on the job is entitled to receive death benefits for life. Prior to the passage of the legislation, the benefits of a spouse who remarries was limited to 104 weeks. The amended rule was formally proposed on December 4, 2015. The public comment period for the proposed rule ended at 5:00 p.m. CST on January 4, 2016. The DWC is expected to adopt the amended rule in the near future. Amendment of Burial Benefits Rule – Rule 132.13 The DWC published amended Rule 132.13 to raise the burial benefits for an injured employee killed on the job to $10,000. The rule amendment is required to implement SB 653 which increased the amount of burial benefits required to be paid by a workers’ compensation insurance carrier for the burial expenses of an employee who is killed on the job. The amended rule was formally proposed on December 4, 2015. The public comment period for the proposed rule ended at 5:00 p.m. CST on January 4, 2016. The DWC is expected to adopt the amended rule in the near future. Reorganization of Rule 134.204 into 10 Separate Rules The DWC has published informal draft rules that are part of the non-substantive reorganization of Rule 134.204 regarding workers’ compensation specific services.

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WC Bulletin No. 2016-2: Report on DWC’s January 27, 2016 Quarterly Insurance Carrier Meeting A Copyrighted Publication of the Insurance Council of Texas The rule is being reorganized into several new sections for ease of compliance for system partici-pants. The DWC has also published a chart that provides an overview of the reorganization of Rule 134.204 into multiple rules. The public comment period for the informal draft rules ended at 5:00 p.m. CST on November 4, 2015. This rule-making project is in progress. Amendment of DWC’s Telephone Number Rule The DWC has proposed amendments to Rules 110.108 and 110.110. The rule amendments provide employees with updated DWC phone numbers in order to report possible exposure to communicable disease or HIV, and inquire about workers' compensation coverage requirements for construction sites. These proposed amendments were published in the August 7, 2015 issue of the Texas Register. The formal comment period for the rules ended at 5:00 p.m. CST September 8, 2015. The rule adoption was published in the December 11, 2015 issue of the Texas Register. The amended rule was effective on December 14, 2015. DWC Rule-Making Status Chart The DWC has posted an agency rule-making status chart on the TDI website. DWC Website Now Includes Adopted and Proposed Rule Webpage The DWC has changed their website and added a Workers’ Compensation Proposed and Adopted Rules webpage that allows system stake holders to view the progress and status of DWC rule-making projects. Rule-making projects for 2016 are available here. The rule-making projects initiated in 2015 are available here. Performance Based Oversight Update Teresa Carney, the DWC’s Director of System Monitoring & Oversight, provided an update on the 2015 Performance Based Oversight (PBO) Assessment for health care providers and notice of dates for the 2016 Insurance Carrier PBO Assessment. The 2015 health care provider PBO results are available on the DWC’s website. An overview of the PBO assessment process, applicable statute and rules, key regulatory goals, and PBO instruments can be found on the DWC’s website at http://www.tdi.texas.gov/wc/pbo/pbo.html.

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WC Bulletin No. 2016-2: Report on DWC’s January 27, 2016 Quarterly Insurance Carrier Meeting A Copyrighted Publication of the Insurance Council of Texas The 2015 Health Care Provider PBO Assessment Methodology Paper can be found here. Carney reported that the 2015 health care provider PBO Assessment consisted of the following three performance categories:

Source: Texas Department of Insurance, Division of Workers’ Compensation, January 27, 2016 Carney provided the following overview of the 2015 Health Care Provider PBO Assessment results:

Source: Texas Department of Insurance, Division of Workers’ Compensation, January 27, 2016

Source: Texas Department of Insurance, Division of Workers’ Compensation, January 27, 2016

Source: Texas Department of Insurance, Division of Workers’ Compensation, January 27, 2016

Source: Texas Department of Insurance, Division of Workers’ Compensation, January 27, 2016

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WC Bulletin No. 2016-2: Report on DWC’s January 27, 2016 Quarterly Insurance Carrier Meeting A Copyrighted Publication of the Insurance Council of Texas

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Carney reported that the DWC is currently in the midst of collecting data for the 2016 Insurance Carrier PBO Assessment. She announced the following key dates for the insurance carrier PBO assessment: ● July 2016 – DWC will distribute initial findings to the selected insurance. ● September/October 2016 – DWC will review insurance carrier management responses to the initial PBO findings. ● December 2016 – Final insurance carrier PBO assessment results will be announced and published on the DWC’s website. The insurance carriers selected by the DWC to participate in the 2016 Insurance Carrier PBO Assessment will be assessed on the following performance measures:

1. 40% weight - Timely payment of initial Temporary Income Benefits by the insurance carrier; 2. 30% weight - Timely processing of initial medical bills by the insurance carrier; 3. 10% weight - Timely processing of request for reconsideration medical bills by the insurance

carrier; 4. 10% weight - Timely submission of Initial Payment data via Electronic Data Interchange

(EDI); and 5. 10% weight - Timely submission of Medical Bill Processing data via EDI.

The insurance carriers selected for the 2016 PBO assessment will be selected based on the volume of initial payment of Temporary Income Benefit transactions between January 1, 2015 and June 30, 2015. The overall performance standard for insurance carriers is:

High Tier: 95 or greater Average Tier: 80.00 through 94.99 Poor Tier: 79.99 or less

Question & Answers Session Bill Weldon, Regional Legal Counsel for The Travelers Companies, Inc. and Chairman of ICT’s Workers’ Compensation Committee, asked it would be possible to have the designated doctor’s e-mail included on the designated doctor set notice. He said many insurance carriers would like to send their medical records to the designated doctor. Weldon noted that the designated doctor scheduling companies would like to receive electronic copies of the medical records. He noted that the records are sent via an encrypted e-mail system. DWC staff said they would look into adding the designated doctor’s e-mail address to the set notice. Conclusion of Quarterly Insurance Carrier Meeting Carney thanked everyone for attending the meeting and announced that the next Quarterly Insurance Carrier Meeting will be held in April 2016.