Katrina Daniel

1
Status of Workers Compensation Health Care
Networks in Texas
TSIA Conference June 8, 2009 Austin, TX

• Katrina Daniel
• Associate Commissioner
• Life, Health and Licensing Program
• Texas Department of Insurance

2
What are Workers Compensation Health Care
Networks?

• Organizations that are
• Formed to provide health care services to injured
  employees,
• Certified in accordance with Insurance Code
  Chapter 1305 and related rules, and
• Established by, or contracted with an insurance
  carrier (includes a certified self-insured
  employer).

3
House Bill 7 79th Legislature(Insurance Code
Chapter 1305)

• Authorizes the establishment of workers
  compensation health care networks
• Provides standards for the certification,
  administration, evaluation, and enforcement of
  health care service delivery by networks

4
Networks Who and how many?

• Formed by carriers, managed care entities, TPAs,
  self-insured employers and self-insured
  governmental entities
• 33 Certified Networks
• Complete list of certified networks provided at
  end of presentation
• Service area and contact information for each
  network is available at www.tdi.state.tx.us/wc/wcn
  et/wcnetworks.html
• 59 Approved Service Area Expansions
• 0 Pending Certifications
• 5 Pending Service Area Expansions

5
Certified WC Networks per County
6
Texas Certified WC Networks

1. Aetna Workers' Comp Access (AWCA)
2. Argus Provider Network
3. Bunch Associates, Inc. Texas Health Care
   Network
4. Bunch Coventry TX HCN dba Bunch Associates
5. Bunch HCN-First Health
6. Corvel Healthcare Corporation / Corcare
7. Coventry Health Care Workers Compensation Inc.
8. First Health / AIGCS Texas Health Care Network
9. First Health/CSS HCN
10. First Health Texas Health Care Network
11. First Health / Travelers Health Care Network
12. Forte Inc. / Compkey Plus
13. Genex Services Inc. / Genex Care For Texas' Comp
    Access (AWCA)
14. Genex Services Inc. / Genex Health Care Network
15. Hartford Workers' Compensation Health Care
    Network- FH, The
16. Houston Independent School District
17. IMO Med-Select Network / Injury Management
    Organization, Inc.

1. Interplan Health Group, Inc. / Zenith Health Care
   Network (ZHCN)
2. International Rehabilitation Associates, Inc. /
   Intracorp-2008
3. Intracorp / Lockheed Martin Aero Employee Select
   Network 2008
4. Liberty Health Care Network 
5. Majoris Health Systems
6. Memorial Hermann Health Network Providers, Inc. /
   Worklink 
7. National Choicecare,  NCC Choicenet
8. North Texas Innovative Healthcare Network, Inc.
9. Sedgwick Claims Management Service, Inc./
   Southwest Medical Provider Network
10. SHA, LLC / /Firstcare Network
11. Specialty Risk Services Texas Workers'
    Compensation Health Care Network (First Health)
12. Texas Star Network
13. The lone Star Network
14. Zurich Services Corporation Healthcare Network
15. Zurich Services Corporation Healthcare Network /
    Corvel
16. Zurich Services Corporation Healthcare Network
    (HCN)- First Health

7
Network Size

• Largest Service Area 234 counties
• Smallest Service Area 1 county
• Largest Provider Panel 8,703 providers
• Smallest Provider Panel 47 providers

8
Certified Self-Insureds

• Assume the responsibilities of
• Carriers,
• Employers, and
• Networks (if own network is formed
• and certified).

9
Network Options

• Carriers (includes insurance companies, certified
  self-insured employers, and certain self-insured
  governmental entities) can
• Contract with certified network, or
• Form a network and apply for certification.

10
Application Requirements

• Organizational description
• Financial information and business plan
• Contracts with 3rd parties and form of provider
  contract
• Service area maps and descriptions
• Provider panel contracted and credentialed
• Proof that care is accessible, available,
  comprehensive
• Treatment and return to work guidelines
• (Refer to 28 TAC 10.22 for complete list of
  requirements)

11
Provider Contract Requirements

• No transfer of risk
• Fee schedule
• Hold-harmless clause for injured employees
• No retaliation for appealing on patients behalf
• List of services requiring preauthorization
• Agreement to use network treatment guidelines
• Provider appeal process for terminations
• Agreement to participate in certified network
• (Refer to 28 TAC 10.42 for complete list of
  requirements)

12
Employee Notice -Acknowledgment Form Requirements

• Service area map and description
• Must use network providers if living in service
  area
• Except emergency approved out-of-network
  referral
• Employee living in service area may be liable for
  non-emergent, unapproved, out-of-network care
• No charge for network care for compensable injury
• Complaint process explained
• Right to contest where employee lives
• Provider directory updated quarterly
• Acknowledgment form
• (Refer to 28 TAC 10.60 for complete list of
  requirements)

13
Employee Responsibilities

• An employee who lives in the service area must
• Comply with network requirements,
• Select treating provider for each injury from
  list of network providers or HMO PCP,
• Obtain care through network providers except for
  emergency and approved out-of-network care, and
• Notify employer of any change of address.

14
Network Responsibilities

• Maintain adequate, accessible network
• Credential and contract with providers
• Update provider directories
• Meet access standards
• Treating providers 30 miles in urban areas and
  60 miles in rural areas
• Specialty care providers 75 miles in all areas
• Arrange for care within appropriate time but no
  later than 21 days after request
• File amendments to application within time
  constraints

15
Employer Responsibilities

• Provide notice of network requirements and get
  signed acknowledgment
• Either at inception of the network plan or within
  employees 3rd day of employment
• Obtain and maintain acknowledgment form signed by
  employee
• Provide notice of network requirements to the
  employee again at the time they are notified of
  an injury
• Establish standardized process to notify
  employees of network requirements
• Maintain current addresses of employees

16
Insurance Carrier Responsibility for
Out-of-network Care

• Emergency care
• Care provided to an injured employee who does not
  live in the service area
• Care provided out-of network pursuant to a
  network-approved referral from the injured
  employees treating doctor
• Care provided to an injured employee before the
  employee received notice of network requirements
  and information about the appropriate network and
  service area

17
Certified Self-Insureds

• Assume the responsibilities of
• Carriers,
• Employers, and
• Networks (if own network is formed and certified).

18
Legislative Changes 80th Legislature SB 458

• Amends Labor Code 401.011
• Requires coverage for prosthetic or orthotic
  devices including the fitting of, change or
  repair to, or training in the use of an
  appliance, brace, member or device

19
Legislative Changes TX R 80th Legislature HB 472

• Amends Insurance Code Chapter 4151
• Requires a person who adjusts or settles claims
  for workers compensation benefits and a certified
  network that administers a workers compensation
  claim for an insurer to hold a certificate of
  authority as a Third Party Administrator.

20
Legislative Changes TX R 80th Legislature HB
1005

• Adds Labor Code 408.0272
• Creates an exception to the 95-day claim filing
  requirement if the provider submits proof that
  the claim was
• timely filed to the workers health insurer, HMO
  or another workers compensation carrier or
• not timely filed due to a catastrophic event, as
  defined, and
• correctly refiled within in 95 days of receiving
  notice of the erroneous filing.

21
Legislative Changes 80th Legislature HB 1006

• Amends Insurance Code Chapter 1305
• Requires that doctors who perform reviews of
  health care services including utilization,
  retrospective and peer reviews be licensed in
  Texas

22
Legislative Changes 80th Legislature SB 1253

• Amends Insurance Code 1305.251
• Requires networks to pay a fee as set by the
  Commissioner by rule for examination expenses

23
Resources

• To obtain list of certified networks, service
  area maps, all-network combined map, etc. go to
  www.tdi.state.tx.us
• Locate the star in the upper left corner and
  click on Workers Compensation Networks which is
  located to the right of the star
• Scroll down to view information on certified
  networks and click on a networks name for
  additional details

24
Questions?

• Send an e-mail to wcnet_at_tdi.state.tx.us
• Please include your contact information and phone
  number
• Call TDI Health and Workers Compensation Network
  (HWCN) staff
• 800-554-4926 (toll-free)
• 512-322-4266 (in Austin)

25
Texas Certified WC Networks

1. Aetna Workers' Comp Access (AWCA)
2. Argus Provider Network
3. Bunch Associates, Inc. Texas Health Care
   Network
4. Bunch Coventry TX HCN dba Bunch Associates
5. Bunch HCN-First Health
6. Corvel Healthcare Corporation / Corcare
7. Coventry Health Care Workers Compensation Inc.
8. First Health / AIGCS Texas Health Care Network
9. First Health/CSS HCN
10. First Health Texas Health Care Network
11. First Health / Travelers Health Care Network
12. Forte Inc. / Compkey Plus
13. Genex Services Inc. / Genex Care For Texas' Comp
    Access (AWCA)
14. Genex Services Inc. / Genex Health Care Network
15. Hartford Workers' Compensation Health Care
    Network- FH, The
16. Houston Independent School District
17. IMO Med-Select Network / Injury Management
    Organization, Inc.

1. Interplan Health Group, Inc. / Zenith Health Care
   Network (ZHCN)
2. International Rehabilitation Associates, Inc. /
   Intracorp-2008
3. Intracorp / Lockheed Martin Aero Employee Select
   Network 2008
4. Liberty Health Care Network 
5. Majoris Health Systems
6. Memorial Hermann Health Network Providers, Inc. /
   Worklink 
7. National Choicecare,  NCC Choicenet
8. North Texas Innovative Healthcare Network, Inc.
9. Sedgwick Claims Management Service, Inc./
   Southwest Medical Provider Network
10. SHA, LLC / /Firstcare Network
11. Specialty Risk Services Texas Workers'
    Compensation Health Care Network (First Health)
12. Texas Star Network
13. The lone Star Network
14. Zurich Services Corporation Healthcare Network
15. Zurich Services Corporation Healthcare Network /
    Corvel
16. Zurich Services Corporation Healthcare Network
    (HCN)- First Health